Meddling Again?: Florida Dept. of Children and Families

From the Washington Post "In 2003, the Florida Supreme Court struck down a law requiring parents to be notified if their minor daughters seek an abortion. Florida's high court also cited privacy rights in 1989 when it tossed out a law that would have required parental consent for a minor's abortion."

In a current case described in the news article, a 13 year-old girl living in a state shelter ran away at least five times without the Florida Department of Children and Families who was the social service agency responsible for the child's protection, allegedly didn't inform the court about her absences. After an absence of a month, the girl returned pregnant and she requested an abortion which was to have been performed. However now the agency, citing a state law which apparently prohibits the agency from consenting for abortions, asked the court to block the abortion. A juvenile court judge has blocked the abortion but the ACLU has appealed based on the above previous court decisions about the minor's right to decide about an abortion. The 4th District Court of Appeals is said to take on the case.

It seems that the Florida Department of Children and Families, now having failed their primary legal responsibility, as in the Schiavo case, may be meddling again in the legal personal rights of individuals. ..Maurice.

Paying More Attention to Votes Than to Science

I got the following e-mail today allegedly from the ACLU. Perhaps some of my visitors got a similar e-mail too. If the facts are true, what it appears to me is that the current U.S. administration is trying again to prevent or delay scientific discovery simply because of their own political bias. It seems similar to the prohibition against full embryonic stem cell research. This may be another example of our government paying more attention to votes than to science. What do you think? ..Maurice.



From: psilva@aclu.org (Paul Silva)

Science, Not Politics, Should Govern Medical Research, Says ACLU in Challenge to DEA's Marijuana Policy

FOR IMMEDIATE RELEASE
April 25, 2005

CONTACT: Anjuli Verma, ACLU Drug Law Reform Project, (831) 471-9000 x11 or cell, (434) 825-9208

WASHINGTON - The American Civil Liberties Union today announced a legal challenge to the Drug Enforcement Administration's policy of obstructing private research that could lead to marijuana being approved as a prescription medicine.

The ACLU filed the case Friday on behalf of University of Massachusetts Professor Lyle Craker, Ph.D., who wants to grow an alternative, privately funded source of research-grade marijuana. The challenge comes in advance of an expected U.S. Supreme Court ruling in Raich v. Ashcroft, which addresses the question of whether the federal government can enforce federal marijuana laws in states where medical marijuana is legal.

"The public has a right to know about possible health effects of marijuana and whether this plant material has any medicinal value," said Professor Craker. "Only through unobstructed medical research can doctors and scientists determine the value of marijuana in treating human afflictions. My job is to make plant material available for research, and the refusal of the DEA to allow me grow marijuana for medical research prevents a full investigation of the potential health benefits of the plant material."

In oral arguments last November in the Raich case, Justice Stephen Breyer suggested that patients ask the Food and Drug Administration to reclassify marijuana for medical use as "the obvious way to get what they want," adding, "Medicine by regulation is better than medicine by referendum."

But in legal papers filed on Professor Craker's behalf, the ACLU points out that the federal government has a policy of obstructing research that could lead to the development of marijuana as a legal prescription medicine.

"Doctors and patients would like to take Justice Breyer up on his proposal during the oral arguments in Raich to develop marijuana as a medicine through the FDA approval process," said Alan Hopper, a staff attorney with the ACLU's Drug Law Reform Project. "Justice Breyer calls for 'medicine by regulation,' but the government's idea of 'regulation' is to obstruct research."

Through the National Institute on Drug Abuse (NIDA), the federal government currently has a monopoly on supplying marijuana available for research, Hopper noted. In contrast, all other controlled substances are provided to researchers by DEA-licensed private laboratories - including heroin, cocaine, MDMA (Ecstasy), and LSD. Scientists who want to study the medical benefits of marijuana with the goal of developing it into an FDA-approved prescription medicine either cannot secure marijuana for their research or receive from NIDA marijuana of insufficient quality and potency.

The DEA's refusal to allow Professor Craker to provide an alternative, privately funded supply of research-grade marijuana obstructs scientists' ability to conduct the research necessary to develop marijuana as a legal prescription medicine, the ACLU said in legal papers.

"We are frustrated with the DEA's red tape and the federal government's heavy-handed policies that stifle our research," said Rick Doblin, Ph.D., president of the non-profit Multidisciplinary Association for Psychedelic Studies (MAPS), which wants to privately fund Professor Craker's cultivation site and the development of marijuana into a legal medicine. "Drug war politics should not obstruct our pharmaceutical development process, especially when it comes to researching drugs with the potential to reduce chronic suffering and reduce the negative side effects of life-saving medicines."

The ACLU also said that NIDA discriminates against scientists who want to conduct research that aims to establish marijuana's efficacy and safety as an FDA-approved prescription medicine. Such research programs clash with NIDA's mission to study only the harmful effects of drugs.

Allowing Professor Craker to cultivate an alternative source of marijuana for research is in the public interest and the DEA's denial of his application is driven by the politics of the "war on drugs," the ACLU said.

A hearing on the matter before a federal administrative law judge is scheduled for later this summer. A group of nationally renowned experts are expected to testify on Professor Craker's behalf.

The ACLU is co-counsel in the case In the Matter of Lyle Craker with the Washington D.C. law firm Jenner & Block, LLP and is assisted by Steptoe & Johnson, LLP. The pre-hearing statement is online at: http://www.aclu.org/DrugPolicy/DrugPolicy.cfm?ID=18101&c=81, and further background information is available on the MAPS website: www.maps.org

Political Definitions: Born Alive and Global Warming:Where is the Science?

Excerpted from the Washington Post: "The Bush administration issued guidelines yesterday advising physicians and hospitals that under a 2002 law they are obligated to care for fetuses 'born alive' naturally or in the process of an abortion, and medical providers could face penalties for withholding treatment.

The law, signed by President Bush nearly three years ago, conferred legal rights on fetuses 'at any stage of development.' It specifies that a fetus that is breathing, has a beating heart, a pulsating umbilical cord or muscle movement should be considered alive and entitled to protection under federal emergency medical laws and child abuse statutes."

Is there no more science in the standards of medical practice? Is a live birth that which is defined by the politicians and the President? What are the treatments that the President and the politicians have prescribed which if withheld will penalize the medical providers? Remember that a fetus of 14 to 16 weeks cannot live out of the womb. What about an anencephalic fetus who has a heartbeat but NO brain to know or think? Where is the science and where are the scientists? And on top of all this we are told by our government that "global warming is an exaggeration"!

I worry that this U.S. administration is forgetting about science and are only concerned with political advantage. Am I mistaken? ..Maurice.

More on Plan B: Conscientious Objection by Pharmacists

On January 28th and March 30th of this year I posted the ethical issue of whether physicians or hospitals should deny patients the “morning-after” Plan B pill if the providers had moral objections to the use of the pill.
Now, in the news, is the hot ethical question whether pharmacists who have conscientious objections (CO) about the dispensing of the “morning-after” Plan B pill should be required to fill the prescription or may they refuse. Excerpted from the New York Times, April 19 2005:

“In at least 23 states, legislators and other elected officials have passed laws or are considering measures in a debate that has attracted many of the same advocates and prompted much of the same intensity as the fight over abortion.

In some states, legislators are pushing laws that would explicitly grant pharmacists the right to refuse to dispense drugs related to contraception or abortion on moral grounds. Others want to require pharmacies to fill any legal prescription for birth control, … which requires pharmacies that stock the morning-after pill to dispense it without delay. And in some states, there are proposals or newly enacted laws to make the morning-after pill more accessible, by requiring hospitals to offer it to rape victims or allowing certain pharmacists to sell it without a prescription.”

An ongoing discussion on this issue by ethicists is appearing on a bioethics listserv currently. Two different views are anonymously presented below regarding whether conscientious objection clauses should be within the codes of ethical behavior of a profession, such as the profession of pharmacy.

The View For CO Clauses

“Is there to be no room for conscience-clauses within a profession? Can those occupying
the minority position be granted no latitude? My own sense is that
conscience-clauses come along with pluralism and disagreements resolved by
a majority while giving minorities some room to hold to the view that the
profession itself does not embrace. Conscientious objector status is the
majority's concession to the minority opinion. As such, it comes along
with a recognition that we differ over what is ethical. When a people
realize that they differ over their view of the good, they can agree that
while the majority's view of the good will prevail, others will not be
coerced to follow it in those respects that they find it objectionable. To
the extent to which our times are marked by disagreement, I would think
that CO clauses would abound.”

The View Against CO Clauses

“I don't think there is room for CO clauses for pharmacists that would allow
them to abstain from implementing classes of prescription. In rega to
medicines, I think physicians have a duty not to prescribe poisons and the
like or to prescribe narcotics without a proper license, and a duty to do
the best job technical job they can with prescription choices, taking into
account side effects. For their part, pharmacists have a general duty to
implement the prescriptions presented to them accurately. Within that
general duty, pharmacists also have a duty to apply their particular
knowledge about drug dosages by age and weight and drug interactions (based
on knowledge of all the drugs being taken) and get back to physicians about
possible prescription changes needed for efficacy reasons, and to respond
to queries from patients to the best of their knowledge. I don't think it
rises to a duty but it is certainly a good characteristic of pharmacists if
they take the trouble to suggest generic drugs to the physicians when that
would result in lower consumer prices or copays. Allowing pharmacists to
make CO objections to types of legally prescribed medications opens a
Pandora's box and interferes with these desired roles: what if the
pharmacist's religious beliefs suggested that pain should be fully
experienced, for example, and therefore they should abstain from filling
certain pain prescriptions? What if their beliefs compelled or prohibited
uses of various types of psychoactive drugs? What if the pharmacist
believes in so-called "natural" classes of drugs to the exclusion of
others? Will we need a procedure for determining whether the pharmacist's
beliefs, as with those of military COs, come from a properly established
religion or just a strongly held belief, and will this matter? What kind
of disclosure of their own beliefs must the pharmacist give the patient,
and when? Must they be posted on the pharmacy wall, giving at least some
consumers a chance to take their business to pharmacies that leave their
subjective morality behind. And do we have time for all these processes to
play out? If pharmacists can introduce their own moral filter that
includes information about the patient's marital status and social behavior
(e.g. no contraceptives for unmarried individuals), it implies at best that
dispensing pharmacists have a relationship with patients and their complete
social history in ways that cannot be assured. … I think
pharmacists who cannot or will not fulfill legal drug prescriptions because
of their own particular moral objections to a class of meds or to use of
certain meds in certain social circumstances (as opposed to technical
grounds of objection to what seem to be prescribing errors of too little,
too much, or the wrong med) should get a new occupation. Further, it seems
to me that condoning pharmacists in their adding a subjective moral filter
to prohibit certain prescriptions will undercut all efforts to see the
pharmacist as a health team member whose technical expertise about
pharmaceuticals should be expressed to and heeded by physicians. I have
always been a staunch advocate that pharmacists should raise objections to
a prescription that seems wrong to them and have wanted to elevate the
status of pharmacist at the true medication expert.”

Any more comments on this issue? ..Maurice.

Another Drug Company Gift!

On the topic of physician behavior to gifts from drug companies, I couldn't let my visitors miss this cartoon on GruntDoc.
Go visit there and enjoy. ..Maurice.

"Good" "Mistakes" and "How" in Medical Education and Practice

I found a written paper which clearly summarizes in a relatively few words much of what I have posted since July of last year about medical education and the practice of medicine. The paper is by Ladislav Šoltés and it is titled
Medical ethics in Slovakia. Go to the website to read the full article including the portion on Slovakian medical ethics. I fully agree with the view of medicine as presented below by Ladislav. I also want to point out an important point he makes: "'How to learn' rather than 'what' you to learn, is the critical issue."
I can give an example from my medical school teaching activities. What is most important is for the students faced with a myriad of accumulated diagnoses they have studied, to learn how to think out a differential diagnosis of a sick patient. Just knowing a lot of diseases is not good enough. ..Maurice.

My paper is divided in two different (but in reality) related aspects. In the first part 1 would like to analyse some aspects of medical and ethical educations from our point of view and, in the second, Slovak experiences in establishing ethics in medicine and health care and legal support for medical ethics.
The universal nature and meaning of medicine itself proves that medicine is inherently ethical. In every cultural context medicine is needed, recognized and valued by all. ( ucha, J., 1997) That medical education which aims at making its students and physicians good doctors is not an individualistic task, (me and my students, my colleagues, etc.), it takes place within a context of medical practise, a medical community, that although concrete in particular place and time, is also of universal significance.
The moral integrity of health professionals should be saved by permanent ethical education and training and by developing and strengthening their up to date professional competence.
What is a good medicine? What makes for a "good" doctor? But the essential underlying question is: "who has the competence to judge what is good or bad; whether the doctor is good or not?" To claim this competence is audacious. The physician plays many roles, not only one. And to be good as a diagnostic, a therapist, a head of department, a confessor or husband and father, is not a state, rather,' it is a process. A physician maintains, increases his goodness by improvement: he must maintain and defend it, or he may regress and loose lt. To be a good means to endeavour to become good and to continue that goodness.
Albert Schweitzer (who became a physician in order to become the better theologian), pointed out the ethics of respect to life, to the ethics and to science. In this sense, science and life, in medical praxes, go together and their relation is like the relationship between a good coalition and a good opposition. The process to become a good doctor is an education of self-awareness.
The relation between professional and private life can not be one of independence in relationship to each other. The one who is fighting for rights, liberty and justice, must not be a despot in his own family, cannot mislead his nearests and has to be fair also in his own family. In reforming the surrounding world we may not neglect ourselves. It is the testimony to the values, in the name of which we are acting. (~olt6s, L., 1997)
Frustration, deprivation and mistakes are on all sides in a professional life. Physicians should be sensitive to their mistakes. The mistakes seduce. Every man who contemplates his mistakes knows how success is manipulated by his own mistakes. To face, no confront our own mistakes and the limitations of mistakes of the others is very difficult. The myth of seducer and temptater is one of the central myths of humanity. Certainty is not by chance. To be aware of mistakes is not only the rule of the scientific analysis but also an ethical imperative. To be good is a lifelong process. (bolts, L., 1995)
"How to learn" rather than "what" you to learn, is the critical issue. It is a fact that of the three basic questions in the teaching process, (i.e., the Why, What and How), the latter is often neglected.(Kou ilea, M., 1997)
Briefly, the "How" is the rationale, a set of organizational and operational principles and strategies underlying those processes which facilitate acquisition.
The basic premise is that the learning process must be selective and integrating rather than discrete. Our aim is meaningful learning: learning by understanding that is both selective and organizing. Efficient dealing with the information burden is one of the most urgent challenges in the world of both business and science. The renowned news agency, Reuters, has recently organized a conference in London addressing the questions :
a. How does the information overload affects our mental and physical health ? and,
b. How to survive the information deluge ?
A monster has been created which makes us feel inferior, incompetent, lost, and affected by " Information Fatigue Syndrome" causing physical illness and mental anguish. Paradoxically, one symptom is an addictive drive to seek even further information being obsessed by a fear of missing something important. The result is paralyses of analysis, characterized by distorted judgment, wrong decisions, flawed conclusions and even serious blunders. This carries ethical implications to our approach to our present and future problems.

Gifts: Give Soulfully, Without Cunning

Here is a German poem "Give from the heart"
by Joachim Ringelnatz translated by Hans Springer and found on
LCMS Foundation website

Give from the heart and freely

give with it that which is inside of you

such as opinion, taste and humor

So that your own joy

will richly reward you, prior to the giving.

Give little or big

but always genuinely, purely;


When the recipient considers the gift

let your conscience be clear.

Give soulfully, without cunning

be aware

that your gift

is you, yourself.

I think this poem clearly shows the ethical line between a gift from a patient whom the physician has cared for and helped and the gift from the pharmaceutical company.
The first is given "soulfully" and the second is given, but not without "cunning". ..Maurice.

Drug Company Gifts to Doctors:Prescribing Under the Influence

E. Haavi Morreim's article "Prescribing Under the Influence" in the publication of the Markkula Center for Applied Ethics of Santa Clara University clearly provides realistic examples of the influence of pharmaceutical companies "gifts" to doctors. If you don't yet know what has been going on to get physicians to prescribe and advertise their drugs, please go to the site and read her entire article. The excerpt from the first part is posted below. ..Maurice.

Gifts to doctors from drug companies have implications for patient interests.

It’s morning report in the Department of Pediatrics at an academic medical center. A senior faculty member is working through a case with a group of residents and interns. "First we saw these symptoms. Now that the laboratory results are back, how does that change what we think?"

In the back of the room, there’s a table with bagels and juice. On the table is a supply of pens, notebooks, and little stuffed toys, all with a pharmaceutical company logo prominently displayed. Next to the table is a representative from the drug company.

When you ask doctors whether this kind of drug marketing is effective, the answer is always the same: "It doesn’t influence me at all. They’re not going to buy my soul with a laser pointer." In a recent syndicated newspaper column, one doctor commented, "I blame the pin-striped MBAs, who mistakenly believe that physicians are going to prescribe certain medicines because the company plies them with pens."

The truth is, the physicians may need to reconsider. This kind of advertising is crucial to sales. A doctor is not going to prescribe something he or she has never heard of, and it’s the drug representative’s job to get the products’ names in front of the physicians. Maybe the drug representative does that while the resident is slathering cream cheese on a bagel; maybe it’s while the intern is saying, "Oh, what’s this cute little stuffed bear?" Either way, the doctor stops and spends a moment.

In private practice, the little gifts are often even more important. If you’re a drug representative, physicians are usually not interested in talking to you unless you have something to catch their attention. Then you can get your three sentences in: "We’ve got such and such on the hospital’s formulary now." Or "The new form of this drug can be given once a day instead of four times a day. The patients will love it." It’s a way to get in the door so that your information rather than somebody else’s reaches the doctor’s brain.

“Here are Tickets to Disneyland”:Gifts to Physicians from Medical Industry

Gifts to physicians from patients represent one issue, only rarely occurs and usually is trivial. Gifts to physicians from medical industry is quite another issue and in one form or another is an ongoing practice. This practice, if unchecked, could easily bias the physicians prescribing patterns toward the contributing pharmaceutical company or instrument buying patterns or recommendations for patient use medical equipment. The American Medical Association has challenged this practice with a series of ethical guidelines to avoid what is felt to be actions which potentially could lead to conflict of interest. The guidelines are presented below:

Opinion 8.061, "Gifts to Physicians from Industry"
Many gifts given to physicians by companies in the pharmaceutical, device, and medical equipment industries serve an important and socially beneficial function. For example, companies have long provided funds for educational seminars and conferences. However, there has been growing concern about certain gifts from industry to physicians. Some gifts that reflect customary practices of industry may not be consistent with the Principles of Medical Ethics. To avoid the acceptance of inappropriate gifts, physicians should observe the following guidelines:

(1) Any gifts accepted by physicians individually should primarily entail a benefit to patients and should not be of substantial value. Accordingly, textbooks, modest meals, and other gifts are appropriate if they serve a genuine educational function. Cash payments should not be accepted. _The use of drug samples for personal or family use is permissible as long as these practices do not interfere with patient access to drug samples. It would not be acceptable for non-retired physicians to request free pharmaceuticals for personal use or use by family members.

(2) Individual gifts of minimal value are permissible as long as the gifts are related to the physician’s work (e.g., pens and notepads).

(3) The Council on Ethical and Judicial Affairs defines a legitimate “conference” or “meeting” as any activity, held at an appropriate location, where (a) the gathering is primarily dedicated, in both time and effort, to promoting objective scientific and educational activities and discourse (one or more educational presentation(s) should be the highlight of the gathering), and (b) the main incentive for bringing attendees together is to further their knowledge on the topic(s) being presented. An appropriate disclosure of financial support or conflict of interest should be made.

(4) Subsidies to underwrite the costs of continuing medical education conferences or professional meetings can contribute to the improvement of patient care and therefore are permissible. Since the giving of a subsidy directly to a physician by a company’s representative may create a relationship that could influence the use of the company’s products, any subsidy should be accepted by the conference’s sponsor who in turn can use the money to reduce the conference’s registration fee. Payments to defray the costs of a conference should not be accepted directly from the company by the physicians attending the conference.

(5) Subsidies from industry should not be accepted directly or indirectly to pay for the costs of travel, lodging, or other personal expenses of physicians attending conferences or meetings, nor should subsidies be accepted to compensate for the physicians’ time. Subsidies for hospitality should not be accepted outside of modest meals or social events held as a part of a conference or meeting. It is appropriate for faculty at conferences or meetings to accept reasonable honoraria and to accept reimbursement for reasonable travel, lodging, and meal expenses. It is also appropriate for consultants who provide genuine services to receive reasonable compensation and to accept reimbursement for reasonable travel, lodging, and meal expenses. Token consulting or advisory arrangements cannot be used to justify the compensation of physicians for their time or their travel, lodging, and other out-of-pocket expenses.

(6) Scholarship or other special funds to permit medical students, residents, and fellows to attend carefully selected educational conferences may be permissible as long as the selection of students, residents, or fellows who will receive the funds is made by the academic or training institution. Carefully selected educational conferences are generally defined as the major educational, scientific or policy-making meetings of national, regional or specialty medical associations.

(7) No gifts should be accepted if there are strings attached. For example, physicians should not accept gifts if they are given in relation to the physician’s prescribing practices. In addition, when companies underwrite medical conferences or lectures other than their own, responsibility for and control over the selection of content, faculty, educational methods, and materials should belong to the organizers of the conferences or lectures. (II) Issued June 1992 based on the report "Gifts to Physicians from Industry," adopted December 1990 (JAMA. 1991; 265: 501 and Food and Drug Law Journal. 2001; 56: 27-40); Updated June 1996 and June 1998.

..Maurice.

“Pick one.. it’s Yours”: Patient Gifts to Their Doctors

When I was an intern at Philadelphia General Hospital, my introduction to the hospital was on the general medical ward. This particular ward was where the firemen and policemen went when they were sick and also the politicians of the city. I remember that one of the first patients I was responsible for was a politician. I came to the bedside to perform the patient’s first history and physical in the hospital. I remember, I was greeted with a smile as I approached and then the patient raised his arm. On his wrist were several expensive looking watches. His words to me: “Pick one.. it’s yours.” Well, I didn’t. I felt he was trying to “buy” my personal attention and service before I even started. (Remember, I said he was a politician!) I politely refused his offer and explained that a watch wasn’t necessary. It was my responsibility to provide care to all hospital patients and I would be satisfied to take care of him without a watch. After a bit of further urging, he finally gave up and I did my task without further event.

This episode in my medical experience has been long remembered (40 some years) but also brings up the ethical issue of whether physicians should ever accept gifts from patients. If so, under what circumstances and what kind of gifts? I think it is improper to accept a gift before the act of attending to the medical needs of the patient as in the my intern experience. But what about a gracious gift representing thanks and appreciation for my services after they have been completed? Certainly, it would be inconsiderate of the feelings of the patient to refuse. Would a gold watch be acceptable or should it be a home-made fruit cake? Where does one draw the line? How about a monetary “tip”? I never had that! But if this was offered to me, should I accept that like my barber does? If so, how much of a tip is acceptable? I realize that his issue of a patient’s gift is not the most important issue in medical practice but it does represent ethical concerns: Avoiding acts which may be seen as or indeed are conflicts of interest in the practice of a just form of medicine for all patients could also be paternalistically ignoring the emotional needs of the treated patient to relate to the physician. Before I go any further, I welcome the views of my visitors including physicians. ..Maurice.

Life With Doctors: A Psych and Physical Medical Merry-Go-Round

OK Doctors.. you think you are doing a good job? Well, read the following, written by a visitor (who I will keep anonymous) to my blog today. Maybe you, also I, may have to improve a bit. Oh well.. there is always the next patient. ..Maurice.

Arrived @ Blog while seeking to understand "MD". (in the universal
sense). (PT does not know what a "Blog" is.sorry :-(...)

PT has 40+ yr history with MD (many, many, MDs...as in the individual
sense)

MD = impossible to understand.

MD always gets frustrated with PT..even though PT always tells truth,
even though, PT = normally upbeat/happy (even whilst dying. :-()

Frustrated MDs threw many temper tantrums at PT - (snide remarks,
yelling, screaming, throwing things, sometimes even walking out..)
PT's heart became broken (no pun intended). Sometimes, PT cried.

But PT had no power...MD had it all.

Because MD often accused PT of hypochondria, treatment was delayed for
YEARS with each & every illness.
MD was wrong. MD has NEVER apologized...

Eventually, PT concluded MD = Medical Demon. NIH = Nuts in House.

One day, after reaching this conclusion, PT told a "nice" Nurse
practitioner the truth about how PT was feeling. (PT felt suicidal
:-()
"Nurse practitioner" had PT "escorted" by police to Psychiatric
Hospital. PT was soon "incarcerated" therein. PT observed, Psych
workers = more messed up than PT will ever be!!

PT was/is physically ill. (Why did/does MD still not believe PT?)

Who is PT?

PT = "Left Main Coronary Artery Fistula", Cardiology in Review, Feb
2004.
(Cardiac symptoms dismissed for 5 years by multiple MD's, including
cardiologists)
PT = Hashimoto's Thyroiditis (13 yr wait for diagnosis/treatment)
PT = Premature Ovarian Failure (5 yr wait for diagnosis, 10+ yr to
find effective HRT)
PT = Alopecia (5 month wait for diagnosis - no treatment as of yet...)
PT = Ruptured Appendix (MD's waited 3 days after initial onset of
appendicitis, before attempting surgery, because an MD didn't want to
"risk" surgery so
soon after fistula repair.)
PT is also well traveled. Degreed. Sensitive. ( MD never knew. Or
cared? )

Now PT is "stuck" in psychiatric-medical-merry-go-round ( and remains
stuck in the "physical"-medical-merry-go-round.as well.)

Who is Maurice?

Insurance Companies and Genetic Information

A visitor to my "Bioethics Discussion Pages" today wrote the following:

"...here is my response to
the bioethical question of should insurance companies have the right to
request and receive the results of genetic tests of close relatives or
the person requesting insurance?

In my opinion, insurance companies have no right to genetic testing
results from individuals or members of a persons family. If these
results are provided to insurance companies the whole health care system
could be sent downward. Insurance companies would then have the ability
to identify high risk patients and either cancel their coverage or raise
the premium to a point where the patient is unable to afford them. An
insurance companies responsibility is to provide a safety net for the
unexpected, hence the name insurance. It is very unethical for
insurance companies to pick and choose there clients based on the
patients genetic testing. If an individual chooses to have genetic
testing done, it is often to help plan the patients life. These
individuals should not have to worry about whether these test results
will affect the ability to receive proper health care if and when a
predicted disease comes to be."

AND apparently supporting the view of this visitor, the American Medical Association Code of Medical Ethics has stated the following in their section on Insurance Companies and Genetic Information:

"Physicians should not participate in genetic testing by health insurance companies to predict a person’s predisposition for disease. As a corollary, it may be necessary for physicians to maintain separate files for genetic testing results to ensure that the results are not sent to health insurance companies when requests for copies of patient medical records are fulfilled. Physicians who withhold testing results should inform insurance companies that, when medical records are sent, genetic testing results are not included. This disclosure should occur with all patients, not just those who have undergone genetic testing. (IV)Issued June 1994 based on the report 'Physician Participation in Genetic Testing by Health Insurance Companies,' adopted June 1993; Updated June 1996."

One would think that if an insurance company was to function and survive as a resource provider for society, it would have to base it's decision to accept a customer for health insurance and death insurance on some kind of probability determination of illness or death. Insurance companies would argue that the more reliable the data for estimating probablility the better for the company. The question arises as to whether genetic information in all cases really provides reliable data with regard to health outcomes. Since much genetic information related to diseases is not predictive that the individual will actually develop that disease, use of such data would be misleading and perhaps bias the true status of the customer. The extrapolation of genetic data from one individual to family members is also likely to be non-predictive and most importantly would represent an unethical if not illegal invasion of privacy. Are there any visitors in the insurance business out there to present the company's side of the argument? ..Maurice.

Becoming A Physician: Information from the American Medical Association

There may be some visitors to this blog who after reading this blog and the host of other fine medical blogs available, would like to consider becoming a physician. There are some basic ABC information that you need to know first. A great source for that information is to go to the American Medical Association website and read about becoming an MD. There you will find in addition to “How do you become a physician?” which I have posted below, the following topics which are also present: Preparing for medical school, Applying to medical school, Paying for medical school, Choosing a specialty, Medical glossary and Frequently asked questions. Please go there to see what is necessary for you to start a career as a physician.

How do you become a physician?
The education of physicians in the United States is lengthy and involves undergraduate education, medical school and graduate medical education. (The term 'graduate medical education' [GME] includes residency and fellowship training; the American Medical Association does not use the term "postgraduate education.")

· Undergraduate education: Four years at a college or university to earn a BS or BA degree, usually with a strong emphasis on basic sciences, such as biology, chemistry, and physics (some students may enter medical school with other areas of emphasis).

· Medical school (undergraduate medical education): Four years of education at one of the U.S. medical schools accredited by the Liaison Committee on Medical Education (LCME). Four years at one of the LCME-accredited U.S. medical schools, consisting of preclinical and clinical parts. After completing medical school, students earn their doctor of medicine degrees (MDs), although they must complete additional training before practicing on their own as a physician. (Note: Some physicians receive a doctor of osteopathic medicine [DO] degree from a college of osteopathic medicine.)

· Residency program (graduate medical education): Through a national matching program, newly graduated MDs enter into a residency program that is three to seven years or more of professional training under the supervision of senior physician educators. The length of residency training varies depending on the specialty chosen: family practice, internal medicine, and pediatrics, for example, require 3 years of training; general surgery requires 5 years. (Some refer to the first year of residency as an "internship"; the AMA no longer uses this term.)

· Fellowship: One to three years of additional training in a subspecialty is an option for some doctors who want to become highly specialized in a particular field, such as gastroenterology, a subspecialty of internal medicine and of pediatrics, or child and adolescent psychiatry, a subspecialty of psychiatry.
After completing undergraduate, medical school and graduate medical education, a physician still must obtain a license to practice medicine from a state or jurisdiction of the United States in which they are planning to practice. They apply for the permanent license after completing a series of exams and completing a minimum number of years of graduate medical education.

The majority of physicians also choose to become board certified, which is an optional, voluntary process. Certification ensures that the doctor has been tested to assess his or her knowledge, skills, and experience in a specialty and is deemed qualified to provide quality patient care in that specialty. There are two levels of certification through 24 specialty medical boards — doctors can be certified in 36 general medical specialties and in an additional 88 subspecialty fields. Most certifications must be renewed after six to 10 years, depending on the specialty.
Learning does not end when physicians complete their residency or fellowship training. Doctors continue to receive credits for continuing medical education, and some states require a certain number of CME credits per year to ensure the doctor's knowledge and skills remain current. CME requirements vary by state, by professional organizations, and by hospital medical staff organizations.
—Some of the above information was adapted from "Your Doctor's Education" in JAMA, September 6, 2000.

By the way, I know from experience that some patients really don’t know what goes into the education and practice development of their physician. To be a good and educated partner with your doctor taking care of your illness, I would advise patients to go to the AMA website linked above to learn about how their doctors came to where they are. ..Maurice.

Doctors: the Bold, the Seekers of the Way

Continuing our thread of thinking about why a person might wish to become a doctor, Rudyard Kipling in his poem "Doctors" defines his view of the goal and quality of a doctor.

Man dies too soon, beside his works half-planned.
His days are counted and reprieve is vain:
Who shall entreat with Death to stay his hand;
Or cloke the shameful nakedness of pain?

Send here the bold, the seekers of the way--
The passionless, the unshakeable of soul,
Who serve the inmost mysteries of man's clay,
And ask no more than leave to make them whole.

I am not sure we doctors are passionless but we do try to be empathetic and try to be understanding of the patient. I do think however that it is our introspection and fascination of our own "mysteries of man's clay" that induce us to join the profession.
What do you think? ..Maurice.

Why are You a Doctor?

STRANGER: It's better for your health to leave your window opened. You let in fresh air. PERSON: Why, are you a doctor? STRANGER: No, I am a thief.

Lets take the comma away and ask the question again “Why are you a doctor?” or “Why become a doctor?” In view of the last posting about the uncertainty within the life of a doctor these questions are good questions. DB’s Medical Rants picked up my last posting and posted another doctor’s view including an example of the uncertainty which commonly occurs and what good can come from a tragic result. Read the comment. A visitor to Rants then asked “can you point to something you’d say makes it worth [becoming a doctor]?” An excellent question. I wrote on that blog the following answer:

I don’t think about why I chose the medical profession. It has been my life for almost 50 years. But if I thought about it, as I am doing now, I guess it had to do with joining as a human being a unique profession which is given by society tremendous challenges, responsibilities and permissions to other humans and which is given to noone else. We can hold the comfort but also the life of others in our own hands. We are different than the airline pilot or bus driver who is responsible for the life of many but that also includes their own. When we save a life it is not because to do so saves our own life. And I think that difference is important. But there is more to wanting to be a doctor than society’s approval. There is the good feeling from doing good to someone but also the wonder and excitement (even to the point of raising gooseflesh) of making emotional and spiritual contact with your patient. This kind of “closeness” with another human being, which is possible as a physician, is just plain remarkable and fulfilling.

I think it would be very interesting to read from other physicians either on my blog or DB’s Medical Rants their personal answers to “why did you become a doctor?” ..Maurice.

Addendum 5-31-05: Not only does piloerection ("gooseflesh") occur to doctors who recognize that they have made a real contact with the patient but according to the
essay by John Bayley titled LARKIN, PYM AND ROMANTIC SYMPATHY", he recalls the example of piloerection developing on identifying real poetry: "A. E. Housman's famous claim, made in his Cambridge lecture 'The Name and Nature of Poetry' that he could only tell real poetry – but then he could tell it at once – from its physical effect on him. If a line of poetry entered his head while he was shaving his beard bristled up and resisted the razor."

Uncertainty and the Life of a Doctor

The life of a physician is full of uncertainties. With regard to diagnosing or treating a disease we know that illnesses by the same names are not the same in every patient and neither is there always the outcome we had expected on treatment. There are days, however, when everything goes as expected. We are please with ourselves and get the warm loving hug of a patient who is pleased with us and what we have accomplished. We have all experienced this. But then there is the day when we experience the cold sweat of personal concern: was the diagnosis correct? was the treatment the best? why did the patient die? We have all experienced this too.

Following on this theme is the poem "Doctor Meyers" by Edgar Lee Masters and located at AmericanPoems.com

No other man, unless it was Doc Hill,
Did more for people in this town than l.
And all the weak, the halt, the improvident
And those who could not pay flocked to me.
I was good-hearted, easy Doctor Meyers.
I was healthy, happy, in comfortable fortune,
Blest with a congenial mate, my children raised,
All wedded, doing well in the world.
And then one night, Minerva, the poetess,
Came to me in her trouble, crying.
I tried to help her out -- she died --
They indicted me, the newspapers disgraced me,
My wife perished of a broken heart.
And pneumonia finished me.

Yet, you know, our medical schools are still filled with students. There must be, despite the uncertanties of the medical profession, still something worthy to become a doctor. ..Maurice.

Schiavo case: Speculations About Bulimia and Dysfunctional Family

The Schiavo case will go down in bioethical history just as Quinlan and Cruzan have. Whether Schiavo will be the beginning of a change in bioethical and legal thinking with regard to surrogacy and autonomous decisions to terminate life support remains to be seen. Beyond this, the case, as suggested by others, has opened speculation regarding the psychodynamics involving Terri Schiavo and her parents. It has been suggested that it is more than coincidental that food and fluid has played a significant role in both the start and conclusion of Terri's illness. One may speculate that the bulimia of over-eating and purging through vomiting which precipitated the immediate near-fatal electrolyte imbalance may have had as its etiology a severe emotional disturbance related to a need to demonstrate self-control as a reaction to life in a possible dysfunctional family. We don't know this as a fact but certainly there are long established theories regarding such reaction as well as some surveys, self-reported, by bulimic patients. If this was the case with Terri, one might speculate about an apparent controlling behavior of Terri's parents with regard to their response over the years to override her request to terminate her life support and perhaps another control issue which led to the bulimia response itself. If the facts about this daughter-parent relationship, in this already widely publicized personal case, could be investigated, it might contribute to a better understanding of the nature of the bulimic illness. ..Maurice.

Medical Ethics in the Nazi Era: “Medicine Gone Bad”?

When one thinks about medical ethics back in the early 1940s, one of the first examples that come to mind is the behavior of Nazi physicians and scientists. We readily conclude that this period in Germany clearly demonstrated the unethics of medicine as practiced by those physicians and scientists and that whatever science and medicine which came out of Germany at that time, because of the unjust and murderous treatment of many peoples, was bad science and bad medicine. Robert N. Proctor writing in the Perspectives in Biology and Medicine, Spring 2000 p. 335 “NAZI SCIENCE AND NAZI MEDICAL ETHICS:SOME MYTHS AND MISCONCEPTIONS”
and which can be obtained through this link in pdf format presents a view which, while not ignoring the horrific behaviors and results, points out that we shouldn’t jump to the conclusion that there was nothing more to the story of the Nazi medicine/science era than “medicine gone mad”. To view a different perspective of this era than what you and I usually hold, reading Proctor’s article is worthwhile. Here is an excerpt from the conclusion:


“My point is not to rescue the honor of medicine in its darkest hour, but
rather to stress its subtlety and complexity. The history of medicine in this
period is a history of both forcible sterilization and herbal remedies; we
cannot forget the crimes of a Karl Brandt or a Hermann Voss, but we
also should not forget that the SS built the world’s largest botanical medical
garden in Dachau, or that German nutritionists mandated the production
of whole-grain bread. Fascist physicians willfully murdered their
handicapped patients, but organic farming and species protection were
also going concerns. The question is not one of balance, but of the proper
understanding of origins, context, continuities, and contradictions. It is
part of the horror of this period, that such an “advanced” technological
society could fall so far into butchery and barbarism.

I do not believe there is an inherently totalitarian tendency in modern
science, but I do think it is important to recognize that, just as the routine
practice of science is not incompatible with the routine exercise of cruelty,
so the dictatorial and murderous aspirations of fascism were not necessar-
ily at odds with the promotion of cutting edge science and progressive public
health—at least for certain elements of the population. The exclusive
focus on the heinous aspects of Nazi medical practice makes it easy for us
to relegate the events of this era to the monstrous or otherworldly, but
there is more to the story than 'medicine gone mad.' The Nazi campaign
against carcinogenic food dyes, the world-class asbestos and tobacco epidemiology,
and much else as well, are all in some sense as fascist as the yellow
stars and the death camps. There is sometimes white in black, and
black in white; appreciating some of these subtler speckles and shadings
may open our eyes to new kinds of continuities binding the past to the present.
It may also help us better see how fascism triumphed in the first place.”