Professionalism without Humanism: Pretending to Care

In so many of my blog threads there are responses by my visitors that show that they find that their physicians seem competent but are missing something in their relationship to their patients or seem to have other agendas in their minds by what they say or how they behave. Appearing professional ("acting like a doctor") is one thing but being humanistic ("feeling like a doctor should with concern and caring for the patient as a person")is totally another thing. Medical schools, training students to become doctors, are currently quite aware of the importance of instilling humanism into their students while they describe the duties of a professional. Still, students and others may not understand the relationship between professionalism and humanism. The November 2007 issue of Academic Medicine devotes the issue to humanism and the article by Jordan J. Cohen MD "Linking Professionalsm to Humanism: Why it Matters" helps the reader understand that one is not the other but a doctor just can't be truely professional without being humanistic.

There are many factors which lead doctors to fail to maintain this critical link such as personality development from youth, inadequate education in humanism in medical school or degrading what was learned by poor role models in later training years (the so-called hidden curriculum). In addition, there are the pressures of medical practice, lack of time with patients, need to see more patients to reach some financial goal or standards required by HMOs and the more impersonal technical means now available for diagnosis and treatment.

Hopefully, with more attention being paid at least by those in medical education to the need for doctors to be humanistic as well as professional perhaps the young doctor will be able to go beyond the pressures of medical practice and become the doctor that patients love and not the ones that patients hate. ..Maurice.

500 Threads: Time for Blog Feedback

It appears that the thread on November 21 2007 "Your Medical Prescription: Who Gets to See It?" was the 500th thread I published on this blog since I started the blog almost 3 1/2 years ago. All threads cover different subjects or different aspects of the same general subject and all cover some aspect of the ethics within the practice of medicine, medical education and medical social issues. Virtually all,despite when the thread was published, are still meaningful for visitors and myself to comment upon. So if one thread is not quite what you wanted to read or write about, there are very likely a number of others available here. Pick one from the Archives.

I would like to designate this current posting as a site for general comments and suggestions from my visitors about this blog. I would like postings here that deal with what threads and features of this blog which the visitor felt was helpful and of value and should be continued and what threads or aspects of this blog which were inappropriate, inadequate, could be improved or not repeated along with constructive suggestions. So if you see anything here that you like or dislike or think could be improved, write your comments here.

Thanks to all my visitors who have come and have participated. It is not just my words that I write that make this blog valuable but it is the comments that my visitors write on topics from circumcision to patient modesty amongst many, many others that help to inform and educate all of us--including me! ..Maurice.

Doctors Educating Doctors the Drug Company Way

I didn't know that 25 percent of the physicians in the U.S. have become representatives of the pharmaceutical companies, having given talks to other physicians for money to educate them to prescribe the drug companies favorite drugs. That statistic and a description of one psychiatrist physician's one year experience in this "job" comes from an article in today's New York Times Magazine Section

Read it, learn and think about the benefit (whose benefit?) and harms (whose harms?) of this kind of physician recruiting and use by the drug companies. Also the psychiatrist describes the process of "prescription data-mining", the method by which phamaceutical companies get information about patient prescription writing by physicians, a topic discussed in my last thread on prescription privacy issues.

Do you want your doctor to take a drug company paid side-job to advertise to the doctors? Let me know. ..Maurice. p.s.-I am not one of the 25%.

Your Medical Prescription: Who Gets to See it?

Do you think screening of phone calls of U.S. citizens by the U.S. government as part of the “War on Terror” is the only way you can lose your privacy? How about a doctor’s prescription? It’s not about the “War on Terror” (though see the last two statements in this posting) but many other excuses, some apparently legitimate and others with a profit or other motives.
When a physician writes a prescription for your medical condition, the class of drug prescribed can often indicate the name or nature of your medical condition.
What do you think happens to the prescription that your doctor wrote out after the pharmacy fills it? Does it stay in the pharmacy for the refill? Not at all. Your “Protected Health Information” with the implied medical condition may go out to many other people.

As an example in the United States, the CVS Pharmacy Privacy Policy is reproduced below. You may object to the revelation of your information and it might be accepted by the pharmacy but also your objection may be overruled. Is this privacy? Is this all ethical? Well, you decide. ..Maurice.

The Health Insurance Portability and Accountability Act (“HIPAA”)
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices (the “Notice”) describes the privacy practices of CVS/pharmacy including CVS retail outlets, CVS.com, and CVS ProCare retail outlets.
CVS/pharmacy wants you to know that nothing is more central to our operations than maintaining the privacy of your health information (“Protected Health Information” or “PHI”). PHI is information about you, including basic information that may identify you and relates to your past, present, or future health or condition and the dispensing of pharmaceutical products to you. We take this responsibility very seriously.
Our Pledge Regarding Your Health Information
We are required by federal and applicable state law, regulations, and other authorities to protect the privacy of your health information and to provide you with this Notice. Our pharmacy staff is required to protect the confidentiality of your PHI and will disclose your PHI to a person other than you or your personal representative only when permitted under federal or state law. This protection extends to any PHI that is oral, written, or electronic, such as prescriptions transmitted by facsimile, modem, or other electronic device. This Notice describes how we may use and disclose your PHI. In some circumstances, as described in this Notice, the law permits us to use and disclose your PHI without your express permission. In all other circumstances, we will obtain your written authorization before we use or disclose your PHI.
This Notice also describes your rights and the obligations we have regarding the use and disclosure of your PHI. Under federal and applicable state law, we are required to follow the terms of the Notice currently in effect.
HIPAA’s standards may be pre-empted by certain state laws relating to the privacy of health information. Please see state provisions at the end of this Notice. [Moderator's note: Go to the above link to enter your state for specific state provisions.]

How We May Use and Disclose Your PHI Without Your Permission
TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS. Below are examples of how Federal law permits use or disclosure of your PHI for these purposes without your permission:
1. Treatment: Dispensing medications. PHI obtained by CVS/ pharmacy will be used to dispense prescription medications. We will document information related to the medications dispensed and services provided in your record. Patient Contacts. We may contact you to provide treatment-related services, such as refill reminders, treatment alternatives (e.g., available generic products), and other health related benefits and services that may be of interest to you.
2. Payment: We may contact your insurer, payor, or other agent and share your PHI with that entity to determine whether it will pay for your prescription and the payment amount. We may also contact you about a payment or balance due for prescriptions dispensed to you at CVS/pharmacy.
3. Health care operations: Service. Your PHI may be used to monitor the effectiveness of our services. Transfer. Your PHI may be transferred for purposes of carrying out the pharmacy services if we buy or sell pharmacy locations. Benefits/Research. We may also use your PHI to tell you about opportunities that may be of interest to you, such as benefits for preferred CVS customers or clinical research projects.

OTHER SPECIAL CIRCUMSTANCES:

We are permitted under federal and applicable state law to use or disclose your PHI without your permission only when certain circumstances may arise, as described below.
We are likely to use or disclose your PHI for the following purposes:

Business associates: We provide some services through other companies termed “business associates.” Federal law requires us to enter into business associate contracts to safeguard your PHI as required by CVS and by law.
Individuals involved in your care or payment for care: We may disclose your PHI to a friend, personal representative, or family member involved in your medical care. For example, if we can reasonably infer that you agree, we may provide prescriptions and related information to your caregiver on your behalf.
Disclosures to parents or legal guardians: If you are a minor, we may release your PHI to your parents or legal guardians when we are permitted or required under federal and applicable state law.
Worker’s compensation: We may disclose your PHI to the extent authorized and necessary to comply with laws relating to worker’s compensation or similar programs established by law.
Law enforcement: We may disclose your PHI for law enforcement purposes as required by law or in response to a court order, subpoena, warrant, summons, or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about a death resulting from criminal conduct; about crimes on the premises or against a member of our workforce; and in emergency circumstances, to report a crime, the location, victims, or the identity, description, or location of the perpetrator of a crime.
As required by law: We must disclose your PHI when required to do so by applicable federal or state law.
Judicial and administrative proceedings: If you are involved in a lawsuit or a legal dispute, we may disclose your PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process.
Public health: We may disclose your PHI to federal, state, or local authorities, or other entities charged with preventing or controlling disease, injury, or disability for public health activities. These activities may include the following: disclosures to report reactions to medications or other products to the U.S. Food and Drug Administration or other authorized entity; disclosures to notify individuals of recalls, exposure to a disease, or risk for contracting or spreading a disease or condition.
Health oversight activities: We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections, as necessary for our licensure and for government monitoring of the health care system, government programs, and compliance with federal and applicable state law.
United States Department of Health and Human Services: Under federal law, we are required to disclose your PHI to the U.S. Department of Health and Human Services to determine if we are in compliance with federal laws and regulations regarding the privacy of health information.

Although we may not engage in the following activities, under federal or applicable state law, we are allowed to use or disclose your PHI without your permission for these purposes:

Research: Under certain circumstances, we may use or disclose your PHI for research purposes. However, before disclosing your PHI, the research project must be approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.
Coroners, medical examiners, and funeral directors: We may release your PHI to assist in identifying a deceased person or determine a cause of death.
Administrator or executor: Upon your death, we may disclose your PHI to an administrator, executor, or other individual so authorized under applicable state law.
Organ or tissue procurement organizations: Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Notification: We may use or disclose your PHI to assist in a disaster relief effort so that your family, personal representative, or friends may be notified about your condition, status, and location.
Correctional institution: If you are or become an inmate of a correctional institution, we may disclose to the institution or its agents PHI necessary for your health and the health and safety of others.
To avert a serious threat to health or safety: We may use and disclose your PHI to appropriate authorities when necessary to prevent a serious threat to your health and safety or the health and safety of another person or the public.
Military and veterans: If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authority.
National security and intelligence activities: We may release your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective services for the President and others: We may disclose your PHI to authorized federal officials so that they may provide protection to the President, other authorized persons, or foreign heads of state, or conduct special investigations.

Equipoise and Autism: Fairness of Research Within a Controversy

Equipoise is said to be an essential element in clinical trials--not knowing beforehand which arm of a trial will give the best results. I understand that equipoise is necessary to provide an ethical basis for the use of experimental drugs in a patient subject. I would like to extrapolate equipoise to medical research in general. Should the public be subject to the apparent results of research into clinical conditions where the investigators are or appear to be associated with activist organizations or organizations holding a particular point of view? That is, researchers with an apparent conflict of interest? For example, in this morning's news is a study which suggests that autism is related to wi-fi radiation.

The article is

“Wireless Radiation in the Etiology and
Treatment of Autism: Clinical Observations and Mechanisms"

J. Aust. Coll. Nutr. & Env. Med. Vol. 26 No.2 (August 2007) pages 3-7

By Tamara J Mariea, Internal
Balance Inc, Nashville TN and Safe
Wireless Initiative, Washington, DC
and
George L Carlo, Science and
Public Policy Institute, Safe Wireless
Initiative and The George Washington
University School of Medicine and
Health Sciences, Washington, DC

Except for the George Washington University School of Medicine, all the other associations appear to be directed toward one goal.. one "arm". Although there should be freedom of investigation and freedom of speech, in view of such a public controversial and heated issue such as the cause of autism, shouldn't investigations and their publicity be carried out by researchers who themselves hold an "equal position" as they initiate the research? ..Maurice.

I Love My Doctor and Here is the Reason Why

If you read the threads on this blog such as "I Hate Doctors", "Male Cirecumcision:Should It be a Crime?" or "Naked" , reflecting on what many of the visitors wrote, you would think that doctors are the lowest form of animal life and as disgusting to many as a black bug in the kitchen. Could this be the general consensus of the public about physicians in this age of "medical miracles"?

With this thread, I wanted to give another view to express their stories about their doctors and their positive feelings about them. If you have something good to say about doctors, write it here and tell us why you have this positive view of them. Please don't name any names when you write since I would rather you don't indentify the physicians because there may be some visitor who might misuse your commentary. ..Maurice.

“See One, Do One, Teach One” A Medical Education Mantra and Issues of Patient Safety in Teaching Hospitals

From an article “Resident’s Suggestions for Reducing Errors in Teaching Hospitals” in the February 27, 2003 issue of the New England Journal of Medicine by Volpp and Grande:
"I put in a central line today that was complicated by a pneumothorax. I had never done this procedure before, and I am not sure the resident who was supervising me had much more experience than I do."
"See one, do one, teach one" has been a long-standing mantra of medical education.


Well, if it isn’t one, it may be only 3 or 4 or a few more but the person supervising the intern or resident performing the procedure may often be also a resident in training and not a seasoned attending physician who has done 1000 or more and has experienced all the necessary nuances of performing the procedure and has had the opportunity to develop reliable responses to any complications that may occur. Even if the intern or resident has performed a number of procedures, the issue arises as how to establish that the individual has become competent sufficiently to perform the procedure alone and without supervision as may be necessary.
“See one, do one, teach one” is only one example of the concerns regarding patient safety within teaching hospitals. Others involve “handoffs”, the transfer of the care of a patient from a resident physician going off duty to one who is just coming on. When there are many patients to discuss, some details in this relatively brief communication between the two physicians may be missed and the consequences of such “forgotten” information may be critical. Time available to take a thorough history and perform the physical exam may be limited and the time which is available may include distractions for the resident such as interruptions by “urgent” phone calls or paging. In addition, unsatisfactory system practices, also not uncommon to all hospitals, teaching or not, may lead to medication errors or surgical errors as examples. Long work hours, as set by the system, with resident fatigue has been attributed to errors. And errors can lead to patient deaths as publicized in the Institute of Medicine’s 2000 report “To Err is Human” with estimates of as many as 98,000 deaths occurring annually in U.S. hospitals due directly to medical errors. Though the high figure has been debated by some as too high and not an accurate estimate, nevertheless any death due to medical error is of concern.


Teaching hospitals will inform the patient, in print, on admission that they may be examined and treated by staff that are still in training but is this enough information for informed consent by the patient? Admission to a teaching hospital is often unavoidable and always there is the altruistic value to the patients of a contribution to society by permitting the training of physicians on themselves. How else do you think that physicians should be trained to go out into practice with the needed skills for their care of their own patients if not in teaching hospitals? And if teaching hospitals are necessary, what changes would you suggest to make them and all hospitals safer places to be treated? ..Maurice.

Being Hugged By Your Doctor: Invasion of Privacy vs Sign of Compassion?

According to the article in Fox News "Affectionate students are feeling the squeeze around the country as their displays of affection land them in trouble with school administrators." Even if the intent is to express, though the act of a hug, a social connection with their peers on the school grounds, this behavior may be considered sexual harassment. I find this news story has directed me to consider something some of us doctors do as part of being a humanistic human being beyond simply a doctor of medicine. Some of us actually hug our patients or patients' family members. We hug, not out of sexual excitement or anticipation, but out of a sense of the need to express directly compassion and support at the time of a patient crisis. Is hugging a patient professional? Does it exceed boundaries of professional behavior? Does it invade the patient's privacy? Should doctors first ask the patient "may I hug you?" and wait for permission? When you are upset and in distress and need the attention and compassion of someone who shows that he or she cares about your feeling, should you or would you accept a hug from your doctor even without them asking? ..Maurice.

Acute and End-of-Life Medical Decision Forum: November 17 2007

Here is information regarding a program to be presented at hospitals of the Providence Healthcare System for patients, families and interested healthcare providers in the San Fernando Valley and nearby regarding perplexing decisions needed to be made during acute or end-of-life medical situations.

CLICK ON IMAGES TO ENLARGE THEM TO READ THE TEXT.. Maurice.

Responsibilities of a Radiologist: Acknowledging Interpretation Errors to the Patient?

The doctor-patient relationship and the trust which is expected by the patient has been discussed on this blog and others. But the question can be asked as to where the doctor-patient relationship begins and ends. One example of a professional activity where the relationships might be unclear and perhaps ambiguous is that of the radiologist who inspects and interprets (?diagnoses?) the radiologic results. The patient may have never seen the radiologist and may be even unaware of the radiologist's name or experience. When the radiologist has performed his or her duties by interpreting the film, to whom is the radiologist professionally related? The patient? Or the physician who ordered the X-ray or other exam? And what if later it is found that the radiologist has made a mistake or missed a critical diagnosis..has, for example, made an interpretation which is regarded as a false negative. If, as is currently emphasized in the medical, ethical and legal literature the importance of acknowledging medical error and offering the patient an apology at a minimum, if not also an offer of compensation as indicated, which professional should assume that responsibility? The current treating physician who may or may not have been involved in the previous diagnosis or the radiologist who may have never seen the patient but had read the film?

Here is the scenario that was presented in this month's Virtual Mentor on this subject which was then commented upon by Thomas H. Gallagher, MD, and R. James Brenner, MD in the article entitled "Disclosure and the Retrospectoscope." Please go to the link, read the commentary and then return to express your views of this case and what you think would be the right and ethical approach toward resolution. ..Maurice.


Mrs. Lee is a busy, working mother. She has raised three children, all of whom are successful attorneys, and was looking forward to retirement when she was diagnosed with breast cancer in her left breast. Her tests following surgery showed no cancer, and six months later Mrs. Lee went to a breast imaging center for a follow-up visit.

Dr. Harris reviewed old imaging studies in preparation for her meeting with Mrs. Lee. She looked at the mammogram that had been interpreted as normal by another radiologist, 18 months before Mrs. Lee was diagnosed with breast cancer. After careful examination, Dr. Harris noted a small, ill-defined density in the left breast. It was in the location where the cancer was diagnosed on the subsequent mammogram and, in retrospect, it most likely represented the cancer in an earlier stage. In her own mind, Dr. Harris believed that many radiologists, possibly even she herself, would have interpreted the mammogram as normal. She wondered whether to tell Mrs. Lee what she had seen.