Use vs Abuse of Hysterectomy: Section 2

In Section 2 of this subject we will continue with the discussion of the role of the hysterectomy in the practice of medicine and whether it is a necessary or unnecessary procedure and whether their is limited or biased information being presented to patients as part of the patient consent process. For those of you who are new to this blog thread, you may want to go to the original thread "Use vs Abuse of Hysterectomy: Hysteria vs Realism". DO NOT WRITE FURTHER COMMENTS ON THAT ORIGINAL THREAD. WRITE YOUR COMMENTS HERE. ..Maurice.


ADDENDUM 3-11-2009: I think the following Essay is of value for patients to take into consideration factors that lead to an unprofessional doctor and subsequent patient anger and what doctors ought to consider.

TEXAS MEDICAL BOARD BULLETIN
The newsletter of the Texas State Board of Medical Examiners
Fall 2004 Volume 2, No.1

On the Sagging of Medical Professionalism
by Herbert L. Fred, MD, MACP

For the past two decades, medicine has been a profession in retreat,plagued by bureaucracy,by loss of autonomy,by diminished prestige,and by deep personal dissatisfaction.' These ills would be bad enough by themselves.But another malady confronts us-the sagging of our professionalism.

Medical professionalism defies precise definition. Fundamentally, however, it boils down to service in the patient's best interest. Among its central elements are (1) commitment to excellence; (2) altruism, with service before self-interest; (3) avoidance of harm; (4)trustworthiness; (5) pursuit of truth based on scientific and humanistic criteria; (6) close cooperation with others in the health care field; and (7) humility.2

In this essay, I address our sagging professionalism and offer my thoughts on its clinical manifestations, consequences, causes, and cures.

Clinical Manifestations and Consequences

To me, the most common, and yet most subtle expression of betrayed professionalism is
serving ourselves before serving our patients. By doing so, we sacrifice the very core of doctoring humanism. And as a result, the patient-physician bond becomes weakened-or never even forms. Additional manifestations include abuse of power, arrogance, lack of conscientiousness, and conflicts of interest.3
Certain other types of behavior deserve special attention because they are sometimes
interpretable as being dishonest.4 Failure to take charge is a common example. In such cases, the attending physician shirks his or her responsibility, deferring to an army of consultants, each managing a part of the body with no one managing the whole. This buck-passing5 frequently leads to a host of ill-advised activities-more consultations,inappropriate testing, undocumented diagnoses, over-prescribing of medications, uncalled-for procedures, needlessly prolonged hospitalizations, and unnecessary office visits.The consultants in these cases commonly shirk their responsibility as well. Although ideally positioned to halt this medical merry-go-round, they ride it instead. Moreover,those with a "gimmick" use it, even when they know it isn't indicated. And let us not forget the fraudulent reimbursement claims to Medicaid and Medicare or those physicians who, attracted by remuneration and perhaps by a desire for public recognition, serve as expert witnesses even though they clearly are not qualified for the role.
Finally, most physicians simply remain silent when they know or suspect a colleague to be emotionally disturbed, a substance abuser, or just plain incompetent. This reluctance to get involved is particularly deplorable when they know or suspect that an associate is cheating or lying.

Causes

Clearly, numerous factors contribute to our sagging professionalism. Heading the list in my opinion is a change in society's overall priorities and values. Old-fashioned hard work, devotion to duty, and pursuit of excellence have taken a back seat to an emphasis on limited work hours and quests for financial and other types of personal gains. As a result, people at all levels-including many physicians-are satisfied with mediocrity. In fact, mediocrity has become the standard. Given this environment, no wonder our professionalism sags.
External forces largely beyond our control also playa role. Examples are the myriad
constraints imposed by insurance companies, the incessant pressures resulting from
federally mandated regulations, the glut of "for-profit-not-for-patient" hospital administrators,the lawsuits lurking around every corner, and the reams of paperwork
required. Attending to these various demands cuts deeply into the time we could
otherwise spend attending to our patients. And complicating the picture are human
frailties; especially ignorance, greed, fear of being wrong, and the need for
aggrandizement.

Cures

Can we remedy our sagging professionalism? Only-Insofar as we are wiflfrigto be role
models of integrity and honesty for each other. Only if we show commitment,
compassion, competence, candor, and common sense. Only if we understand and
believe that medicine is a calling, not a business. Only if we strive diligently to restore,preserve, and promote the human element in medicine. Only if we look at, listen to, and talk with our patients, working as hard and as long as it takes to ensure their welfare. Only if we always put our patients first.

Final Thought

I leave the reader with a quotation from Bela Schick (1877-1967), renowned
Hungarian pediatrician and bacteriologist: First, the patient, second the patient, third the patient, fourth the patient, fifth the patient,
and then maybe comes science. We first do everything for the patient 6

Not only do his words capture the essence of this essay, but they serve to remind us
of the ruling principle of our profession.

References
1) luger, A. Dissatisfaction with medical practice. New Engl J Med 2004; 350:69-75.
2) Bryan CS, Brett AS, Saunders DE Jr, Khushf G, Fulton, GB. Professionalism. In:
Medical Ethics and Professionalism: A Synopsis for Students and Residents. Center for
Bioethics and Medical Humanities. University of South Carolina; 2004: 13.
3) ibid, p. 14.
4) Fred HL, Robie P. Dishonesty in medicine. South MedJ 1984; 77:1221-22.
5) Fred, HL. Passing the buck. South MedJ 1982; 75:1164-65.
6) Strauss MB. Familiar Medical Quotations. Boston, Mass: Little, Brown and
Company; 1968:374.

Dr. Fred is a Professor, Department of Internal Medicine The University of Texas Health Science Center at Houston. He received the American College of Physicians
Distinguished Teacher Award for 2004. The Board thanks Dr. Fred for providing this essay.

Graphic: My ArtRage creation of a hysterectomy forcep as the focus of the current discussion question.

Homelessness and Medical Care: Can Professional Attitudes be Changed?

Homelessness, if not “living”, attempting to survive without a home has not been an uncommon state throughout human history. As noted in an article on homelessness in Wikipedia there is an estimation of 100 million people, worldwide, being homeless. They “lack housing, because they cannot afford, or are otherwise unable to maintain, regular, safe, and adequate shelter.”

There will certainly be more individuals and families who will become homeless associated with the current recession throughout most of the world including the United States. The problems, including social, legal, political and medical associated with the condition of homelessness are enormous. How should society look on these people and react to their plight and their behaviors? Are additional descriptive names such as “vagrant, tramp, hobo (U.S.), transient, bum (U.S.), bagman/bagwoman, baghuman, street walker, urban outdoorsmen, or the wandering poor” fairly describe and treat the homeless? What part of society, if any, should feel responsible for what has happened to them and take responsibility to attend to them and help to restore them? Should the legal system look at the homeless as outliers of the public who must be forced to conform to accepted social standards or otherwise removed from public view one way or another? How do politicians look upon the homeless? Do they consider them as much a constituent as those who can live their lives and their days away from the streets or away from living under some transient roof? And what about the medical system and how healthcare providers look at the homeless problem, the homeless themselves and what role healthcare plays and should play in the lives of those without homes? What attitudes should healthcare providers including physicians hold toward the homeless patients?

Those visitors to my blog who frequently scan my threads here may recognize that I have used the American Medical Association’s Virtual Mentor website as a resource to develop medical ethics topics.

I have used that resource again, this time, the January 2009 issue, for the topic regarding medical care for the homeless. There are a number of articles there dealing with the subject and which can be obtained free in a PDF format by clicking on this link.
.
Homeless patients entering the medical system provide a challenge to all who serve them. Many arrive in later stages of untreated diseases or diseases for which they were previously diagnosed but because of various reasons have not followed the therapeutic prescriptions and repeatedly return still ill or worse. Many, because of their illicit drug habituation, complicate their conditions. These homeless patients through their appearance, their demands, their non-compliance, their behavior and other factors may be looked upon as “difficult patients” by the physicians who attend them. But it is not unlikely that these patients seem “difficult” also because the physicians simply have not been trained to understand and therapeutically relate to those deemed “homeless”. This negative attitude of physicians in practice toward the homeless is suggested to be a reflection of the lack of constructive educational experience with the homeless during their early years of medical training. As a participant in the teaching of medical students, I recognize that this expectation is probably correct. Constructive and humanitarian educational experience represents the key words regarding what the students need.

An example of such an educational experience is described in the Virtual Mentor education article "Medical Student Self-Efficacy and Attitudes toward Homeless Patients" by David S. Buck, MD, MPH, and Benjamin T. King can be accessed through the above PDF link. The authors conclude: “As educators, we must change the way physicians and other health care professionals are taught. We must design substantial and effective ways of transmitting professional, empathic, and culturally sensitive attitudes that will improve relationships with estranged patient populations. We must remove the barriers to care that negative perceptions create and promote active advocacy. Students need more exposure to the economic, behavioral, social, and environmental determinants of health. Research has shown that these dynamics are best learned through an experienced-based curriculum within a positive, supportive, and rewarding environment and that these can eventually outweigh the negative experiences so common in the current system. Making students better able to serve the “difficult” patient will make them better physicians.”

What do you think about the homeless in the medical care system and how they are cared for? What do you think about negative physician attitudes about the homeless? What are your suggestions regarding solutions for this general social but also personal problem that afflicts many? ..Maurice.

Graphic: Photograph from Wikipedia taken by Eric Pouhier and digitally modified by me using Picasa 3.

Physician-Assisted Suicide: Which State is Next?

With the vote approval of the residents of Washington state last November and to take effect March 4, 2009, physician-assisted suicide (“physician-assisted death”,”physician aid in dying”,”death with dignity”,take your pick) is now permitted (and supported by the Supreme Court) in two states. Oregon was the first in 1997 and has been well documented. Read the documentation in the full free article “Physician-Assisted Death — From Oregon to Washington State” by Robert Steinbrook, M.D. in the December 11, 2008 issue of the New England Journal of Medicine.

“The act permits terminally ill state residents, defined as adults with an illness expected to lead to death within 6 months, to request and receive a prescription for a lethal dose of a medication that they may self-administer in order to end their life.”

There is controversy regarding these acts both on the part of the general public but also amongst physicians. The professional question is whether it is the duty of physicians to facilitate the death of those patients who desire to die. An interesting social question would be whether it is simply a matter of state’s best interest to permit and allow the facilitation of such autonomous death decisions by terminally ill patients and in this way perhaps to conserve scarce resources that could be used on other patients or citizens in general. On the other hand, one might ask if the primary motivation for the state would be to look to the best interest of the terminal patient irrespective of the shepherding of these resources. And would everyone agree that it is in the patients’ best interest to have the option to allow death to come sooner? There are arguments that adequate diagnosis and treatment for depression may be ignored or that none or inadequate attempts at palliative care is being rendered for these patients.

If physician-assisted suicide with the limitations and controls already set by the states of Oregon and Washington were considered in your state or country, would you vote or agree to approve it?

For more on this topic, here are the links to the previous threads on this blog:

Summary of Oregon’s Death with Dignity Act - 2007


Should Physicians Provide Information so Patients can Hasten Dying?


Should The Mentally Ill Deserve Assisted Suicide?


“A Wasted Illness” And The Request To Jump From The Train with the poem by Thomas Hardy

Thomas Hardy - A Wasted Illness

Through vaults of pain,
Enribbed and wrought with groins of ghastliness,
I passed, and garish spectres moved my brain
To dire distress.

And hammerings,
And quakes, and shoots, and stifling hotness, blent
With webby waxing things and waning things
As on I went.

"Where lies the end
To this foul way?" I asked with weakening breath.
Thereon ahead I saw a door extend -
The door to death.

It loomed more clear:
"At last!" I cried. "The all-delivering door!"
And then, I knew not how, it grew less near
Than theretofore.

And back slid I
Along the galleries by which I came,
And tediously the day returned, and sky,
And life--the same.

And all was well:
Old circumstance resumed its former show,
And on my head the dews of comfort fell
As ere my woe.

I roam anew,
Scarce conscious of my late distress . . . And yet
Those backward steps through pain I cannot view
Without regret.

For that dire train
Of waxing shapes and waning, passed before,
And those grim aisles, must be traversed again
To reach that door.
..Maurice.

The Health of an "Important Person": Should It be Revealed?

Yes, we all know about HIPAA regulations with regard to the restriction of patient medical information but how far does any limitations of public dissemination go with regard to the health of an "important" person. Read this brief article in today's New York Times regarding this very issue as it applies to Apple's Steve Jobs. What defines an "important person" (any business man who runs a public shares company? A well-known movie or sports star? A candidate for a public office or one who is already in public office? A scientist who is on the verge of discovery? A physician in active medical/surgical practice? An airline pilot? .. and so on), Who sets the limits of personal medical information which must be disclosed? Is there a Consitutional basis for this relaxation of personal privacy? Is there any ethical argument against it? ..Maurice.

Communication in Medicine: Looking With the Eyes of the Receiver

Clarity in communication: that is what it is all about particularly when communication is involved within the critical specialties such as the air controller, the police and other emergency services and so many other interactions between someone who has important information and someone who should know but also understand as fully as possible that information as presented. The other examples include that of the medical profession.

As one example, I teach medical students how to take a history and perform a physical exam and how to write it up, I repeatedly find that students tend to write but really not read what they have written. This lapse leads to the possibility of the medical bloopers which are exampled on a previous thread. For the uniformed reader of a medical record written by someone who hasn’t read their own writing, confusion and possible error can abound. I emphasize to the students the need to read what they wrote but with the eyes of that uninformed reader. Does what is written tell the whole story or are parts so abbreviated that significant parts known to the student are missing? Does the written description of symptoms or their relationships or treatments, in the patient’s own words make sense? If the student doesn’t understand what the patient means, it may well be that the uniformed reader of the medical record will also fail to understand. Unfortunately, as the student’s career continues, the time available for re-reading and review of what is written will become limited yet the importance will not be diminished.

Another profession where clarity in communication is very important but has been found to be faulty and should be improved is that of healthcare journalism. Susan Dentzer, who is editor-in-chief of Health Affairs, Bethesda Maryland and an on-air analyst on health policy for the NewsHour with Jim Lehrer on the Public Broadcasting Service, has written an article “Communicating Medical News — Pitfalls of Health Care Journalism” in the January 1st 2009 issue of the New England Journal of Medicine which is available to read free at this link.

Susan gives examples of incomplete, inaccurate and misleading communication to the public by some reporters of medical “news”. The consequences can be that some members of the public may make unhealthy and unwarranted personal medical decisions based on their understanding of what they were informed. Particularly important is that the reporters become educated in some of the technical details of the stories they write, take broader and more complete views of what they are reporting and finally consider with the eyes of the public what they are writing or talking about. Susan writes “Journalists could start by imposing on their work a ‘prudent reader or viewer test’: On the basis of my news account, what would a prudent person do or assume about a given medical intervention, and did I therefore succeed in delivering the best public health message possible?”

It is my opinion that failure to deliver an accurate, balanced and realistic message as either physicians or journalists do their jobs only adds to confusion and misinterpretation by those who are expected to receive it. And such consequences can easily be detrimental to effective healthcare. My advice to doctors or journalists: communicate with care. ..Maurice.
ADDENDUM:
Graphic: A photograph of a garlic which I took. The text is mine..to make a point on what you might get in a medical news film clip on TV. But there is some truth in what I wrote though you wouldn't know it without getting ALL the facts. You have that chance to learn the facts by going to this link to the American Academy of Family Physicians website.

Patient Modesty: Volume 8

From Fisheaters.com, a Catholic website:



"Ecclesiasticus (Sirach) 19:26-27: "A man is known by his look, and a wise man, when thou meetest him, is known by his countenance. The attire of the body, and the laughter of the teeth, and the gait of the man, shew what he is."

I Timothy 2:9-10: "In like manner women also in decent apparel: adorning themselves with modesty and sobriety, not with plaited hair, or gold, or pearls, or costly attire, But as it becometh women professing godliness, with good works."

Read the link. I thought that the picture, the biblical notations and the religious narrative at the Fisheaters website seems to be suggestive, in my opinion, of the view currently being discussed on these Patient Modesty threads: that physical, bodily modesty is considered less an issue for men than for women. I would be most interested to know how my visitors fit religious doctrines (not just Catholic but perhaps Muslim and others) into this discussion of patient modesty and differences in what is generally considered or practiced between genders. ..Maurice.

NOTICE:

AS OF FEBRUARY 7 2009 THIS THREAD WILL BE CLOSED FOR ALL COMMENTS. DO NOT ATTEMPT TO WRITE ANY FURTHER COMMENTS HERE. PLEASE GO TO "PATIENT MODESTY: VOLUME 9" TO CONTINUE COMMENTS. ..Maurice.

What to Do About “Frequent Flyers” in Medical Practice

The topic of this thread is the ethics involved in the attention and care by healthcare providers of patients who make repeated visits to the physician’s office or to the emergency room which on clinical evaluation could be considered excessive, unnecessary and perhaps in some cases part of a malignant habit or simply out of loneliness. The patient population this thread is concerned about are called “frequent-visit patients” though perhaps a less sympathetic way but the way some professionals seem to be calling them, in an airline lingo, “frequent flyers”.

I want you to read two articles which dissects in rather great detail who these patients are, what appears to be their motivation or diagnosis and how best in our current medical system to manage their propensity for these repeated visits.

The first is a blog article (December 13 2007) by a hospitalist who classifies the particular such “flyers” in his experience into categories of motivation or condition: pain, mental illness, drug abuse, social issues, nursing home patients, dialysis patients, “low functioning” patients, single organ end-stage disease and finally the patients with chronic multi-organ failure.

The second article is from the American Academy of Family Physicians website May 2003 titled “Caring for Frequent-Visit Patients” by a semi-retired family physician. He takes a somewhat different categorization of these patients into: patients with rational questions, misinformed patients, patients who are ashamed or embarrassed, patients with mental disorders, drug seekers, lonely dependent patients, the “worried well” and finally patients who “don’t want to get well”.

My opinion after reading these articles is that those patients who have chronic or end-stage diseases which specifically do require frequent visits for monitoring and support, even though they may represent a burden to the physician in terms of the care of more acute illness patients, they should be in a separate category with regard to the ethics of their care. I cannot find any reason to debate whether they disserve the attention and care they need or whether such care is justified. They need the care and providing the care is ethical. However, some may argue that treating some end-stage diseases represents unethical use of scarce resources.

It is the other classes of frequent visitors, some might argue whether the physician should take the time and attention to attempt to satisfy the needs of those patients yet at the same time be responsible for the care of others who need active medical attention. If the condition of these patients is one of some mental, emotional or social need or some habit that motivates them to request frequent attention and treatment, how often and how much should a physician “give in” to their requests? Should there be triage of these patients amongst all the other patients with regard to attention and care, considering keeping the system ethically just with the need to provide the time for care and to conserve available resources for those who require them for more acute or “bodily” needs rather than mental or behavioral demands? If doctors and nurses disregard these “frequent flyers” what should and will happen to them? And is this attitude what the profession of medicine is all about? Finally, should those patients who make the frequent visits to doctor's offices or emergency rooms bear any ethical responsibility for any harms to others this may produce in our current medical system? Any thoughts? ..Maurice.