Yes, The House of Medicine is Haunted! Boo!

Haunting ahead.. just follow me:

It is still Halloween 2009 in the United States and still time to retell a scary story of, well, ghost writers. Yes, ghost writers. Oh! They don’t write ghost stories. Doctors are grabbed, yes grabbed in their busy offices and convinced that for a bit of money slipped to them from a pharmaceutical company they can write a journal article to educate other doctors and the public about their own experiences with a drug the pharmaceutical company would love to promote and promote.

Ah! That’s where the ghost writers come in. Without any scientific studies but with some flourishing words, they take the bits of experience from these doctors and come up with a beautiful article which could be published and, in fact, have been published. It’s all so simple and a little money paid out by the pharmaceutical company gets an article.. oh, not titled with the name of the ghost writer.. but the name of the grabbed doctor..it makes it oh so much more official and well, professinal. But remember, it is all part of a haunting ghostly experience and one that can raise a few more million bucks for the drug company. You know, I changed my mind: Maybe what they write are truly “ghost stories”.

Want to read more? Read the article by ethicist-physician Howard Brody in his “Hooked: Ethics, Medicine and Pharma” blog August 24, 2009 titled “Friendly Ghosts--Why Should Academic Docs Get All the Credit?”





Boo! ..Maurice.

Graphics: Photographs of student Halloween projects located at the Lombardi Farm Halloween Pumpkin Festival, Santa Clarita, California by me today..Halloween 2009.

What is a "Good Death"?

What is a “good death”?


That is a question that every living person must eventually contemplate. Is a quick death, a sudden demise by a heart attack, some accident or by violence or intent, such as a self-inflicted gun shot to the head really a good death? Or is death which is delayed long enough to allow one to have the life issues settled and to see and relate to family for the last time good? Or is a death which comes on painless and without the burden of discomfort and anxiety also a good death? Each person may have a different view. Certainly, physicians should have the goal to understand and attempt to provide a good death for their patients when it comes. It is their professional obligation to the patient. But is a “good death” something that the doctor can define or must it come from the patient’s own lips? Often, physicians are unaware of how their patient might set the definition.


Tony Back, MD writing in the Ethics of Medicine End-of-Life Issues of the University of Washington School of Medicine sets some guidance for medical students and physicians. Amongst other advice he suggests:


In caring for a person who is dying, knowing what would make the experience of dying "good" is an important goal for physicians and other members of the care team. I find it doesn't take fancy techniques-you just need to be sincere and patient and interested. Listen more and talk less. Try asking something like, "Knowing that all of us have to think about dying at some point, what would be a good death for you?" What people choose when they think about a good death for themselves is often beyond what medicine can provide-for instance, an affirmation of love, a completion of important work, or a last visit with an important person. As a physician, I can't always make those things happen. But I can help the dying person get ready-and in this way, contribute to a death that is decent.

What is your view of what would constitute a good death for you?

I would like to end this introduction with another way of looking at a “good death” but looking at death after one dies. It comes in the form of the lyrics of a song written by Lee Hays of the Weavers, famously sung by Pete Singer and immortalized by a film by that name. ..Maurice.


Dead Earnest

If I should die before I wake
All my bone and sinew take
Put them in the compost pile
To decompose a little while

Sun, rain and worms will have their way
Reducing me to common clay
All that I am will feed the trees
And little fishes in the seas

When corn and radishes you munch
You may be having me for lunch
Then excrete me with a grin
Chortling, There goes Lee again

'Twill be my happiest destiny
To die and live eternally

Lee Hays, 1981

Disappearing Diseases: When Benefit Leads to a Dilemma

An interesting dilemma is raised in a Perspective article in the October 22, 2009 issue of the New England Journal of Medicine. The article titled “When Diseases Disappear-The Case of Familial Dyautonomia” by Barron H. Lerner M.D.,Ph.D.


Dr. Lerner writes “The success of genetic-screening programs raises an intriguing possibility: some dread diseases of the 20th century may soon become history. A representative example is familial dysautonomia, a severe neurologic condition, the incidence of which has decreased precipitously since population screening began in 2001. By giving prospective parents the option of terminating affected pregnancies, screening is doing exactly as was intended, but the disappearance of diseases such as familial dysautonomia should also give us pause. On a practical level, will interest and funding shift away from these conditions, leaving affected adults without advocates or the possibility of scientific breakthroughs? And philosophically, is the disappearance of a disease always an unmitigated good? What does it say about — and to — people currently living with a severe genetic disease when prospective parents would rather abort than bear a child with the same condition?”


Well, what are your answers to Dr. Lerner’s pertinent questions? ..Maurice

Patient Modesty: Volume 26

The issue of patient modesty and healthcare provider gender selection and provision is as most of my followers of this topic know a multifaceted complex issue. We can't learn enough about the topic simply by reading the comments of those patients who have found the issue affecting them personally and medically burdensome. We needed to have input from other views but, unfortunately, such visitors with other views are rare here. Nevertheless, we have to able to have a naturist, CSM, in past Volumes and who has returned briefly in Volume 25. We have had a male nude art model, Edo, who is back and with us. And now, we have a female physician urologist, Lisa who is providing us with the insight of the issue in a specialty in which the issue is particularly pertinent.

With this introduction, let's go on with the discussion.. ..Maurice.

Graphic: Physician Performing a Cystoscopy. The original image from the United States National Institutes of Health, modified by me with Picasa3.

AS OF TODAY NOVEMBER 11, 2009 "PATIENT MODESTY: VOLUME 26" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 27.

One Embryo at a Time: A Suggestion or a Law?

From the Opinion section (Room for Debate-A Running Commentary of the News) of the New York Times for October 11, 2009:

Ever since in vitro fertilization became an option, there has been widespread concern about the multiple births that result from implantation of multiple embryos. Yet most doctors and patients are comfortable with implanting two or three embryos, despite the costs involved and the far higher risk of prematurity associated with twins.
Should the United States move beyond recommended guidelines for fertility treatments to impose stricter regulations on I.V.F. procedures? Should transfers be limited to one embryo at a time?

• Mark I. Evans, Fetal Medicine Foundation of America
• Robert Stillman, reproductive endocrinologist
• James A. Grifo, professor of obstetrics and gynecology
• Arthur Caplan, bioethicist, University of Pennsylvania
• Helen Richens, the Human Fertilization and Embryology Authority
• Rebecca Dresser, law professor, Washington University
• Josephine Johnstone, Hastings Center
• Zev Rosenwaks, professor of obstetrics, gynecology and reproductive medicine
• Joanne Stone, professor of reproductive science

Read the opinions of these professionals and then come back and voice your opinion. ..Maurice.

Graphic: Collage by me using Picasa 3 from a photograph on Wikipedia of an estimated 8 week old spontaneously aborted fetus.

Patient Modesty: Volume 25

To many of those posting on these Patient Modesty volumes, there appears to be something "broken" in the United States medical care system that is not really being discussed in all the current public commentary about healthcare reform issues. The broken part is what should have been an attention, concern and resolution of patient physical modesty but where, according to the posters, there is generally none or if present it is very limited. We will continue with discussion of approaches to fix this broken part. ..Maurice.

Graphic: Photograph by me of a broken pot composition.

NOTICE: AS OF TODAY OCTOBER 24, 2009 "PATIENT MODESTY: VOLUME 25" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 26

Learning More about Bioethics

Are you interesting in knowing more about bioethics? Here is a resource.

The following is a copy of a page on my inactive since July 2004 "Bioethics Discussion Pages" which was prepared by an ethicist for a university web-based Masters program in bioethics. I posted it, with the ethicist's permission, on my "Pages" in 2002 and I think the material is still of value almost 7 years later. Hopefully all the links, addresses and phone numbers are still currently accurate and active. If not, please let me know at DoktorMo@aol.com ..Maurice.

Bioethics: History & Resources
Mark G. Kuczewski, PhD.
Neiswanger Institute for Bioethics & Health Policy
Loyola University Chicago Stritch School of Medicine.

[Moderator's Note: This lecture is one in a series that is used in their Web-based MA in Bioethics and Health Policy Program. The contents below has not been edited for presentation here. See http://bioethics.lumc.edu for further details of the Program]

Objectives:

At the end of this session, participants should be able to:

1. identify several of the historical roots of contemporary bioethics
2. identify major resources for procuring information on pertinent ethical questions including major reference works, professional societies, and leading journals
3. apply these resources to a practice task and analyze how the resources can assist in meeting your personal educational objectives.

The lecture will help you to reach these objectives by identifying:

1. Key terms and their definitions including medical ethics, bioethics, and medical humanities
2. The difference between contemporary bioethics and traditional bioethics
3. Some major events that could qualify as the birthplace of contemporary bioethics
4. Journals, bibliographic resources, Web sites, and professional societies that can assist in study and research of contemporary bioethical issues.

Following the online lecture, two questions are provided (a "Quiz") that will serve as practice to gain facility in the use of these multifarious resources.


Readings: Albert R. Jonsen, "The Birth of Bioethics: The Origins of A Demi-Discipline," Medical Humanities Review, 2(1): 9-21, 1997.

Suggested Further Reading:

Albert R. Jonsen, The Birth of Bioethics, New York: Oxford University Press, 1998. ISBN: 0195103254

"The Birth of Bioethics," Special Supplement, Hastings Center Report, 23(6), 1993, Includes articles by Albert R. Jonsen, Shana Alexander, Judith P. Swazey, Warren T. Reich, Robert M. Veatch, Daniel Callahan, Tom L. Beauchamp, Stanley Hauerwas, K. Danner Clouser, David J. Rothman, Daniel M. Fox, Stanley J. Reiser, and Arthur L. Caplan.
Lecture
Terminology: Medical Ethics, Bioethics, Medical Humanities

Medical Ethics -- ethics of the physician-patient relationship, provider-patient relationship, includes all general duties a provider has to a patient, e.g., duty help the patient and avoid harming him or her, as well as specific rules of conduct, e.g., duties of confidentiality


Bioethics -- literally "life ethics." It is usually used in a way that includes medical ethics as a subset. (For this reason, you also see the term "biomedical ethics.") As the more general category, bioethics seems to include additional issues that are not necessarily a part of medical ethics, e.g., research ethics, ethical issues related to new scientific techniques such as cloning, and environmental policy. In general usage, persons may sometimes try to contrast bioethics with medical ethics by seeing the former as a more general and philosophical approach to the same issues that the latter considers from a strictly clinical case-oriented approach. For instance, we can talk about ethical issues related to abortion from a general philosophical approach, e.g., what kind of society do we become if abortion is a frequently used method of birth control? Or a clinical perspective, e.g., What right does the doctor have to impose treatment on a dying woman in order to try to bring a fetus to viability?


For our purposes, we will see bioethics as a general category of which medical ethics is a subset. When talking about issues in medical ethics, we will often use the terms interchangeably.
Medical Humanities -- A term that was initially coined to cover philosophical, literary, and humanistic approaches to problems in medicine. As such, medical humanities was thought to include bioethics since ethics is an area of study in philosophy and philosophy is in the humanities. However, the usage of the term medical humanities has become more specialized. Now it mainly refers to the use of literature, poetry, and film to increase appreciation for the humanistic, interpersonal, or empathetic aspects of medicine.
(II) When and where was bioethics "born"?

Candidates:

* 1962 Life magazine article by Shana Alexander on Seattle Artificial Kidney Program.
* 1973 Roe v. Wade- seldom cited as bioethics' birth
* 1973 Fetal Tissue debate
* 1974 The Tuskegee Syphilis Study exposed
* 1975 The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research.
* 1976 Quinlan Case

Clearly, questions of how physicians should conduct themselves toward patients were considered as early as the time of Hippocrates, several centuries before the birth of Christ. Similarly, questions of life and death, including reproductive choices such as infanticide and abortion, have been with the human race for several thousand years. Philosophers and theologians have even given systematic treatment to them in various eras, especially the Medieval period. Therefore, if we are talking about the "Birth of Bioethics" as being somewhere between 1962 and 1976, we are presupposing that contemporary bioethics is different from medical ethics as it evolved throughout the ages. What's the case for this?


Ethicist Al Jonsen's answer is that prior ages thought about medical ethics in a very traditional way, e.g., as (1) part of ethics or the (2) standard practices of the culture/craft of medicine. As a result, medical ethics was a specialized discipline that was the concern of academic philosophers and theologians or physicians. It was not necessarily a part of public discourse, a concern of the populace at large.


Jonsen terms contemporary bioethics a "demi-discipline," a half-discipline. It works within a larger picture that is public discourse or public policy.


The demi-discipline: gathers a variety of types of persons who collect a plethora of facts, who listen to advisors and to each other, and move the debate toward closure (recommendations).


The public discourse: uses the reports and publications of those in the demi-discipline as part of the discussion that takes place in a variety of venues including law courts, legislative systems, professional societies and their committees, health-care institutions, and the media.


You can see that if contemporary bioethics is conceived as an interaction between people who make a kind of interdisciplinary study of certain issues and a process of public discourse about these issues, that bioethics genuinely was born in the second half of the twentieth century. The possible places of birth include several good candidates.


The attention the Seattle Artificial Kidney Program received certainly demonstrated that controversies involving life-saving medical technologies could command widespread public attention. However, the response to the problem of rationing such technologies based upon unwarranted social judgments was for Congress to simply allocate funds for everyone to receive this technology. No specialized groups were convened to study the problem or to contribute to the public deliberation. The demi-discipline had not yet emerged.


By the time of the famous Supreme Court decision in the case of Roe v. Wade, many academics were writing scholarly studies that were meant to contribute to the public discourse on the controversial issues such as abortion and the Supreme Court was able to draw upon several of these sources in its reasoning about this case (see especially Daniel Callahan, Abortion: Law, Choice, and Morality, New York: Macmillan, 1970.). However, few bioethicists are willing to claim the field's lineage in this controversial issue. Bioethics has often made advances by seeking issues on which people will compromise rather than to focus on such an intractable problem.


As a result, Jonsen is certainly correct in that the public debates and scandals that led up the work of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research probably are the strongest candidates for the birth of the field. In these instances, we have a public debate about controversial issues (e.g., the use of not yet dead fetuses and/or fetal tissue in experimentation) and public scandals (i.e., the Tuskegee Syphilis Study) and a call for "experts" to come together to make public policy recommendations. The way in which they proceeded has become legendary in the field and exemplifies bioethics as a demi-discipline that contributes to the public discourse. The principles the Commission enunciated in the Belmont Report and the guidelines they set forth in their succeeding reports still guide biomedical research in the U.S. And, of course, this is a beginning to which bioethicists are willing to lay claim.
(III) Resources

Bioethics is an interdisciplinary pursuit that embraces contributions from medicine, philosophy, law and other fields such as the social sciences. As a result, relevant materials are often found in the medical literature, law reviews, and some philosophical journals.
Journals: General Bioethics Journals

* Hastings Center Report -- probably the most widely read of the bioethics journals; not especially clinically oriented.
* American Journal of Bioethics (visit www.bioethics.net) - AJOB is a new and hot journal. It’s format is unique in that it typically has 2 target articles which are each followed by about 15 commentaries.
* Journal of Clinical Ethics
* Kennedy Institute of Ethics Journal
* Journal of Medicine and Philosophy
* Bioethics (Based in Australia)
* Theoretical Medicine and Bioethics (Based in the Netherlands)

Bioethics Journals for Ethics Committee Members:

* Cambridge Quarterly of Healthcare Ethics -- excellent journal but can be rather theoretical in tone.
* HEC Forum -- probably the most successful at being pitched to such an audience.

Bioethics Journals with a Legal Emphasis: (Both of the following journals are available with membership in the American Society of Law, Medicine, and Ethics (ASLME))

* Journal of Law, Medicine, & Ethics
* American Journal of Law and Medicine

Medical Journals that Frequently Feature Articles on Bioethical Issues:

* Journal of the American Medical Association (JAMA)
* New England Journal of Medicine (NEJM)
* Annals of Internal Medicine
* Archives of Internal Medicine

[Note: The American Medical Association (AMA) maintains a web-site that will allow you to search JAMA and the Archives of Internal Medicine by keyword.]

Bibliographic Resources: Internet-Based Bibliographic Sources:

* www.bioethics.net - This website is maintained by the AJOB and the University of Pennsylvania. It’s the best source of daily news related to issues in medicine, science and bioethics.

* Bioethicsline -- This is a database developed at the Kennedy Institute of Ethics, Georgetown University. Bioethicsline is part of the National Library of Medicine's MEDLARS system and online access requires that your library subscribe to this database. However, free bibliographic searches are available. One can order a printout of a search by phoning 1-800-MED-ETHX.
* NYU Literature and Medicine Database: This is especially useful to those interested in the medical humanities. A hard copy version of the database is available by sending a check or money order for $35 (U.S., $4.00 postage and handling; Foreign, $9.00) to: New York University Medical Center, Dept. of Physiology, 550 First Ave., New York, NY 10016, Attention: Dr. Felice Aull

Printed Bibliographic Materials:

* Bioethics Literature Review -- This publication reviews numerous bioethics articles from the bioethics literature and medical journals. It is published monthly. The cost is $49.00 a year and can be procured by writing to the University Publishing Group, 12 S. Market Street, Suite 300, Frederick, MD, 21701 or calling 1-800-654-8188.
* Healthcare Reform & Ethics -- This is a bimonthly review of bioethics literature. It is far less comprehensive in scope than the Bioethics Literature Review but more detailed. For subscription information, call 714-997-7907 or write PO Box 14132, Orange, CA 92863-1532.
* Each issue of the Hastings Center Report also contains a feature called "In The Literature" that abstracts recent books and articles from the bioethics and medical literature. It is distinguished from Bioethics Literature Review and Healthcare Reform & Ethics in that it's reviews include books. However, it is not as comprehensive regarding articles as the Bioethics Literature Review.
* The Kennedy Institute of Ethics also publishes a Bibliography of Bioethics. This is an annual index containing over 3,600 new citations to documents in the bioethics area. This bibliography is derived from the Bioethicsline database. The cost is $60.00 for persons in North America; $70.00 for those elsewhere. To order, call 1-800-MED-ETHX.

Encyclopedias:

* The Encyclopedia of Bioethics, Warren T. Reich (Editor), New York: Simon & Schuster Macmillan, 1995. ISBN 0-02-897355-0. Note: This is a highly regarded reference source and an excellent place to begin one's research on most topics. Most articles carry important bibliographic citations with them. (A third edition is presently in press)
* The Encyclopedia of Applied Ethics, Ruth Chadwick (Editor), Academic Press, 1997. ISBN: 0122270657. A quality source.

Listservers: (Listservers are ongoing e-mail discussion groups. Some are open to all interested parties, others require that you explain your interest and credentials.)

* MCW-BIOETHICS -- A closed list that discusses any issue in bioethics. The way to enroll is to address a message to the listserver . Skip the subject line and in body of message type: SUBSCRIBE MCW-BIOETHICS (without the parentheses). You should receive a reply asking for your qualifications since it is a closed list. Explaining that you are a student in MCW's distance learning program is invaluable. If you run into difficulties, you may wish to send a message directly to the list's moderator, Arthur Derse, MD, JD (aderse@mcw.edu)
* IRB Forum -- A listserver and website devoted to research ethics, particularly problems encountered by IRB administrators. Enrollment instructions for the listserver are available at www.irbforum.org

Professional Societies:

* There is now one main society in bioethics, the American Society of Bioethics and Medical Humanities (ASBH). It has a Web site with an online membership application. Or, you can contact the society through more traditional means: American Society of Bioethics and Humanities, 4700 W. Lake, Glenview, IL, 60025-1485, Phone 847/375-4745, fax 847/375-4777.

(I highly recommend that anyone interested in bioethics should become a member of this group. You receive the society's newsletter, receive discounts on registration for the annual meeting, and you are eligible for membership in any of the society's "affinity groups": Disability & Rehabilitation Ethics, Nursing, Hospice and Palliative Care Medicine, Visual Arts and Cultural Representation, Residency Interest Group, and Student Interest Group) Historical Note: The American Society for Bioethics and Humanities (ASBH) was formed from a merger of the three major bioethics societies:

* The Society for Health and Human Values (SHHV - a group that concentrated on the medical humanities)
* Society for Bioethics Consultation (SBC - a group that focused on clinical consultation)
* American Association of Bioethics (AAB - a group that focused on public policy)

There is still one group that has remained independent. It has a legal orientation: American Society for Law, Medicine and Ethics (ASLME); Web site, e-mail (aslme@bu.edu) or phone: 617-262-4990.

Ethics Networks:
Bioethics centers at academic health science centers sometimes try to provide resources for hospitals, nursing homes, and other health-care facilities in their region. These are known as ethics networks or HEC networks (Health-care ethics committee networks.). A network near you may be found by Web-surfing among bioethics centers or visiting the site of the American Society for Bioethics and Humanities, esp., http://www.asbh.org/links/cat1.html

Calendar of Events:
International Calendar of Bioethics Events, Division for Medical Humanities, University of Medicine and Dentistry of New Jersey - Robert Wood Johnson Medical School, P.O. Box 896, Piscataway, NJ 08855-0896, Russell L. McIntyre, Th.D., Director http://www2.umdnj.edu/ethicweb/upcome.htm

The ASBH also maintains a calendar at http://www.asbh.org/events/



Navigating the Available Resources:
It is important to realize that there is no comprehensive list of bioethics resources and centers of study anywhere. Because bioethics is a rapidly expanding field, any lists are quickly incomplete. You should try to become comfortable "surfing" the Web and enjoying the discovery of new resources. You might wish to start at the home page of the ASBH, www.asbh.org and use the "links" to other centers to visit their pages. You'll note that each center's page contains its own list of links that will facilitate further surfing. You should take note of pages that have resources that might prove helpful to you or are pertinent to your interests. You'll wish to use the "bookmark" function on your web browser to mark those pages for future access.

ADDENDUM 10-7-2009: A visitor brought the following link to my attention which has a listing of worthwhile humanities sites which would be good for further education and resources regarding bioethics.

To Tell and Not to Tell: The Illinois Law on HIV Disclosure

“In the name of protecting the health of all men and women, states should extend the privilege of HIV disclosure to any and all endangered third parties, not just spouses. As it stands, Illinois law uses marriage as a test of moral entitlement to public health protection in a way that works against the full value of disclosure privileges and that is ultimately inconsistent with a principled respect for all people at risk of HIV infection.”

So writes Timothy F. Murphy in the Perspective section of the September-October 2009 issue of The Hastings Center Report. As it currently stands, Illinois as other states do “gives physicians the privilege-but not the duty-to disclose an HIV infection to a patient’s spouse, even if they must override the patient’s wishes that they not do so.”


What Illinois lawmakers, however, did not extend was this privilege to a permanent couple who were not married or were simply sexual or needle-sharing partners.Thus the potential benefit, under these conditions, of informing, educating, diagnosing and initiating treatment if that other party was found to be HIV positive would be limited only to legally married couples.


What does this say about the Illinois lawmakers and their motivations to facilitate the treatment and prevention of spread of HIV and their apparently greater motivation to encourage a man to woman legal marital relationship?
Is this legislative action true public health or trying to extend a philosophical or religious bias? ..Maurice.

Use of Medical Interpreters: Facilitating Talk but Delaying Actions: Benefit vs. Annoyance

In the United States the use of medical interpreters is becoming more common in view of the influx or non-English speaking patients and state laws such as in California. But while the interpreter is valuable in obtaining the patient’s history, the patient’s concerns and may help to facilitate the physical examination and the concluding discussion, there is a time factor operating. It may take time to obtain the appropriate interpreter. It takes more time for the interpreter to translate the physician’s words, takes time to make sure the patient understands, takes time to listen to a response and then translate the response into the language understood by the physician. And a physician who has only 15 minutes for an office visit or a hospital resident physician who is simultaneously following a number of patients and/or has various surgeries scheduled throughout the day may find that the time for the use of an interpreter and the process of translation is too time consuming. The value of the interpreter, to that physician, may be simply to get the basic facts and to explain to the patient for informed consent. But beyond that the physician may be comfortable with asking “half-answered “ questions as a memorized couple word expressions and be satisfied with a partially understood patient response and never calling for an interpreter. But is this really fair for the patient who may want to talk more than a brief word or two, expecting to be able to provide the doctor with a full detail of the patient’s concerns and questions?


To help define the problem, here is the result of a study as an abstract regarding the use of interpreters by resident physicians from an article by L.C. Diamond, et al in the Journal of General Internal Medicine, Volume 24, No. 2, February 2009 titled “Getting By: Underuse of Interpreters by Resident Physicians”

Abstract
Background Language barriers complicate physician–patient communication and adversely affect healthcare quality. Research suggests that physicians underuse interpreters despite evidence of benefits and even when services are readily available. The reasons underlying the underuse of interpreters are poorly understood.
Objective To understand the decision-making process of resident physicians when communicating with patients with limited English proficiency (LEP).
Design Qualitative study using in-depth interviews.
Participants Internal medicine resident physicians (n = 20) from two urban teaching hospitals with excellent interpreter services.
Approach An interview guide was used to explore decision making about interpreter use.
Results Four recurrent themes emerged: 1) Resident physicians recognized that they underused professional interpreters, and described this phenomenon as “getting by;” 2) Resident physicians made decisions about interpreter use by weighing the perceived value of communication in clinical decision making against their own time constraints; 3) The decision to call an interpreter could be preempted by the convenience of using family members or the resident physician’s use of his/her own second language skills; 4) Resident physicians normalized the underuse of professional interpreters, despite recognition that patients with LEP are not receiving equal care.
Conclusions Although previous research has identified time constraints and lack of availability of interpreters as reasons for their underuse, our data suggest that the reasons are far more complex. Residents at the study institutions with interpreters readily available found it easier to “get by” without an interpreter, despite misgivings about negative implications for quality of care. Findings suggest that increasing interpreter use will require interventions targeted at both individual physicians and the practice environment.

A physician’s personal experience with this issue is presented in a New York Times article.


All patients deserve beneficent attention and care by physicians despite the handicap of the inability for both to communicate in a common language. In the United States, interpreters are becoming more available to help in this communication and in some states are required by law. But the medical system is complex, not easily changed and tends to produce time limiting necessities but also physician behavioral issues that all lead to impaired doctor-patient communication and potential for errors or inadequacies of care. So what is the answer? Is it medical interpreters or something else? ..Maurice.

Graphic: Illustration by me using ArtRage and Picasa3.