Patient Modesty: Volume 64

In this and the following Volumes, there is no need to go into more detail (and I will not allow that to be published here!) about "unprofessional behavior" if it amounts to describing prurient sexual interest and acts or frank sexual crimes by professionals. This behavior is clearly wrong for a physician or nurse behavior and requires notification of state professional boards in the United States and law enforcement as necessary. That is the solution for that behavior. To educate the patient to ask their provider "are you planning to manipulate my breast or genitals for your own pleasure or do you intend to rape me?" are ridiculous questions to ask at each medical exam or procedure. The way to feel confident in the behavior of the doctor you plan to visit is by getting recommendations from friends and neighbors and by visiting the state board website to see if there are any "bad marks" for that doctor. Also, if the patient can have the opportunity and afford (it certainly may be worth the expense) an introductory visit to talk with the doctor about his or her experiences and views (including religious) and at the start tell the doctor how you want to be treated in terms of your modesty issues but also in other regards. I am sure most patients will be able to size up this doctor and the doctor's environment and enter for an examination at another time with more confidence that the doctor has been "made aware".

What I want is this and the next Volumes to be directed to is listing specific issues to educate and attempt to change the behaviors of the medical system to make the system aware of the need to incorporate programs of attention, mitigation or resolution of issues of patient modesty beyond current concerns about medical mistakes, preventable risks, patients' medical record privacy, ways to pay for patients' medical care and so on.

How do we do this beyond the one on one conversation with a doctor, nurse or medical tech? It is all this that we have to discuss. And where do we start? I believe I have previously mentioned for the United States: the Joint Commission that sets standards for patient care in hospitals and a hospital not passing the regular detailed surveys: no governmental Medicare or Medicaid payments.

In the next Volumes, instead of tearing down the medical system with accusations (and many may well be valid), let's go ahead and progress to "doing something" to meet the requirements for meeting the ethical principles of "justice", "beneficence", "autonomy" and finally "non-malificence" for all patients of either gender and their own degrees of physical modesty. ..Maurice.

Graphic: From Google Images and modified by me with ArtRage and Picasa3

NOTICE: AS OF TODAY APRIL 15 2014 "PATIENT MODESTY: VOLUME 64 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 65.

Doctors May Guess Your Diagnosis and Why They May Be Wrong

This thread is all about heuristic clinical reasoning which means a doctor's mental shortcuts to come to a diagnosis. Heuristic is defined in Wikipedia as:

Heuristic (/hjʉˈrɪstɨk/; Greek: "Εὑρίσκω", "find" or "discover") refers to experience-based techniques for problem solving, learning, and discovery that give a solution which is not guaranteed to be optimal. Where the exhaustive search is impractical, heuristic methods are used to speed up the process of finding a satisfactory solution via mental shortcuts to ease the cognitive load of making a decision. Examples of this method include using a rule of thumb, an educated guess, an intuitive judgment, stereotyping, or common sense.

In more precise terms, heuristics are strategies using readily accessible, though loosely applicable, information to control problem solving in human beings and machines.

In medical practice there may be many reasons which encourage heuristic clinical reasoning such as emergent medical situations or general lack of time for detailed history taking and examinations, lack of resources including an important resource would be a patient who was able to give a medical history or a knowledgeable surrogate. Another factor promoting such reasoning is the expense or potential health hazard to the patient from a procedure which would be appropriate for a definite diagnosis. Finally,  physicians who are not fully educated in a particular specialty may be unaware of all the different diagnoses which are available to consider. Unfortunately, for some physicians heuristic reasoning tends to become a relied upon habit. 

There are a number of categories classifying the types of reasoning which can make up heuristic clinical reasoning.  I found an interesting list by the CanadianAssociation of Emergency Physicians (CAEP).

Here is a list of categories and the description of each by the CAEP:

1. ANCHORING-Focusing on vivid, salient features in a clinical presentation early in the diagnostic process and failing to adjust this first impression later as more information becomes available.

2. ASCERNMENT BIAS-When thinking is unduly influenced by prior expectations (e.g. stereotyping or gender-bias).

3. AVAILABILITY-Options appear more likely when they are readily brought to mind (e.g. a subacrachnoid hemorrhage diagnosis is given more consideration on the differential for headache if it was seen in a case a week ago.)

4. COMMISSION BIAS-The idea that something always needs to be done to the patient instead of letting things take their course--more common in confident physicians; things get done that were unnecessary.

5. CONFIRMATION BIAS-Looking for things to support your diagnosis/hypothesis rather than looking for disconfirming evidence (which is usually a more effective strategy).

6. CONTRAST EFFECT-When interpretation of a particular case is influenced by adjacent cases--even though they are independent of each other.)

7. DIAGNOSES MOMENTUM-When diagnoses gather momentum without gathering evidence.

8. FUNDAMENTAL ATTRIBUTION ERROR- Judging and blaming particular patients (e.g. obese, borderline personality disorder, addicted patients) for their illnesses by focusing on their disposition (character, personality, intelligence) rather than considering their situational circumstances (socio-economic, upbringing, history of physical/sexual abuse).

9. HINDSIGHT BIAS- Learning from past experience is hindsight. However hindsight bias occurs when, knowing the outcome, people either make themselves look good or look bad, thereby distorting any chance of realistic learning.

10. OMISSION BIAS- The tendency toward inaction and non-intervention.  Error arises from things not getting done that should have been done.

11. OVERCONFIDENCE-The general belief that we are better than we really are--a misplaced belief that affects one's thoughts and actions.

12. PLAYING THE ODDS also known as FREQUENCY GAMBLING- is the tendency in equivocal or ambiguous situations to opt for a benign diagnosis on the basis that it is significant more likely than a serious one.

13. PREMATURE CLOSURE-Shutting off thinking before there is sufficient evidence to suggest a particular diagnosis--when the diagnosis is made the thinking stops.

14. REPRESENTATIVENESS RESTRAINT- We tend to look for prototypical manifestations of disease--atypical presentations are more likely to get missed.

15. SEARCH SATISFICING- reflects the universal tendency to call off a search once something is found. Co-morbidities, second foreign bodies, other fractures and co-ingestants in poisoning all might be missed.

16. VISCERAL BIAS- when emotions overly intrude into decision-making.  Countertransference may result in feeling unduly negative or positive toward patients leading to suboptimal decisions regarding diagnosis and management.

17. YIN-YANG OUT-The outlook that once patients have been worked up the Yin-Yang  further effort will be futile.

18. ZEBRA RETREAT- Backing away from a rare diagnosis for reasons other than it being rare: thinking that you will attract a reputation of being esoteric, unrealistic  or a wastrel of resources or time.

19. TRIAGE CUEING- deals with Emergency Room triage: the tendency to inherit the abbreviated thinking that occurred at triage (patients  seen in the minor area are considered as only having minor complaints).

and finally

BLIND SPOT BIAS, a general belief that people have that they are less susceptible to bias than others. 

As you see, there can be many ways that heuristic clinical reasoning can go wrong.  And yet, doctors will use this reasoning as part of the beginning to form a diagnosis when rushed or a diagnosis still not firmly established at the time that some prompt treatment for physical support is critical. But the "guess" has the many limitations as noted above.  So what is most important is that all doctors should be aware that they are at the time practicing heuristic reasoning and should know the details of what potential errors of reasoning can occur by such use and thus use with caution.

Have you ever heard your doctor tell you: "I am just guessing that you have..."? And how did or would you respond? ..Maurice. 

Graphic: From Google Images-Alfred Nobel (1833-1896)

Patient Informed Consent from Partially Uninformed Physicians

The title of this thread clearly sets the topic to be discussed.  Informed consent by a patient for an examination or medical-surgical procedure is an established ethical and legal act which has been even more focused throughout the medical profession in the recent decades when previous professional paternalism behavior dissolved to patient autonomy.  However established the practice is preached, the act still depends on several factors. With regard to the patient becoming informed about the details of the examination and procedure, it requires the patient or patient's surrogate making a decision to comprehend what is being communicated, understanding the words and implications of what was learned but also feeling free and comfortable to ask the physician questions about details told and about information which had not been presented but which is of concern to the patient.  These details therefore must be presented directly by the healthcare professional who will be responsible for the exam or procedure and not only by text on a sheet of paper to be read and signed.

With regard to the professional who provides the details to the patient, the information presented should be in a form which is the best for patient understanding and decision-making.  The talk should be comprehensible both in terminology and in how it is presented. The detailing should not be "rushed through" but slow enough for the patient to hear clearly what was said  but also slow enough for the professional to stop and monitor by questioning the patient that the words are truly being understood. An important aspect of the presentation of information from doctor to patient is to maintain attention to patient autonomy and avoid paternalistic remarks or possible options which only fit  that physician's own personal interests.  However, even though physicians may have decided upon their own options or professional decisions and it is appropriate for the doctor to tell the patient what the doctor has decided is best for the patient's health and well-being and why, it finally becomes the patients' own decision which is the primary goal of the informed consent exercise.  For the patient to do that, it requires that the patient actually be informed.

But, how can informed consent by the patient work if the patient's doctor is not fully informed?  And perhaps the entire medical profession is not fully informed about the interpretation of an examination nor the outcome of a procedure. "How can that be?" you might ask.  The answer is very simple. The medical and surgical profession just doesn't know about everything it carries out.  The profession knows a lot but it doesn't know everything and that "thing" it doesn't know may be a "critical thing" for the best interest of the patient. 

Although, in the United States, the Food and Drug Administration (FDA) attends to prevent medications which have been developed to be used on patients without careful scientific evaluation of the drug's safety and efficacy for treatment, there still occurs side-effects and serious complications that only appear once the drugs are used throughout the whole patient population and not simply in the preliminary investigative tests of small numbers of patients.  With regard to surgical instruments and procedures, the government has far less direct control over studies to evaluate safety and comparative values.  Some techniques and procedures may be informally described in the literature and carried out by surgeons with varying degrees of experience and unlike the case with the prescription of medications, each use becomes for that surgeon a learning experience. 

An interesting example of a surgical technique and its developing but still incomplete knowledge of its complications and the best way to prevent them is the procedure of electric uterine morcellation as described in a Viewpoint article in the March 5 2014 issue of the Journal of the American Medical Association.  The procedure is a method for slicing a large organ within the body, in this case the uterus, in order to remove the organ piecemeal through the very small incisions which are used to enter the abdomen for a laparoscopic surgical procedure.  The advantages of laparoscopic surgery  to surgically treat a variety of abdominal diseases and disorders with a minimum of surgical trauma and a much more rapid patient recovery period is common knowledge. What isn't common knowledge and is not fully known at this time  by the surgical profession is the full risks and degree of risks of incorporating electric morcellation of organs including the uterus.  For example, shredding a uterus to facilitate its removal may also shred and disseminate throughout the abdomen a previously undetected uterine cancer within the body of the uterus.  There are more unknowns about the procedure including the full risk/benefit ratio as compared with removal of the entire organ through a standard operative incision. 

So how can informed consent be asked from the patient when the doctor him/herself is not fully informed? The article stresses the importance and necessity for full information disclosure to the patient and including detailing the various  issues for which the surgeon is uninformed such as regarding risks which are "vague and unspecified because of limited data".  It is my opinion that such disclosure requires the risk and benefit information to be provided in an unhurried manner and so the patient understands them, to be provided by the surgeon responsible for the surgery and all the alternate options be presented. However, as noted in the article, with respect to disclosure of risks and benefits "this is difficult when the risks are vague or unquantified because of lack of data or rarity of an event. Yet a lack of data or rarity of an event should not preclude discussion of serious potential complications".

How would you, as a patient, want the physician to inform you about the risks and benefits of a procedure to obtain your "informed consent" when the doctor him/herself is not fully informed? ..Maurice.

Addendum 3-5-2014:  The original graphic obtained from Google Images and modified by me with ArtRage and Picasa 3 is from an excellent article about the responsibilities of the doctor toward the autonomy of the patient written by Dr. Faisal Saeed in the Team Talk website of the ADK Hospital of Male' in the Maldives.  I suggest, to supplement what I have written above, you go to the above link and read Dr. Saeed's article.

Tampering with Evolution? "Three Parent Embryos"

The following article I wrote for Bioethics.net is reproduced here with permission

03/04/2014

TAMPERING WITH EVOLUTION? “THREE PARENT EMBRYOS”

by Maurice Bernstein, MD

Babies are born with  a progressive neurometabolic disorder with a general onset in infancy or childhood, often after a viral infection, but can also occur in teens and adults.  The disease is seen on MRI as dead or dying tissue within the brain and though the child appears normal at birth,  in a few months to two years of age, though earlier or later,  there is loss of basic skills and finally the child may have  heart, kidney, vision and breathing complications.  What is this disorder?  It is a congenital disease carried by the mitochondrial DNA genes of the mother and called  Leigh’s Disease.  Another disorder found in mother’s egg (oocyte) mitochondria  are the  Creatine Deficiency Syndromes characterized  in the child by mental retardation, expressive speech and language delay, autistic like behavior, hyperactivity, epilepsy and movement disorders. And there even many more congenital disorders expressed by abnormal mitochondria and some are described at the United Mitochondrial Disease Foundation website.

A problem in anticipating these disorders  is that the women carrying these abnormal mitochondrial diseases may be healthy.  The possibilities of a mitochondrial DNA abnormality may only be suggested by analysis of the woman’s oocyte.  If thought to be present, then what?  Can the woman ever expect to deliver healthy babies?   And this is where a technique of assisted reproduction, developed in the recent years in animals, may yield  an answer to this question but does involve ethical dilemmas if performed in humans.  It is all about creating a healthy child by removing the mother’s healthy  oocyte DNA and placing it within another (donor) woman’s oocyte from which the cellular genetic material has been removed but what remains is that woman’s healthy mitochondrial DNA.  Then in vitro fertilization is performed using the husband’s sperm thus introducing the husband’s DNA and then followed by implantation of the finally fertilized egg cell  into the mother for the hopeful creation of a healthy baby.

In addition to the prevention of a child born with a mitochondrial genetic abnormality, there are suggestions that a reason for women after the age of 30 to be infertile was because of changes in their mitochondrial DNA with time and that perhaps the same technique would allow these women to have their child with the use of the donor’s “fresh” mitochondrial DNA.

It is this creation of a “three parent embryo” that provides a controversy regarding the ethics of performing this procedure for future therapy  or even now to begin research in humans.  The controversy  is discussed in a comprehensive news article in the February 21 2014 issue of “Science”. According to the article, the use of this technique for human research has been cautiously approved within the United Kingdom but is currently still being considered in the United States by the Food and Drug Administration which has safety and effectiveness responsibilities regarding  gene therapy in general.

So , what are the ethics issues involved?  Should it be permitted to use a technique, with the purpose to avoid a serious disease for the future child (and future generations), that will result in a genetic modification that will be inherited? if we are using  nuclearDNA from one woman and the mitochondrial DNA from another woman to be included in an ovum to be fertilized by a male to create a healthy child are we also introducing into the genetic germ line a “new human”  which would never have previously existed  and, when mature, part of that “new human’s” DNA would be carried on through future generations?   And would this be the first step on a slippery slope allowing genetic modification also of nuclear DNA?  If cloning “new humans” from designed nuclear genetic material is already said to be unethical and is not allowed, shouldn’t this nuclear DNA transfer be likewise forbidden?  Finally, from a legal viewpoint, should the resultant child be said to have three parents and would the “third” parent (donor) have to be identifiable and have any further obligations to the “family”?

I don’t have all the answers but think only about the question of humans themselves introducing scientifically created changes in the genetic germ line through DNA transfer or even frank cloning which would not have been created by “Mother Nature” through evolution.   Couldn’t all this messing with evolution be exactly what evolution was intending: developing us humans to a point when, through our intellect and science, we could add our own “two cents” to the process of evolution?  Therefore, to me, no problem.

ADDENDUM 3-5-2014 (Not part of the original article): If you agree or disagree with my final conclusion about "tampering" with evolution, please feel free to comment with your own opinion. ..Maurice.