REMINDER: I AM POSTING A NEW TOPIC ABOUT ONCE A WEEK OR PERHAPS TWICE A WEEK. HOWEVER, IF YOU DON'T FIND A NEW TOPIC POSTED, THERE ARE AS OF MARCH 2013 OVER 900 TOPIC THREADS TO WHICH YOU CAN READ AND WRITE COMMENTS. I WILL BE AWARE OF EACH COMMENTARY AND MAY COME BACK WITH A REPLY.
TO FIND A TOPIC OF INTEREST TO YOU ON THIS BLOG, SIMPLY TYPE IN THE NAME OR WORDS RELATED TO THE TOPIC IN THE FIELD IN THE LEFT HAND SIDE AT TOP OF THE PAGE AND THEN CLICK ON “SEARCH BLOG”. WITH WELL OVER 900 TOPICS, MOST ABOUT GENERAL OR SPECIFIC ETHICAL ISSUES BUT NOT NECESSARILY RELATED TO ANY SPECIFIC DATE OR EVENT, YOU SHOULD BE ABLE TO FIND WHAT YOU WANT. IF YOU DON’T PLEASE WRITE TO ME ON THE FEEDBACK THREAD OR BY E-MAIL DoktorMo@aol.com
IMPORTANT REQUEST TO ALL WHO COMMENT ON THIS BLOG: ALL COMMENTERS WHO WISH TO SIGN ON AS ANONYMOUS NEVERTHELESS PLEASE SIGN OFF AT THE END OF YOUR COMMENTS WITH A CONSISTENT PSEUDONYM NAME OR SOME INITIALS TO HELP MAINTAIN CONTINUITY AND NOT REQUIRE RESPONDERS TO LOOK UP THE DATE AND TIME OF THE POSTING TO DEFINE WHICH ANONYMOUS SAID WHAT. Thanks. ..Maurice
FEEDBACK,FEEDBACK,FEEDBACK! WRITE YOUR FEEDBACK ABOUT THIS BLOG, WHAT IS GOOD, POOR AND CONSTRUCTIVE SUGGESTIONS FOR IMPROVEMENT TO THIS FEEDBACK THREAD
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
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.
Here is a list of categories and the description of each by
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
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
7. DIAGNOSES MOMENTUM-When diagnoses gather momentum without
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
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).
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
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
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