"Nudging" Informed Consent Toward One Direction

 

You  enter a grocery store and as you pass through the front door you find a beautiful display of luscious  looking fresh fruits.  You came to the market to buy some spare ribs and wine for supper but that is way in the back of the store.  Prior to entering the store, you had only the ribs and wine on your shopping list but now you find yourself buying a few pounds of the fruit. Moving back through the market, you find the display of bottles of wine. You find that the more expensive and imported wines are displayed at eye level and the cheaper, local and less noteworthy wines are standing on an elevated shelf, accessable, but you have to reach up for them. Might you be tempted to take one of the wines at eye level? Maybe not, but then you hadn't even previously considered buying an expensive wine for this evening's supper. What I am presenting here as examples of how the grocery market can affect your decision-making by creating

"nudges" to change your shopping list decisions. This example of ways to affect decision-making in the grocery decision-making also can occur in the challenge of making your informed consent medical decisions.

The June 2013 issue of the American Journal of Bioethics has one of its target articles and a number of open-peer commentaries just about "nudging and informed consent". If the healthcare provider presents to the patient the information needed for the patient to make informed consent but yet sets a particular detail "in the front of the store" or "on a lower shelf", representing how the facts are presented to the patient, the provider may be essentially "nudging" the patient toward one decision in place of the other but without denying the patient any loss of autonomy to select either to consent or dissent for any of the options presented. The nudging can vary in intensity from something like a very slight nudge to a nudge which might be considered almost a "push".

To demonstrate directly to my visitors some examples of slight nudges as presented in one peer review article in that journal "Nudging and the Complicated Read Life of "Informed Consent" by Charles Douglas and Emily Proudfoot. I would like to present their two "scripts" which they presented to patients in a study to determine whether a nudge in presenting the facts could affect the patient's decision-making. 

Pretend (and I hope it is only a pretend) that as a woman you are concerned about a breast lump or an abnormality which was found only on a mammogram and that may be a cancer. The doctor is aware that there are two approaches in management which are available: perform a "thru the skin" biopsy of the abnormality which involves at the most only a little local

anesthesia with virtually no risk and present results, if negative for cancer, would still leave only a less than 1% chance that a cancer would be missed but the lump continued to be observed  if no cancer was  or to fully excise the

 abnormality under general anesthesia which would carry the risk of anesthesia and the surgery but provide 100% confidence regarding the diagnosis of the lesion and the lesion would have been removed. The patient can be told the facts, the procedure, risks and conclusions in each of two ways. either may represent a nudge in one direction or the other. My own examples of how the facts could be presented as based on the article would be:

1)  "You may have the lump simply biopsied under local anesthesia with negligible risks from the procedure rather than surgically removed under general anesthesia with its known risks, and the results of the biopsy if negative for cancer would be correct over 99% of the time and missing the cancer less than 1% of the time, I would consider that an acceptable risk. After the biopsy, if negative for cancer, the lump will be continued to be observed"

2)"To have the lump biopsied there would be very little risk from the procedure and a less than 1% chance a cancer would be missed. However, you may have the lump fully removed but with the known risks from the general anesthesia and surgery.  If you want to be 100% certain regarding whether the lump is cancer or not, then we should excise, remove it."

Notice that the facts are presented in both examples for the patient's education and decision but with a difference in the wording and emphasis.  If you were only presented with disclosure #1 how would you respond? Would you agree for a biopsy? If you were only presented with disclosure #2 how would you respond? would you agree for an excision?

Do you see the "nudging" of the patient in one direction or another in each of the patient presentations?  Do you think it is fair, that it is ethical for a doctor to tenderly direct (nudge) the  patient in one direction or another based on the doctor's professional opinion as to what would be in the patient's best interest. Have you, as a patient, felt nudged by your doctor?  ..Maurice.

Graphic: From Google Images.

   

Clinical Research:Patient-Centered Goals:Set by Who?: The Patients!

:

It was very interesting for me to read a Viewpoint article in the June 12 2013

issue of the Journal of the American Medical Association (JAMA). It has to do

with medical research and the role of patients in that research. The article is

titled "Patient's Responsibility to Participate in Decision Making and

Research" by Tinetti and Basch. One always thinks that the role of the patient

in medical research should be simply as the "guinea pig" or subject of the

research and that the creation and development of the research project is the

job of the research scientists and physicians. It is these professional folks

who are known to understand the science and the missing information that needs

to be discovered and they are the ones to be involved in deciding upon what and

how and to what ends a medical research study should be designed.

However, on thinking about this a bit further about how medical (also called

clinical) research is to be initiated, one should ask the question as to whose

primary benefit should the research be directed.  One could say that it is to

increase the pool of medical knowledge from which physicians can access in

order to treat all their patients. A more cynical answer would be that the

benefit can be self-serving and really provide a significant benefit to the

professional both in terms of satisfaction of personal inquisitiveness and, of

course, the opportunity to advance one's professional career. The article, on

the other hand, stresses the importance of considering the patients themselves

as the beneficiaries of medical research and as such it should be the patients

themselves who should be involved in setting the basis for a study and involved

in establishing what should be the study's goal. After all, it is the patients

who can provide input into what patients want to get out of the conclusion of

the research. This input could direct the research scientists toward finding

results which would be more acceptable and needed from the patient's point of

view.

Beyond the goal of the study, since the patients are the "guinea-pigs" it would

seem ethical to allow some patient autonomy in the details of the project to

have a say with regard to how they, as subjects, be utilized and more

comfortable with the project. It is important to remember that, in many aspects

of the study, there is a declared responsibility of the patient to strictly

follow the directions set by the researchers and continue their participation

since otherwise the study may be flawed or even lead to its abandonment.

Therefore, patient participation in a study should extend beyond being solely

the subjects to be experimented upon. As the title of the JAMA article suggests

beyond being the subject, shouldn't patients in general be required to

participate in medical research? However, also as the JAMA article implies that

though there is general consensus about the responsibilities of patients to

request information from physicians if they don't understand, participate in

decision about diagnosis and treatment options and agree to adhere to agreed-on

treatment program, "the responsibility of patients to participate in research

is less clear than their responsibility to participate in their own care." One

argument that could be made for patient responsibility would be that "patients

have the duty to participate in research because everyone benefits from the

results and the no one should be a 'free rider'"

Though, ideally, to achieve an effective goal of "patient-centered" healthcare

and decision-making, the JAMA article concludes that to reach that goal

requires that "patients let clinicians know their priorities, understand which

strategies are most likely to achieve their priorities and participate in

research which generates this evidence."

I would be interested to read what my visitors think about the role of patients

to become a study research subject but also contribute to the development of

patient-centered goals for the study.  ..Maurice.

Graphic:  From  www.asbestos.com via Google Images

The Disabled: Ethical and Practical Issues Yet to be Resolved: What Can You Find Out and Tell Us About Them?

I have developed a number of threads on this blog presenting and discussing issues that deal with the disabled person such as the following:

"Thinking and Writing about the Disabled:Courageous or Burdened"

"Eugenics,“Feeblemindedness” and the “Droolers”: Stories of Stereotyping andDiscrimination"

Disability RightsGroups: Sacrificing the Individual for the Agenda?

The MentallyDisabled Women: Sterilization at the Request of Others 

“Better Dead ThanDisabled”: Bad Date and Bad Balance 

The Ashley Caseand What is Ethical?

Refusing to Cast aDeaf Ear to the Ethics of Maintaining Deafness within a Deaf Family

Many of the issues presented in these threads over the past number of years are still not  settled and some, of recent interest have not even been discussed here as yet..

Some of the issues still undecided by ethicists but also by the public are listed below.  I have not performed a library or Google search regarding the current facts regarding the status and full arguments for or against these issues to present here on my blog.

I thought it might be interesting to have my readers do the research on one or more of these topics and write a comment here about the arguments and status of the debate as researched.  On the other hand, based on their experience or current knowledge, some visitors might like to just write about their own opinions regarding any of these issues.

I hope my visitors don't think that I am just lazy making this request. I'm not. I just want to see, through this experiment how others discover and present the facts regarding these issues which are very important both to the disabled person, that person's family and to the society in general.  So go and Google the topic, learn and return and tell us what you know. ..Maurice.

The use of bionic eyes

The use of cochlear implants

Prosthetics for everyday use or competitive sports

“Normalizing” surgery for individuals with Down Syndrome

Limb lengthening surgeries (e.g., for individuals with achondroplasia)

The use of growth hormones

The use of “neuroenhancement” drugs (e.g., to improve focus, memory, or other cognitive functioning)

Laws that influence decision making on behalf of disabled children (e.g., the Swedish law requiring parents to consult with member of the Deaf community prior to agreeing to cochlear implant surgery for their child)

Growth attenuation procedures

Familial or community pressure to modify or refuse modifications of one’s body

Graphic:  Classic "the disabled" signage from Google Images

"Good People Doing Bad Things for Good Reasons": Revision

The following original article which I wrote and was published today at the bioethics.net website is reproduced here with permission.  ..Maurice

05/28/2013

GOOD PEOPLE DOING BAD THINGS FOR GOOD REASONS

Maurice Bernstein, MD

What is ethical or not is often in the eye of the beholder. That is why often the ethics of decisions or acts that we deal with in medicine is established through the process of consensus. And I don’t necessarily mean consensus by only scholars, lawyers or ethicists or even physicians. I think in ethical consensus the many voices of society should be included. I think that an understanding of reason for the divergent views that may occur in ethical analysis can be expressed by what Marcia Angell, former editor-in-chief of the New England Journal of Medicine has said in the past. Perhaps you have already have heard it.“Ethical violations are usually not a case of bad people doing bad things for no good reason, it is usually the case of good people doing bad things for good reasons.” If it were bad people, bad things and bad reasons, there would be no ethical conflicts. The question is whether the acts of those good people carried out for those good reasons best meet the principles of ethics for that particular issue.
Many times in clinical ethics, we find that all of the stakeholders of an issue have meritorious reasons to base their suggested actions. There also may be a meeting of an ethical principle for each action so that there is no strictly unethical violation. The problem arises when one action is inconsistent with another action and we have to decide which act and its ethics trumps another. But trumping may mean that some stakeholders may lose. Therefore, those of us who perform the responsibilities of the hospital ethics committee must remember that we are dealing with good people who have good reasons and perhaps their intended actions are not even that bad except in light of the context of the issue.

Three members of a hospital ethics committee met with 4 family members and two physicians of the patient to come to a decision about the patient’s further management. The patient, a 67- year-old diabetic male who had been a heavy smoker for most of his life, three weeks earlier had suffered a massive stroke which left him unconscious and unresponsive but able to breathe.  Supplemental oxygen by nasal catheter had to be replaced by continuous ventilator breathing support within the Intensive Care Unit when after a week bilateral pneumonia developed and adequate spontaneous breathing ceased.  His course was further complicated by signs of progressive renal failure and gastro-intestinal bleeding of unknown cause, which was significant enough to require repeated blood transfusions to maintain a minimally satisfactory blood count. The patient’s mental state remained unchanged.

The attending physician and neurologist presented to the family and the ethics committee a conclusion to terminate energetic treatment because the patient’s condition was progressively worsening despite intensive medical management, the patient would be unable to tolerate exploratory surgery for the bleeding and the neurologic prognosis was that significant recovery was unlikely. The ethics committee reminded the meeting that the repeated blood use was utilizing a particularly scarce resource.  The son and two daughters agreed with the physicians’ conclusion but the wife who was the legal surrogate stated that she was told by the nursing staff, confirmed by the physician, that the patient had begun triggering the ventilator and that she felt that this was a good sign and that her husband would have wanted treatments to continue.

One of the tools the ethics committee has in this case is compromise. Sometimes compromise mitigates the conflict if even only temporarily. Though it may be only a band-aid in making an ethical solution, it often permits time to get the parties together on a final decision. If, as an example, the issue is end-of-life decision-making and family members are in conflict as to whether enough time on treatment has elapsed to be assured that the patient will not recover, a compromise can be often reached.

In the case presented, at the suggestion of the ethics committee members, the family and physicians agreed to seven more days of current management and then meeting again to re-evaluate the situation and if there was no improvement to then agreed to provide solely comfort care rather than the current attempts to cure.  While the ethics committee agreed with the physicians’ initial conclusions along with that of the children, the committee recognized that the wife, as the surrogate, had some basis for her initial rejection and that compromise with the wife was appropriate.

Those of us “doing ethics” should always temper our dogmatic views, if we carry them, to realize that generally we are dealing with good people and their good reasons. And the “bad” things they may want to do is often just “relatively bad.”.

Patient Modesty: Volume 55

As we move on to Volume 55 of this thread on Patient Modesty there appears to be more discussion about ways to educate physicians, nurses and other healthcare providers regarding the personal feelings and concerns and particularly related to physical modesty.  Scripting responses for the medical staff to communicate to the patients or families is being currently discussed. It may well be that appropriate scripting by administrators in humanistic terms and attention to see that the staff apply this technique properly and consistently may well help in preventing some of the conflicts described on these threads.  Today, I posted on Volume 54 the following in this regard: Here is a wonderful example of "scripting" for the employees if this wasn't (as I suspect)only a public advertisement for the Cleveland Clinic. Maybe more videos of this kind (demonstrating to the staff what is going through the minds of patients) would help toward diminishing the conflicts and emotional trauma as described on our blog thread.
As I have written previously, this thread has had virtually 8 years of descriptions, some quite detailed, of the visitors' experiences and concerns.  What is needed are descriptions of approaches to provide change in the medical system along with changes in the approaches by the patients which will provide an interaction between healthcare providers and patients which is comfortable and valuable to all. ..Maurice.

Graphic: From Google Images and modified by me with Picasa 3.

Smelling the Unethical: Can You? Should You?

The question arises as to how the average person can "smell" (suspect without documentation) that some act or behavior of an individual or individuals is unethical. An often used expression is: "It smells fishy to me." Is everything which determines what we suspect really set down in the past by our "ethics education" through reading or listening to the views of philosophers, ethicists, our religious or grade-school teachers or parents or the outcomes of our own experiences? On the other hand, is what "smells" unethical simply based on individual personal preferences and not some theory or rule developed by others. Then again, perhaps there is some genetically constructed mechanism or instinct which provides every individual with the capacity to establish that suspicion about what might be an ethical "bad" and not an ethical "good". An important point to consider is whether you can fully explain the reason that the action "smells unethical". If you can't, then maybe this would point to the decision as an instinct mechanism.

Beyond considering the mechanism of the this use of smell, is the question as to whether use of this "olfactory" function is of personal or social value. Will it prevent the individual to enter into unethical actions which might be harmful toward ones self or harmful toward others?

Whether you can or cannot "smell the unethical", I would like to express my personal view. I want to emphasize that all ethical decision making (what is a "good" vs what is a "bad") should be made on carefully obtaining and evaluating the facts of the action or behavior and weighing them on the ethical principles and ethical consensus and law with the understanding sufficient to explain the decision, if necessary, to others. I think that whatever the mechanism is for "smelling the ethics" and whatever its "odor" ,ad hoc or premature decision making about an ethical matter, which. by the way is not uncommon, is itself unethical.

Any comments?  ..Maurice.

Graphic: A Mephitidae ("skunk") photographed by me May 26 2013 Whitney Canyon, Southern California.

Patient to Physician Confidentiality: Under All Circumstances?

Within the May 10 2013 issue of the New York Times comes the following concern from a physician:

I am a physician. Years ago, I saw a young patient with headaches, who disclosed — reluctantly — that he had committed a serious crime and that somebody else took the fall for it. I believe he was telling me the truth (his headaches soon resolved after the confession). Before his admission, I assured him that whatever he told me would not leave the room. Later, without giving specifics, I consulted our hospital lawyer, who told me that we were under no obligation to report the incident, because the patient wasn’t in danger of hurting himself or others. But the future of an innocent man hinges on two people’s consciences, my patient’s and my own. I feel like a coward, hiding behind the Hippocratic oath, doing nothing. NAME WITHHELD

Well, if you were going to give advice to this physician..what would you say? If the doctor had initially given the patient assurance of confidentiality, should that promise be kept under any circumstance that arose in further communication? What is your opinion? ..Maurice.

Graphic: From Google Images

A Medical Student and YOU: The "Hidden Curriculum"

Another in a series of threads regarding the ethical/professional issues that could involve a medical student and you or a family member as a patient. This thread is based on the book Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge:Cambridge University Press; 2010 and  from the website "Professionalism in Medicine" prepared by Jefferson Medical College in Philadelphia Pennsylvania. This thread begins with a video dramatization of a vignette which is followed by a faculty member perspective commentary.First go to the following link, read, view and then return and present the visitors to this thread your own view of the particular professional issue from the perspective of the patient:Commitment to Professional Competence

A STARTING COMMENT FROM ME:


Being competent as a physician requires proper education and experience. Much of the basic education in diagnosis and the treatment of the patient's disease actually occurs during the first two years of medical school. It is there where the theory and also the scientific basis for accomplishing these responsibiities are presented. What happens as part of the student, intern or resident's professional development after these two years is a learning activity which can be distorted by various suspected or realistic practicalities and clinical habits of those performing the instruction. This later teaching regarding the profession of medicine has been called the "hidden curriculum". Often this "hidden curriculum" while perhaps assumed to facilitate certain clinical actions and certain doctor-patient relationships may, in fact, pose unnecessary patient cost and unnecessary patient harm and may even go against medical professional code of ethics. Though it is doubtful that the "hidden curriculum" in medical education and behavior will ever be eliminated, however knowing about this phenomenon should provide patients with a reason to retain a touch of attention and indeed a bit of skepticism with regard to the behavior and decisions of their physicians. ..Maurice.

A Medical Student and YOU: Like to Know Who is Closing the Incision?

I am putting up a series of excellent discussions about ethical/professional issues that could involve a medical student and you or a family member as a patient. Each discussion as a separate thread is based on the book Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge:Cambridge University Press; 2010 and  from the website "Professionalism in Medicine" prepared by Jefferson Medical College in Philadelphia Pennsylvania.  Each issue at the website is begun with a brief vignette, and then a brief video dramatization of the vignette and then followed by perspective commentaries by a medical student and followed by that of a faculty member. First go to the following link, read, view and then return and present the visitors to this thread your own view of the particular professional issue from the perspective of the patient: Principle of Patient Autonomy.  

A STARTING COMMENT FROM ME:

In the case of surgery, informed consent for a procedure means that the patient understands the need for the surgery, the risks and in general how and specifically who is performing the surgery. By becoming informed and then agreeing, the patient's autonomy is maintained. To intentionally fail to inform the patient beforehand as to who is part of the surgical team, except in the case of an emergent switch of surgeons, defeats the validity of informed consent. Patients expect the best of surgical skills and to have a novice involved without informing the patient and receiving patient consent for that novice is unethical and fails professional standards regardless of the necessity for novice (student) education. ..Maurice.

A Medical Student and YOU:Patient Confidentiality

I am putting up a series of excellent discussions about ethical/professional issues that could involve a medical student and you or a family member as a patient. Each discussion as a separate thread is based on the book Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge:Cambridge University Press; 2010 and  from the website "Professionalism in Medicine" prepared by Jefferson Medical College in Philadelphia Pennsylvania.  Each issue at the website is begun with a brief vignette, and then a brief video dramatization of the vignette and then followed by perspective commentaries by a medical student and followed by that of a faculty member. First go to the following link, read, view and then return and present the visitors to this thread your own view of the particular professional issue from the perspective of the patient: Commitment to Patient Confidentiality.

A STARTING COMMENT FROM ME:

It's all about the "need to know". Comments about an individual patient's medical or psycho-social condition have to be guarded and away from those individuals who have "NO need to know" where the need is to provide diagnosis, therapy, financial or other specific benefit to the patient unless otherwise specifically requested by the patient. That is why,in the United States, we have the HIPAA regulations which penalizes those who violate the "need to know" dictum.

One could argue that, if the information is unidentifiable regarding any specific patient such release of information is safe. Unfortunately, in these days of mass communication and the internet with search engines, specific patient identification is easier and unidentifiable can be a "wishful thinking" concept. ..Maurice.

 

  ..Maurice.

A Medical Student and YOU: The Matter of Honesty

I am putting up a series of excellent discussions about ethical/professional issues that could involve a medical student and you or a family member as a patient. Each discussion as a separate thread is based on the book Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge:Cambridge University Press; 2010 and  from the website "Professionalism in Medicine" prepared by Jefferson Medical College in Philadelphia Pennsylvania.  Each issue at the website is begun with a brief vignette, and then a brief video dramatization of the vignette and then followed by perspective commentaries by a medical student and followed by that of a faculty member. First go to the following link, read, view and then return and present the visitors to this thread your own view of the particular professional issue from the perspective of the patient: Commitment to Honesty with Patients.

A STARTING COMMENT FROM ME:
Honesty with the patient or family requires that those who are called "doctors" are indeed "doctors" and not medical students who haven't graduated. As I have written on a much earlier thread, I totally disagree with the identification of the student as even a "student doctor" as I also disagree with the term "student nurse". I think all those who interact with a patient should be identified as to their role. This is part of being honest with the patient. So let's call the students what they are: "nursing student" and "medical student"--- NOT a nurse and NOT a doctor. ..Maurice.

Medical Slang Leading to Logical Fallacy: A Practice to be Avoided

The following original article which I wrote and was published today at Bioethics.Net website is reproduced here with permission.  I will put some additional comments as an Addendum at the end of the copy.  ..Maurice.

05/03/2013

MEDICAL SLANG LEADING TO LOGICAL FALLACY: A PRACTICE TO BE AVOIDED

Maurice Bernstein, M.D.

Medical slang is a form of slang used by doctors, nurses, paramedics and other hospital or medical staff. It is expressed either in informal vocabulary as words, abbreviated terms or also as acronyms (words made up of initial letters of the words the acronym represents) related to medical terms or conditions, persons or events. Presumably the basis for the use of medical slang is to communicate one’s concept or clinical finding or evaluation or diagnosis to other caregivers in a rapid and concise way. Unfortunately, the use of medical slang may lapse into derogatory expression or become ambiguous. Derogatory means that findings or persons are expressed in a disrespectful or degrading manner. Ambiguity can be related to the fact that an acronym or abbreviated word may not be sufficiently distinctive and can be used or interpreted for more than one medical term.

Examples of medical slang can be as benign as but also potentially ambiguous as the following medical transcription terms: “lytes”=electrolytes, “nitro”=nitroglycerine,”sats”=saturations, “crit”=hematocrit, “mets”=metastases, “osteo”=osteoporosis. On the other hand, medical slang can be derogatory even though amusing when applied to medical specialties. For example: “baby catcher” for obstetrician or “butchers” or “knife happy” for surgeons. Examples of medical slang as applied to patients include “dirt ball” for a patient who enters the emergency room filthy and smelling badly or “druggie” for patients known or suspected for illicit drug use or “goldbrick” for a patient who demands more attention than their (minor) condition warrants or the acronyms LOBNH for “lights on but nobody home” for a patient with suspected dementia and, of course, GOMER for “get out of my emergency room!”.

My argument is that medical slang generally can not only be or become disrespectful or ambiguous but also in the case relating to patients themselves, the derogatory descriptions may actually represent an action by the professional to create a logical fallacy. What is a logical fallacy? It is an error in reasoning that renders an argument invalid. Why attribute a medical slang expression as promoting a logical fallacy? First, a basic premise within the profession of medicine is the responsibility to obtain history and facts, if possible directly from the patient, and then to attempt to draw and present a conclusion from the facts. Drawing that conclusion is a logical exercise. Because, unlike the application of medical slang to “conditions” when this slang is applied to a person (an ad hominem), it may allow a fallacious conclusion by the healthcare provider originating the slang which rejects any argument or facts given by the patient since these arguments or facts are trumped by the provider’s own conclusion about the character or reliability of the patient. This is a logical fallacy since such a conclusion may be unwarranted. The explanation and facts provided by the patient must be logically evaluated separately for their validity and value and not invalidated by simply the provider’s personal decision regarding the patient as a person. The doctor can’t fairly make a judgment that the patient’s descriptions of pain should not be considered and reconsidered because the patient is known or suspected and described as a “druggie.” Some person on the street may say “that guy over there looks like a druggie” but that person is not required professionally to go beyond that assumption and so the statement may only be considered “unfair” or “uncouth.” My argument is that in a doctor-patient relationship such a slang expression by the doctor would represent a professional ad hominemimproperly affecting the doctor’s judgment regarding the history and facts presented by the patient.

For a number of reasons, including medico-legal, there is said to be a diminution in the general use of medical slang. Hopefully this is true and will continue to diminish. Certainly, expressions by physicians, nurses and other healthcare providers which are non-humanistic, are demeaning to the patient and indirectly to the profession itself and finally, as a consequence, allows a logical fallacy to be exercised, which distracting from and preventing proper clinical evaluation of the patient, cannot be considered of value to be continued to be used in medical communication.

Addendum: Beyond the issue of how derogatory medical slang may affect a physician's fair decision making  responsibilities, what do you think about medical slang in general, particularly if it was applied to you as a patient? ..Maurice.

"Incidental Finding": No Symptoms and Rarely Dangerous: Now What??

"Incidental Finding". The finding was one which was not sought for when a patient is being worked up to explain their symptoms and treat a disease, if present. The finding was not producing any symptoms. The dilemma for both the doctor and the patient is what to do if the examination or testing discloses an abnormality in the body not sought for.  And what, as is not uncommon, the abnormality is not normal as the word states but the abnormality has developed absolutely no symptoms for the patient and most of the time the abnormality does no harm to the patient if left alone and untreated.  Rarely, it may cause some symptom and rarely it would be considered dangerous, threatening the activities or life of the patient.  If the test had not been performed neither the patient nor the doctor would know about the abnormality. But yet, it was found and now what?  Just knowing may be very disturbing to the patient but also even for the doctor.  If the incidental finding was a growth, should the growth be removed despite routine procedure risks and financial costs to the patient?

The issue of the "incidental finding" in medicine was recently discussed at the Presidential Commission for the Study of Bioethical Issues and was written up in the Commission's blog, blog.bioethics.gov and a section of the discussion is reproduced below. My question to my blog visitors is how would you react and what would you want if you were told that you had such a "incidental finding".  Would you accept the risks and cost of doing something about the finding or would you go on the statistics and feel comfortable with the "incidental"
description and statistics? ..Maurice.

Incidental Findings in the Clinic: Extra Information and Extra Worry

Written by Bethany Brookshire on April 30, 2013 

During today’s meeting of The Presidential Commission for the Study of Bioethical Issues, it soon became clear that dealing with an incidental finding can involve more than just reporting to the patient impacted. As Haavi Morreim, J.D, Ph.D. Professor of Internal Medicine at The University of Tennessee Health Science Center, stated, there may be a difference between “standards by which care should be provided… and standards by which care should be assessed.”

Danielle Ofri, M.D., Ph.D., Associate Professor at the New York University School of Medicine, spoke of a patient with gastrointestinal pain. While Ofri, as her primary care physician, Ofri knew that the gastrointestinal pain was a common occurrence and probably nonthreatening. However, when her patient checked into the Emergency Room, the doctors, who did not know the patient’s history, performed a CT scan. The CT scan showed no cause of gastrointestinal pain. But it did turn up something else: “a 2 cm nodule in the right adrenal gland” or as Ofri wryly called it “The dreaded incidentaloma.”

Nodules in the adrenal glands are common, and while Ofri notes that 98% are entirely benign, in rare cases they can lead to problems such as the overproduction of hormones, or to cancer. “Nevertheless,” Ofri said, “once the incidental finding had been given life, so to speak, it was no longer incidental.”

Ofri had to refer to the standard-of-care for an adrenal incidentaloma, which involved a list of complicated tests. “As clinicians,” said Ofri, “we have a bias toward doing something, as opposed to doing nothing…Our patients, almost uniformly, want us to do something. Both doctor and patient are enthralled within this overwhelming medical imperative to act.” The tests would cost thousands of dollars, and also threatened to expend Dr. Ofri’s medical capital with her patient.

There was only so much time she had to spend with the patient, and with all of the information required to discuss the incidental finding, Ofri was obliged to skip over many other issues that the patient needed to have discussed, such as high blood pressure, cholesterol, and diabetes. These issues “…ended up with the short end of the clinical stick that day—an outcome” Ofri noted, “that is surely not incidental.”

Next, Carol Krucoff spoke of her experience as a patient who received an incidental diagnosis of a small acoustic neuroma. Even though her so-far benign neuroma has caused her significant anxiety, Krucoff stated that she would rather know about the presence of the neuroma than not. She recommended policies to help patients deal with incidental findings, including keeping patients informed in simple, direct language, training providers with communication skills to ensure both compassionate and clear communication, and to add a support person to the healthcare team, to help patients and their families process difficulty information.  And, she says “Unless it’s a necessity, don’t rush to treatment.”

Patient Modesty: Volume 54

It seems that back and forth comments on this thread continues the disagreement regarding which gender is subjected to or is suffering more from acts within the medical community which intrudes upon the patient's physical modesty, perhaps even causing psychological harm.  My view is this discussion shouldn't be relegated to a gender issue but directed to establishing changes in medical practice to be followed by all of its caregivers for patients of all genders.

For those who are first time visitors to this thread may benefit to follow the discussion by reading  the previous Volume "Patient Modesty: Volume 53".   ..Maurice.

Graphic: A repeat of the graphic I set for "Patient Modesty: Volume 4" June 26, 2008.

NOTICE: AS OF TODAY MAY 26,2013  "PATIENT MODESTY: VOLUME 54" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 55.

Are There Ethical and Legal Limits to Emotional Comfort?

"Creature comforts" have been usually defined as "things that contribute to bodily comfort and ease of mind as food, warmth or sleeping facilities" (The Free Dictionary). However, the "creature" in that definition is us. What if it is animal creatures that have been selected to provide the human with psychological comfort? And now we are talking about "emotional support animals" (ESA), which are a variety of animals which provide emotional comfort for their emotionally ill owner but unlike dogs for the deaf or blind or psychotic patients which are trained for specific duties, these emotional support animals are untrained but after being prescribed by a physician or psychologist or other therapist, the animal's owner has been provided with certain legal rights under federal and state laws to keep the animal with them in housing and travel.

Here is an excerpt from "Comfort Creatures" in the April 22 2013 issue of

Time Magazine: "Petey the pig contains multitudes. He is a beloved member of the Forgione household in suburban Whitestone, Queens. He is a bona fide form of prescription medicine. He is an enemy of the New York City department of

health. And on a spring afternoon walk with his owner, Danielle Forgione, 1-year-old Petey is just a pig pursuing wholesome piggish endeavors: snorting, grazing, rooting through the dirt, searching out bugs." Read the article.

A variety of animals have been used for emotional comfort from dogs, cats, pigs, horses, birds and even lizards. Though ESA have been shown to be of value to those in emotional distress, they all have not been fully accepted by others in all

environments. Indeed as of March 15 2011 in a revision of the Americans with Disabilities Act, those creatures which are not trained to perform specific services to a patient are no longer considered "service animals" and are no longer permitted in environments where they pose problems with regard to safety, sanitation or disturbance. A question can be asked as towhy in our society it is necessary to turn to lower animals to provide emotional comfort? Is there no adequate benefit available from inter-personal relationships. Or is a common denominator of the discomforted patient

the lack of personal ability to develop a helpful relationship with another person who could provide needed emotional support?

The issue of providing emotional comfort can be looked at beyond the use of ESA but also with regard to drug and alcohol abuse and other behaviors which society might look upon unfavorably. Beyond the treatments utilized for comfort, there is the overriding question of whether attempting to maintain emotional comfort is always an ethical "good" and should always be encouraged including with legal support if necessary. Does such comfort always provide a path to the betterment of the

individual or society? Shouldn't emotional discomfort be considered a natural and acceptable challenge to stimulate the individual to make constructive changes with improvements in his or her life and perhaps even in addition better the life of

others? What is your opinion regarding use of ESA but also that of the primacy of maintaining emotional comfort under all circumstances?  ..Maurice.

Graphic: From Wikimedia commons

Ethics: Not Hiring/Firing Those Who Smoke

There is a thread on this blog titled "Ethics of Smoking".  It was started in April 2009  In that posting, a visitor wrote that her insurance company was " threatening their employees who will not quit smoking with a dock in pay of $25.00 per pay period, until they decide to quit. The employees must have quit for 12 weeks before they can be reimbursed the so-called surcharge."

The issue of companies non-hiring prospective employees or penalizing or firing employees who do not stop smoking continues on as an occupational, public health and ethical issue and dilemma. There are two opposing commentaries in the Perspective section of the April 11, 2013 issue of the New England Journal of Medicine with each looking at the two sides of the issue. The first commentary "Ethics of Not Hiring Smokers" presents the following conclusion: "By cherry-picking “low-risk” employees and denying employment to smokers, employers neglect this obligation, risk hurting vulnerable groups, and behave unethically. The same goes for imposing high penalties on smokers under the guise of providing wellness incentives.
We believe that employers should consider more constructive approaches than punishing smokers. In hiring decisions, they should focus on whether candidates meet the job requirements; then they should provide genuine support to employees who wish to quit smoking. And health care organizations in particular should show compassion for their workers. This approach may even be a win–win economic solution, since employees who feel supported will probably be more productive than will those who live in fear of penalties."

Whereas the next commentary "Conflicts and Compromises in Not Hiring Smokers", the authors conclude "We recognize that these hiring practices are controversial, reflecting a mix of intentions and offering a set of outcomes that may blend the bad with the good. We know that many companies will want merely to continue their current level of anti-tobacco efforts, but given the threats that tobacco presents to our communities and institutions, we believe it's time to climb another rung on the ladder,,," [toward the final rung "Eliminate Choice: Make Smoking Illegal"].

Read both free articles (click on the above links) and then return and present your opinion here. ..Maurice.

Graphic: From Google Images and modified by me with Picasa3

Texting and Driving: Is That You and Is That Ethical?

The content of this thread is about the ethics of texting when driving and my visitor's views on this currently common activity. When one reads the statistics available regarding the  extent of the texting while driving activity and the known statistics of the outcomes of distracted driving,  unless my visitors represent a special statistical outlier population, it could be reasonable to consider that half of my visitors are out there texting and driving. Am I correct?

OK..what are the statistics? According to the article in the March 28 2013 issue of USA Today as extracted: Forget teenagers. Adults are the biggest texting-while-driving problem in the USA. What's worse — they know it's wrong.Almost half [49%] of all adults admit to texting while driving in a survey by AT&T provided to USA TODAY, compared with 43% of teenagers. More than 98% of adults — almost all of them — admit they know it's wrong. Six in 10 say they weren't doing it three years ago."I was a little bit surprised," Charlene Lake, AT&T's senior vice president-public affairs, says of the survey of 1,011 adult drivers. "It was sobering to realize that texting while driving by adults is not only high, it's really gone up in the last three years."  

Though statistics of death and injuries are not yet available regarding the activity of texting itself which is considered as distracting driving, according to US Government statistics "in 2011, 3,331 people were killed in crashes involving a distracted driver, compared to 3,267 in 2010. An additional, 387,000 people were injured in motor vehicle crashes involving a distracted driver, compared to 416,000 injured in 2010. 18% of injury crashes in 2010 were reported as distraction-affected crashes."  It appears that repeated texting while driving can be a habit of major health significance such as smoking, excess alcohol or illicit drug use. 

With regard to the ethics, an  activity or decision is ethical if the consequences can be shown to be an ethical "good" not a "bad" to an individual and if pertinent to others and society.  An example of an ethical "good" would be an activity which is of value to the individual or others without causing harm or that the value is of such a magnitude that it would easily trump the degree of harm which might occur. It is hard to argue that texting while driving is an ethical "good". but what do you think? And if you text while driving tell us how you personally look at this activity. Is this a habit of yours and if you think it is a bad habit do you feel motivated to break it?
You are writing anonymously, so speak up!  ..Maurice.

Graphic: Photograph taken by me today and edited with Picasa3.

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The Ethics of "Hand-Offs" in Medicine

The following original article which I wrote and was published today at the bioethics.net website is reproduced here with permission.  I will put some additional comments as an Addendum at the end of the copy. ..Maurice.

04/02/2013

THE ETHICS OF “HAND-OFFS” IN MEDICINE

Maurice Bernstein, M.D.

Here is a realistic scenario as written in the U.S. government’s Agency for Healthcare Research and Quality “Web M&M” website which could occur in any teaching or even in non-teaching hospital with hospitalists on duty.

An 83-year-old man with a history of chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), and paroxysmal atrial fibrillation with sick sinus syndrome was admitted to the cardiology service of a teaching hospital for initiation of dofetilide (an antiarrhythmic medication) and placement of a permanent pacemaker.

The patient underwent the pacemaker placement via the left subclavian vein at 2:30 PM. A routine postoperative single view radiograph was taken and showed no pneumothorax. The patient was sent to the recovery unit for overnight monitoring. At 5:00 PM, the patient stated he was short of breath and requested his COPD inhaler. He also complained of new left-sided back pain. The nurse found that his pulse oxygenation had dropped from 95% percent to 88%. Supplemental oxygen was started and the nurse asked the covering physician to see the patient. The patient was on the nurse practitioner (NP) non-housestaff service; however, the on-call intern provides coverage for patients after the NPs leave for the day. The intern, who had never met the patient before, examined him and found him already feeling better and with improved oxygenation with the supplemental oxygen. The nurse suggested a stat x-ray be done in light of the recent surgery. The intern concurred, and the portable x-ray was done within 30 minutes. About an hour later, the nurse wondered about the x-ray and asked the covering intern if he had seen it. The covering intern stated that he was signing out the x-ray to the night float resident, who was coming on duty at 8:00 PM.

Meanwhile, the patient continued to feel well except for mild back pain. The nurse gave the patient acetaminophen as prescribed and continued to monitor his heart rate and respirations. At 10:00 PM, the nurse still hadn’t heard anything about the x-ray so he met with the night float resident. The night float had been busy with an emergency but promised to look at the x-ray and advise the nurse if there was any problem. Finally at midnight, the nurse signed out to night shift, mentioning the patient’s symptoms and noting that the night float had not called with any bad news. The next morning, the radiologist read the x-ray performed at 4:00 PM and notified the NP that it showed a large left pneumothorax. Cardiothoracic surgery service was consulted and a chest tube was placed at 2:30 PM, nearly 23 hours after the x-ray was performed.   Luckily, the patient suffered no long-lasting harm from the delay.

The team subsequently learned that the night float resident had mistakenly examined the radiograph done immediately postoperatively rather than the chest x-ray done at 4:00 PM, and therefore did not see the film with the large pneumothorax.

The ethical issue is to preserve patient beneficence and to avoid patient harm. Although the Joint Commission—the organization in the United States charged, through scrutiny of practices to maintain patient safety in hospitals receiving federal payment—has mandated structured signout systems, it is still the personal professional duty of each healthcare provider to make those systems work. The systems themselves involve both written and verbal forms of communication and with regard to the verbal communication, the opportunity for both parties to ask and answer questions is considered important.

There is the problem with systems described on paper: how to convert words into effective actions. This hoped for reaction is limited, I think, by a virtual natural conflict of interests within each professional participant in the care of a patient. One interest is physical and mental comfort. Interns and resident physicians working long hours without adequate rest naturally experience fatigue and opportunity to leave work becomes a specific goal. Then there is the natural conflict between the physician’s work and personal life. Beyond these conflicts is a hidden but perhaps unfounded feeling or assurance regarding the capacity or intentions of the upcoming physician toward the attentive, understanding and thus constructive continuity of the patient’s care. That is why, I think, direct communication between doctors is essential and, of course together with the nursing staff. And then, there is the patient. I would think that another participant in the “hand-off” should be, if possible, the patients themselves. They should be introduced to the “new team” and not simply be the “stable post-pacemaker placement patient in Room 231″, an object to be discussed but otherwise not participating.

It is now understood that the action of “hand-off” from one patient care team to another is a critical part of the care of patients in terms of potentially creating medical errors and thus adding to the other errors that can occur in medicine and surgery. Patients may assume that these changes carry no risk. I think patients and their families should be made aware of the need, and patients—within their capacity—be a participant in this transition just as they are asked to monitor their medication or tests performed on them. Hopefully with all actively participating, both beneficence and non-maleficence will be the ethical result of this common hospital action, the “hand-off”.

____________________________________________

ADDENDUM:  I am curious regarding the understandings of my visitors.  When you were in the hospital as a patient  (if you ever were!) were you informed or were aware about "hand-offs" between nurses, nursing staff and physicians or between the physicians themselves? If you were informed, how was that done? Did the physician actually come into your room and identify him/herself?  Did you suspect the possibility of medical errors associated with "hand-offs" or actually had one happen? I'm just wondering.. ..Maurice.