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
"Pimping": Not About Sex-- About Medical Education"
This cartoon below is certainly a good example of "pimping" which has been for years, really generations a technique of medical education. I recently wrote the following to a professional medical educator's listserv:
The December 8 2015 issue of JAMA (Volume 314 No. 22) presents a Viewpoint article which I believe challenges us medical school teachers to find evidence of educational value in a practice carried out by medical school teachers and attendings which is apparently not rarely applied to their students. The practice is "pimping" and is defined in the article by referring to an 1989 JAMA article by Brancati: "a series of difficult and often intentionally unanswerable questions posed to a medical student or house staff in quick succession. The objective of pimping is to teach, motivate, and involve the learner in clinical rounds while maintaining a dominant hierarchy and cultivating humility by ridding the learner of egotism."
So what we must decide is whether this "pimping" is an effective and benign form of Socratic teaching or in most cases really a form of medical student "mistreatment"
To learn more about "pimping" in medical education, read this outline of the practice in eTalk.
The cartoon also brings up another issue as to whether "pimping" medical students, interns and medical residents not only may intimidate and emotionally "harm" them but could this behavior eventually harm the patient. A second year medical student writing in the Pulse website describes not only her own "pimping" but also witnessing her teacher "pimping" a clinic patient.
However, a surgical resident who read the Pulse story wrote me the following:
I may be in the minority when I say, I'm "pro"-pimping/Socratic method. I didn't think it was a fair analogy for the student to compare herself to the patient--the patient is not a medical professional. Making decisions with incomplete information is part of all of our jobs. I say this from the perspective of someone that still has to take written and oral boards as part of my board certification process. Practicing for oral boards is serial escalation of difficult questions.
Pimping exposes the things that "I don't know that I don't know". It is normal to feel defensive when you don't know the answer to a question and pimping teaches you to repress the "fight or flight" response, to acknowledge gaps in understanding, to maintain humility and to remain poised in the face of uncertainty. I consider pimping the surgical love language. How else does the attending quickly assess where deficiencies lie? How do you otherwise also motivate the student that gets great scores on standardized exams to keep studying? You don't take the time to pimp people when you're not invested in their education.You just ignore them.
My favorite attendings can always find me in a crowd of residents and call me out--it's how I know they still care.
So, what do you think about this form of "pimping"? Have you experienced such questioning as part of your own occupation or experience? If you are or were a medical educator would you use this technique to educate your students or could this really be only a form of self-interest on the part of the physician educator and intimidation of the student of any sort should not be part of the education process. Let's hear from you on this behavior. ..Maurice.
Graphic: From Google Images. Referred source: https://euuuh.com/
Patient Modesty: Volume 74
Throughout the entire discussion about the issue of patient modesty there is one issue that still hasn't been resolved. That issue is: within the "doctor-patient relationship" is there really any balance existing or required between the "needs" of the patient and the "needs" of the physician? Yes, there is imbalance in favor of the physician with regard to medical education and medical/surgical skills and the need to apply this knowledge and skills effectively for the patient. However, since it is the patient who has the illness and who is about to be diagnosed and treated should the balance with regard to "needs" be loaded on the patient's side because it is the patient who is ill and because the patient should have the primary interest and concern which then includes all matters of modesty? The physician's "needs", such as facilitation of time spent with the patient, assistance by others (which might include gender other than that of the patient) during interaction with the patient or other physician professional but self-interest demands, should bear far less weight on balance than the patient's modesty needs. On the other hand, shouldn't the goal be an attempt to balance the "needs" to provide a safe and effective outcome of any doctor-patient relationship? And, yes, in that balance some matters of patient modesty might be affected. I speak as the blog moderator and not as a physician as I present this issue of balance for discussion. ..Maurice.
Graphic: Balance--from Google Images
Right Way and Wrong Way: Making an Immediate Ethical/Legal Medical Decision
This thread is about what is the ethical and legal
"right way" and what is
the "wrong way" for doctors and nurses in an emergency room to
respond when they are in the act of attempting to save a patient's life and
then after resuscitation, started earlier by the paramedics, and was in
progress was told by the patient's surrogate to stop at once and let the
patient die, not allowing the opportunity to taper off the resuscitation and
observe possible recovery. Here is the
scenario as written as the Case Study in the September-October 2015 issue ofthe "Hastings Center Report" for which I have received permission to
Robert F. is an eighty-five-year-old who
suffered a heart attack at home in a rural location some thirty minutes from
any major hospital. By the time the paramedics arrived, he was unconscious and
nonresponsive. After spontaneous return of circulation, they began their
standard procedure of therapeutic hypothermia. Robert's core temperature was
lowered using ice packs, and cold intravenous fluids were initiated. Soon
afterward, Robert started to shiver when his body temperature reached 35.6°
Celsius. He was then given a bolus of vecuronium as a neuromuscular blockade,
sedated, and intubated. He was also given a low-dose vasopressin for
blood-pressure control. Shortly after Robert arrived in the emergency room, his
daughter, his medical decision-maker, produced an advance directive documenting
that her father has a do-not-resuscitate (DNR) order, and she demanded that the
breathing tube and any other life-sustaining treatments be withdrawn
The medical staff is very reluctant to comply
with this demand for immediate action. Until the neuromuscular blockade wears
off, removing the ventilator will prevent Robert from breathing. Furthermore,
it may take some time to reverse the therapeutic hypothermia procedure to the
point that the patient is at normal temperature. In addition, therapeutic
hypothermia itself often causes arrest, so the patient may need to be
Should the staff wait until the patient is
warm or honor the decision of his daughter, who holds his medical power of
stop all resuscitation at once will cause the patient to die while being
professionally treated and the patient's status for surviving without injury
would remain unestablished. This obviously was a moral "no no" by the
doctors and nurses since this act at this time might represent to them as
unprofessional "killing" of the patient. On the
other hand, to not follow the request of the patient through an advance
directive for medical care and the demand of the surrogate daughter, would mean
that the doctors and nurses were ignoring the legal and ethical autonomy of the patient.
tell me, which is the "right way" and which is the "wrong
way" for those medical professionals to act. ...Maurice.
Graphic: From Google Images
The "Dark Side" of Medical Education?
It is rare that a medical journal would publish an essay by a physician anonymously which describes the "dark side of medicine" and perhaps including the "dark side" of medical education. The article is in the August 18 2015 issue of the Annals of Internal Medicine
and in an editorial in the same issue, the following:
We hope that medical educators and others will use this essay as a jumping-off point for discussions that explore the reasons why physicians sometimes behave badly and brainstorm strategies for handling these ugly situations in real time. By shining a light on this dark side of the profession, we emphasize to physicians young and old that this behavior is unacceptable—we should not only refrain from personally acting in such a manner but also call out our colleagues who do. We all need the strength to act like the anesthesiologist in this story and call our colleagues “assholes” when that label is appropriate. We owe it to ourselves, to our profession, and especially to our patients.
So this "dark side" can be said to also involves those of us in involved medical education such as myself.. Perhaps medical educators are inadequately inspecting and controlling the content of the "hidden curriculum" being presented to medical students and not facilitating advice and support for those students and doctors who witness "dark behavior" to "speak up" to the perpetrators but also to superiors in administration.
an immediate response to the Annals essay. ..Maurice.
Graphic: From Google Images and modified by me with ArtRage and Picasa3.
Patent Modesty: Volume 72: NOTICE
"PATIENT MODESTY VOLUME 72" HAS BEEN CLOSED TO NEW COMMENTS SINCE AUGUST 5 2015 AND IS NO LONGER ACCEPTING COMMENTS.
YOUR COMMENTS ARE STILL WELCOME. PLEASE GO TO "PATIENT MODESTY: VOLUME 73"
Patient Modesty: Volume 73
So the issue now with regard to patient modesty and patient dignity issues in the care of patients is whether there is "broken" trust in the doctor-patient relationship, particularly with regard to the patient not trusting their physician or nurses. Or, one might argue, was there any trust from the very beginning of the relationship? If so, was the absence of trust because the physician or nurse did not offer evidence which would support trust by the patient or that patients enter or put into the relationship with the mindset that "all professionals in medicine are considered untrustworthy"?
Whatever the origin, it is clear from the comments on the previous Volumes that trust is a missing element in medical care and is clearly a part of any discussion of patient modesty or dignity. ..Maurice.
Graphic: From Google Images.
AS OF DECEMBER 8 2015, NO FURTHER COMMENTS WILL BE PUBLISHED ON VOLUME 73 BUT COMMENTS WILL CONTINUE ON VOLUME 74.
"Commercial Surrogacy": Women'$ Bodie$ as Container$
The title of this blog thread " 'Commercial Surrogacy': Women's Bodies as Containers" with the plural expressed with dollar signs may be a bit over descriptive but yet it emphasizes a commerce present today which is utilizing local women or bringing foreigners into the United States and elsewhere to directly participate in the pregnancy and delivery another family's genetic child. The question is whether this is a fair utilization and commercialization of a woman and her body and whether, after delivery and she is no longer a container for the pregnancy, she should be allowed to maintain some relationship to the child and the child's family.
This topic is, I think, very nicely described, in a paper by a PhD student Hannah Giunta on the Michigan State University Bioethics website. The ethical and humanistic point which is stressed by Ms Giunta is "Commercial surrogacy arrangements where prospective parents possibly supply the raw ingredients, sign a contract, and return for pick-up with the intention never to see the surrogate again require women to do fundamentally relational work without relational support or respect. Effectively, couples are saying,'You’re good enough to carry our child but not welcome as part of our family.' It’s this attitude that is unacceptable."
What I would like to see discussed here on this blog thread is both the ethical good or bad of this form of commerce but also Ms Giunta's concern that if such use of women and their bodies is socially and legally acceptable whether something more should be offered to these women: acceptance into the newly born child's family as a family member. ..Maurice.
Graphic: From Google Images modified with ArtRage and Picasa3..
Patient Modesty: Volume 72
What has been written throughout all these now 72 Volumes of Patient Modesty has been descriptions after descriptions of the "bad", thoughtless behavior of the medical system with regard to the dignity of the patients under the system's care. I have repeatedly voiced on this thread the need for my visitors now, beyond simply writing here about the problem, to make an effort to change the way the medical system "thinks" and "works".
I have found today evidence that the system is looking for ways to make changes in teaching, practice and behavior. The Association of American Medical Colleges (AAMC) has now publicized its attempt to make such changes. It is guided by a statement by the AAMC Board of Directors who in 2014"affirmed the value of fostering a positive learning environment with a formal statement that reads in part: 'We believe that the learning environment
for medical education shapes the patient care
environment. The highest quality of safe and
effective care for patients and the highest
quality of effective and appropriate education
are rooted in human dignity.'"
So, to my visitor, there you are: this major medical system organization involved in medical school education and the teaching of medical practice to the residents and fellows in this profession is looking for change. It is now your opportunity to write to the AAMC and express your concerns of the current system and your advice for the future. This will be your opportunity to "plant a good" which has a chance to flower. ..Maurice.
Graphic: From Google Images and modified by me with Picasa3.
Patient Modesty: Volume 71
I would like to start out this Volume 71 with a basic question to help define what is understood as physical modesty and how it applies to this issue as experienced by patients within the medical system. Is modesty of an individual only related to how the individual feels about their own personal exposure to others or does it also includes how the individual reacts to the exposure or "immodesty" of others? For example, is a patient expressing modesty when they see and react to a woman breast feeding her baby in public? or finding someone on the beach with a "bikini"? Does every patient who finds challenges to their modesty within their experience with doctors and nurses also are emotionally upset upon viewing, experiencing what is felt to be immodest behavior by others? In other words, does patient physical modesty concerns actually involve an individual's general philosophy regarding attention to modesty of self but, in addition, also of others? This distinction, I think, is important. ..Maurice.
Graphic: "Bathing Suits" from Google Images
NOTICE: AS OF TODAY FEBRUARY 25, 2015 "PATIENT
MODESTY: VOLUME 71 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE
POSTING COMMENTS ON VOLUME 72.
WOMAN'S BREAST MILK: SHOULD IT BE UP FOR SALE?
In case you didn't know, a woman's breast milk is a
commercially but also a nutritionally valuable commodity at least as an example
supported by Medolac Labs and Mother's Milk Cooperative. This milk is said to be needed by hospitalized
pre-term infants whose mothers are not yet lactating. I read about it in an article in the Michigan State University Bioethics website on lactation and the laws and actions which have been taken
including commodification of the woman's milk.
A scholarly article on the subject of the sale of mother's
milk was written in the Winter 2009 issue of the Nevada Law Journal
The sale of organs for transplant is not approved in the
United States, only donation. The
question arises as to whether it is ethical to have lactating women provide
their breast milk for sale. Is breast milk analogous to a solid organ?
How about comparing
selling the mother's milk to the legal commodification of eggs and sperm or
A physician ethicist
has reassured me on this topic:
There are American markets for buying and selling human
body parts, including blood, plasma, platelets, breast milk, hair, sperm, and
unfertilized eggs. The National Organ Transplant Act bans compensation for
organs, including livers, kidneys, and bone marrow. Flynn v. Holder adds the acquisition of hematopoietic
stem cells from circulating blood to the list of acceptable activities.
An ethical analysis suggests that the key characteristics
of these acceptable market-based donations of human body products are:
– The donated stuff can with time be regenerated.
– The injury to the donor is minimal and commensurate
with the sale price.
– The risks to the donor of more serious morbidity and
mortality are minimal."
And then, of course, there is the long history of
"wet nursing" when other women took on the task of nursing a child if
the mother was unable to do so.
To my visitors: Do you find any arguments against the
selling of the milk obtained from a
lactating mother and, if you do, what are they? ..Maurice.
Graphic: Migrant Mother, Dorothea Lange, Library of
Congress / Public Domain / Wikimedia Commons
Patient Modesty: Volume 70
The consensus of what is written here about the medical system's behavior toward attention to patient modesty including the ability of patients to select the gender of those who attend to patients is that IT IS TIME TO CHANGE and respond to their serious concerns. Changing a system requires education of the system regarding the need. This education can occur at the level of the single provider who is attending to the patient and may lead to specific changes for that patient but it is doubtful if such limited education unless done by millions of patients will make any significant community, state or national changes within the medical system. What is necessary is the formation of an advocacy group to educate and apply pressure on institutions, medical boards and governmental agencies to make effective and positive changes and meet the concerns of patients about their physical modesty and to prevent unintentional or intentional abuse by members of the medical profession and their institutions. ,..Maurice.
Graphic: From Google Images and modified by me with Picasa 3.
NOTICE: AS OF TODAY JANUARY 23, 2015 "PATIENT MODESTY: VOLUME 70 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 71.
Is Pregnancy a Disease?
a topic hot off the September-October 2014 Hastings Center Report, a bioethics journal, that should raise
a few eyebrows of agreement or rebuttal.
The point of the article
is if pregnancy is NOT a disease then healthcare providers who refuse to
perform abortions need not claim "conscience" as the basis for their
refusal but claim that pregnancy and abortion are not part of what medicine has
always been defined. The premise: "the scope of the very concept of
medicine and disease circumscribes the scope of proper medical practice. Procedures and activities that fall outside the scope of
medicine and disease are not properly within the brief of healthcare
and other healthcare providers can refuse to provide abortions if it is against
their religious or moral views. However,
it also a social understanding that every employee 's responsibility toward his
or her occupation in terms including of "taking on a job" depends
specifically on the what society expects from those trained for that work. You don't expect a plumber to perform an
appendectomy or a physician to design or construct a highrise building as part
of the criteria of the profession of medicine. So the argument could be that the duty to
perform the work of healthcare is set by the standards set by the work itself
and to refuse an activity which has not been formally set is acceptable. Pregnancy
itself is not a abnormal condition or disorder of a healthy life and therefore
a disease and for a healthcare provider whose professional responsibility is to
attend to the issues of disease or the prevention of disease, to be compelled
to terminate a normal life function without a disease basis could be considered
professionally unacceptable. What do you think? What view do you hold?
Graphic: Pregnancy. From
Patients Killing Doctors
A discussion starting on a
bioethics listserv to which I subscribe. The opening of the thread and followed
by 2 responses. Would you want and are you in favor for your physician to have a gun available in his or her office accessible for self-protection? ..Maurice.
The current issue of the New Yorker (Aug.
25, 2014) has a man-bites-dog story "Under the Knife" (pp. 30-35)
about an epidemic of doctor-killings by Chinese patients Physicians, of course,
have been (mostly inadvertently) killing patients throughout the history of
medicine. With a few notable exceptions ( e.g., Gabrielle Zerbi 1455-1505/9 who
was killed by the sons of one in retaliation for the death of one his patients
a Turkish Pasha), patients have seldom retaliated in kind.
This happens in the United States as well.
There seem to be three major categories
The "political murder" of doctors who perform
The murder of psychiatrists.
The murder of doctors because of the patient's believe that the doctor caused a
Then I suppose one must also include what Grace Paley called "the little
disturbances of man" where patients kill doctors over broken hearts. e.g.
Dr. Herman Tarnower,
And maybe another category, related to chronic care of end-stage organ failure.
Nephrologist in MA shot over dialysis scheduling issue. Left paraplegic
Transplant surgeon in FL shot by patient.
Does anyone believe this will not be seen increasingly with "open carry"
laws, and people bringing semi-automatic weapons on errands?
Graphic: From Google Images
Patient Modesty: Volume 69
As we continue on communicating about all the issues of
patient modesty, I find that I may have been suggesting a wrong approach for my
visitors to help resolve these issues: "speaking up" to physicians and the medical system.
"Up" suggests that the patient is somehow less significant and is
inferior in the patient-doctor/medical system relationship. And I don't believe this is true. Even though the
patient may be the one who is ill, to meet the medical system's professional responsibilities,
the system cannot act alone and must give equal attention to the patient as to
their own personal and operational interests.
So, as we move forward on this blog thread, working out ways
to communicate the needs of those who write here, let's change the suggestion
to "speak to..." as part of a more level "speaking field"
rather than the wrong view of "speaking up".
But as we begin Volume 69, let's remember that we have had 9
years and 68 volumes to "moan and groan" about the painful issues
that are seen but now is the time to change the discourse to one of presenting
a positive approach to attaining the needed relief by showing how the
participants here plan and have already started to change the system to meet
Graphic: From Google Images and modified by me with ArtRage.
NOTICE: AS OF TODAY NOVEMBER 14, 2014
"PATIENT MODESTY: VOLUME 69 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN
CONTINUE POSTING COMMENTS ON VOLUME 70.
Patient Modesty: Volume 68
As I have previously noted on this long running thread, there
appears to be a metamorphosis from repeated descriptions in various details of
personal physical modesty experiences and injuries to more generalized conversations with a philosophical, ethical or legal point of discussion. It is these latter postings which will be
more directed toward discussing ways to actually change the medical system,
either piecemeal or overall, to prevent or mitigate the possibilities that such
personal experiences as noted in previous Volumes will happen. It is my opinion now, whether or not the
experiences written here are statistical outliers, the problems previously
described on this thread and the potential consequences are of sufficient
importance that changes in the medical system should be made. ..Maurice.
The following Comments by Doug Capra and followed by myself, I think are important and pertinent in setting the goals of this blog thread after 9 years of presentations here.
"P.S.- I just thought of an explanation why many of our writers here over the past 9 years have stopped writing or have stopped visiting here. Could it be that all they have seen here is personal experiences and argument with me but absolutely no constructive approaches or attempts to make the necessary changes. Can't you all do more? ..Maurice."
That's precisely it, Maurice. For me, most of this thread is same old, same old, same old. Occasionally, someone provides the URL for an interesting article. Sometimes there's an interesting insight. I know there are some on this thread who are really doing things. I applaud them. I check this thread every once in a while, but I just don't have time to go through the repetitions to get to the new.
I'm on two hospital boards, one a governing board, and I'm on a standing committee for another hospital. I'm trying to work on the inside as a patient advocate. Working with doctors and nurses and with the crisis issues most hospital are dealing with these days, has given me insight into what's discussed here. I've gained great respect for most doctors and nurses. I make no excuses for blatant medical abuse and modesty violations. But more people on this thread need to get into the trenches and work from there.
We talk about trust and good relationships with doctors, nurses, mid-levels, cna's and patient techs. If we really mean that, we need to understand that it's about the relationship, not about any one individual. Frankly, it's not all about the patient. It's about the relationship.
That doesn't mean the patient must tolerate abuse or blatant violations of modesty. But, like everything else in life, if you don't speak up and fight, you'll occasional be taken advantage of.
I hesitated to even post this -- because I know some here will want to debate with me. I don't have time for that. I'm too busy with other projects. But I will always work to defend a patient dignity. You can be sure of that.
And following up with Doug Capra's "we need to understand that it's about the relationship, not about any one individual. Frankly, it's not all about the patient. It's about the relationship", how can the relationship be improved from both sides, the patient and the medical system and its providers? Education. Education to and for both sides which is still missing. What education?
The System needs to be educated about all of these concerns based on experiences which have been written here over the years and what have been the limitations both practical and psychologic limiting communication and to what degree the System's responses have been inappropriate and inadequate (or even surprisingly the opposite).
The patients, on the other hand, need to be educated by the System as to the current realities, practicalities and limitations of the System. (One reality is the unprofessional or "criminal" physician that can "pop up".) But both patients and the System need to be aware of the facts in order for the trust on both sides be strengthened and maintained.
With the education to both sides, then there can be a real chance for some creative cooperation to mitigate or even fully resolve the issues and problems related to each of the parties.
That is why, the next step here is to formulate ways to educate the System from the individual healthcare provider to the institutions. And, hopefully, with the help of Doug in his institutional relationship and position and mine in medical education can, in our ways, encourage the System to provide better education about their "current realities, practicalities and limitations" of the System.
You know, knowledge can be potentially therapeutic, as with all "therapy" if properly applied. ..Maurice.
NOTICE: AS OF
TODAY AUGUST 24, 2014 "PATIENT MODESTY: VOLUME 68 WILL BE CLOSED FOR
FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 69
Graphic: "Changing Course" (my title) From Google Images
Patient Modesty: Volume 67
So with Volume 66 reaching some 170 postings,
we should move on to this Volume 67.
What is special on starting this new Volume is the fact that
Artiger joined us in Volume 66. Artiger is a male physician (surgeon)
verified by the Medscape medical website, where we both participate, who has provided
us with the long-needed professional
input and education from the outside of this blog. It appears that those writing to this thread
have found his comments of interest and has accepted his presence here. I have no idea how long Artiger will stick
around but as long as he decides to do so, I will find him most welcome as a
significant contributor to the ongoing discussion. Here is Artiger's last posting from Volume 66.
Misty, participating in this blog
simply reinforced my current practice. I work on the assumption that everyone
cares about modesty. If you'll go back to my original comments (posted by
Maurice on June 26 at 7:30am), you'll see what I am thinking about during an
examination or procedure. When discussing breast incisions with women, I tell
them about where the scar will be, and my method of closure to achieve the best
possible cosmetic outcome. Many of them tell me that they don't care what it
looks like, and I respond by telling them that I care what it looks like.
I certainly understand if a female patient wants to drive another 100 miles or
more to see a female surgeon. Like I said, I've got plenty more here that come
to see me because of the service and courtesy I provide, not to mention how
quickly I get them in to see me or get their procedure scheduled. Some people
care more about that than gender. As an example I may have already mentioned,
in an area we used to live, my wife drove 100 miles (past 2 female OB/gyn's) to
see my best friend from medical school. Why? Because he gave her the best in care
and service. I didn't have to convince her, seeing him was her idea. Never
bothered either of us in the slightest, even when we would go visit them
socially or take trips with them.
Don, yes, discussing these issues and concerns are about half of the office
visit. Although we don't shave (we use clippers) we don't remove any more hair
than necessary, just enough to allow for a clear field for the proposed
incision. As for catheters, that is always discussed ahead of time as well.
Catheters are useful but they are not without their risks, and they are not to
be taken lightly.
No, the referring providers usually don't cover these things (they really
wouldn't have a clue where to begin, I'll tell you candidly), as it's not their
place to do so. That is what the office visit with me is for. If they could
discuss all these things adequately then they could just call and schedule the
procedure. I have never felt comfortable doing it that way, but there are a lot
of places where you can get a colonoscopy without ever meeting the person who
will do it. That's another part of my office visit that I feel is important...I
want the patient to know me, who I am, what I look like, have all of their
questions answered, and be comfortable with me as their surgeon.
AS OF TODAY AUGUST 3, 2014 "PATIENT MODESTY: VOLUME 67 WILL BE
CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 68
Ambroise Paré was a French army
surgeon in the 1500s who invented compassionate ways to handle wounds and
hemorrhages. The painting was done by Robert A. Thom in about 1954.
"P in a Pod":(Physician Owned Distributorship): Physicians as Investors and Distributors in the Gadget Placed in Your Spine
If you have chronic back pain and
your doctor refers you to an orthopedic surgeon who tells you that he or she
can relieve the pain by inserting an appliance in your spine, there is a worry
that the surgeon may be offering the surgery mainly for the surgeon's financial
interest in that very appliance.
A POD is a
Physician Owned Distributorship. Under this business model, a doctor is an
investor in, and distributor of, the devices or hardware he may put into his
patients. Multiple doctors can have a financial interest in one POD.
business arrangement legal?
In and of
itself the arrangement is legal, but the Department of Health and Human
Services’ Office of Inspector General has concluded that PODs are “inherently
suspect under the anti-kickback statute.” It issued fraud alerts about PODs in
2006 and in 2013.
find out if my surgeon is involved in a POD?
your physician is under no legal obligation to disclose that information. The
Sunshine Act, a provision of the Affordable Care Act, does require that each year,
certain medical device makers and distributors disclose to the Centers for
Medicare and Medicaid Services ownership or investment interests held by
physicians or their immediate family members. The law requires the Centers to
post online the first batch of information it received by September.
‘Sunshine Act’ require my doctor to inform me that he is involved in a POD?
No. You will
have to ask on your own, or search that Centers for Medicare and Medicaid
Services website when it is published. The Centers say the site “will be
organized and designed to increase access to and knowledge about these
relationships and to provide information to enable consumers to make informed
Yes, there are laws preventing
physicians from referring their patients to facilities in which they own and
invest for laboratory services or procedures. The Federal regulations called
Stark (after Pete Stark, congressman who was its primary sponsor) can be
summarized as follows: A physician may not make a referral to an entity for the
provision of a designated health service (“DHS”) for which Medicare payment may
be made (and the entity may not present a claim for services provided as a
result of such a referral) if the physician or an immediate family member has a
financial relationship with the entity unless either the referral or the
financial relationship is “excepted” from the statute’s coverage. To read more about Stark regulations, here is
the link to a paper by Homchick and Looney which explains its current status.
Please read the excellent KPCC article about this unsettled and unsettling issue and then return back here and
write what you would you think about Physician Owned Distributorship and its
implications regarding providing the least expensive but the best in medical
care. Balancing the right of private
investment by any person versus the need for unbiased decision-making and care
by your physician, how do you size up POD, ethically, legally and if you were
the patient with that back pain and were told "I have just the operation
that can fix it"? ..Maurice.
Graphic: From Google Images and modified by me with ArtRage and Picasa3.
Can a Tree Experience Hurt?: If It Can, Do Ethics and Law Apply?
I was visiting a well known botanic garden in Southern
California today, taking pictures of all the beautiful flowers when I saw this
tree shown above in the pictures I took.
Honestly, what I saw, a tree apparently being pulled by straps out of
its normal posture, pained me as I projected myself as if I were that tree. Of course, I am not that tree but then this
got me thinking about the bioethics of what had been done to the tree. (First of all, I want to admit that I have no
idea how long the straps were in place or for what future duration and what the
gardeners were intending to accomplish with the straps since I haven't talked
to the garden management. Finally, I am not sure that trees experience
Bioethics is not just about the ethics of humans and
animals, healthy or with disease but it is also about ethics dealing with the
plant kingdom. A current example of ethical concern is genetically modifying
plants, including those we eat. And the question that came to me was whether
what was done to the tree was unethical, that is, failing to meet the ethical
standard for the principles of beneficence (to do good) and non-malificence (avoiding
causing harm). But, though what I saw "hurt" me, the questions were
whether the tree, a living creature of the plant kingdom was, in its own way,
appreciating some "hurt" and with some ethical significance. Was the
tree recognizing discomfort? Was the purpose of the straps to benefit the tree
(which might be considered ethical) or to re-position the tree for its
appearance to the benefit of the viewing public? The latter might be considered unethical if
the tree experienced "hurt".
To try to answer my concerns, as I often do, I go to
Wikipedia to get a bit of help. I found
the article on Plant Rights which I have, as is permitted, reproduced
below. I would be most interested in the
viewpoints of my visitors and perhaps they have found additional information
regarding the science answering the question as to whether trees can "feel" or "express
distress" to physical discomfort. If they can, should they have themselves
certain "rights" both legally and ethically? The question is either
fascinating or just "dumb". Tell me what you think...Maurice.
From Wikipedia, the
On the question of whether animal rights
can be extended to plants, philosopher Tom Regan argues that animals
acquire rights due to being aware, what he calls
"subjects-of-a-life". He argues that this does not apply to plants,
and that even if plants did have rights, abstaining from eating meat would
still be moral due to the use of plants to rear animals.According
to philosopher Michael Marder, the
idea that plants should have rights derives from "plant
subjectivity", which is distinct from human personhood. Philosopher Paul Taylor holds that all life has inherent worth and argues for respect
for plants, but does not assign them rights. Christopher D. Stone, the
son of investigative journalist I. F. Stone,
proposed in a 1972 paper titled "Should Trees Have Standing?" that if
corporations are assigned rights, so should natural objects such as trees.
Whilst not appealing directly to "rights",
Matthew Hall has argued that plants should be included within the realm of
human moral consideration. His "Plants as Persons: A Philosophical
Botany" discusses the moral background of plants in western philosophy and
contrasts this with other traditions, including indigenous cultures, which
recognise plants as persons—active, intelligent beings that are appropriate
recipients of respect and care. Hall backs up his call for
the ethical consideration of plants with arguments based on plant
neurobiology, which says that plants are autonomous, perceptive
organisms capable of complex, adaptive behaviours, including the recognition of
In the study of plant physiology,
plants are understood to have mechanisms by which they recognize environmental
changes. This definition of plant perception differs from the notion
that plants are capable of feeling emotions, an idea also called plant perception. The latter concept, along with plant
intelligence, can be traced to 1848, when Gustav Theodor Fechner, a German experimental psychologist, suggested that plants are
capable of emotions, and that
one could promote healthy growth with talk, attention, and affection. The Swiss Federal Ethics
Committee on Non-Human Biotechnology analyzed scientific data on plants, and
concluded in 2009 that plants are entitled to a certain amount of
"dignity", but "dignity of plants is not an absolute
Inanimate objects are sometimes
parties in litigation. A ship has a legal personality, a fiction found useful
for maritime purposes... So it should be as respects valleys, alpine meadows,
rivers, lakes, estuaries, beaches, ridges, groves of trees, swampland, or
even air that feels the destructive pressures of modern technology and modern
life...The voice of the inanimate object, therefore, should not be stilled.
Samuel Butler's Erewhon contains a chapter,
"The Views of an Erewhonian Philosopher Concerning the Rights of
Constitution contains a provision
requiring "account to be taken of the dignity of creation when handling
animals, plants and other organisms", and the Swiss government has conducted ethical
studies pertaining to how the dignity of plants is to be protected.The
single-issue Party for Plants entered candidates in the 2010 parliamentary
election in the Netherlands. Such concerns have been
criticized as evidence that modern culture is "causing us to lose the
ability to think critically and distinguish serious from frivolous ethical
In 2012 a river in New Zealand was legally
declared a person with standing (via guardians) to bring legal actions to
protect its interests.
Stone, Christopher D. (2010). Should Trees Have
Standing? Law, Morality, and the Environment (Third ed.). Oxford
University Press. ISBN 0-19-973607-3.
Stone, Christopher D. (1972). "Should Trees Have
Standing--Toward Legal Rights for Natural Objects". Southern
California Law Review 45: 450–87.
Hall, Matthew (2011). Plants as Persons: A
Philosophical Botany. SUNY Press.ISBN 1-4384-3428-6.
Michael Heidelberger Nature from within: Gustav
Theodor Fechner and his psychophysical worldview 2004, p. 54
Graphics: Photographs taken by me June 12 2014