A Change of the Medical System to Patient-Centered Consumerism: Is that What You Want?

Here is what Donald M. Berwick, writing in Health Affairs May 2012 suggests a the way the medical system can really become "patient-centered" and not present only partial changes in that direction but, in my words, "not half cocked but going the whole way". So now look at this list of changes and see if this is how you would want your doctor, nurse, hospital and the whole system to behave.

(1) Hospitals would have no restrictions on visiting—no restrictions of place or time or person, except restrictions chosen by and under the control of each individual patient. (2) Patients would determine what food they eat and what clothes they wear in hospitals (to the extent that health status allows). (3) Patients and family members would participate in rounds. (4) Patients and families would participate in the design of health care processes and services. (5) Medical records would belong to patients. Clinicians, rather than patients, would need to have permission to gain access to them. (6) Shared decision-making technologies would be used universally. (7) Operating room schedules would conform to ideal queuing theory designs aimed at minimizing waiting time, rather than to the convenience of clinicians. (8) Patients physically capable of self-care would, in all situations, have the option to do it. 

This might be just the beginning of suggested changes just as sweeping as the ones that Berwick suggests.  Read the entire article and then return and tell us what changes would you as a patient and a consumer would additionally want to see? Also, do you have any criticism of the changes noted above or by my visitors? ..Maurice.

If You Were A Medical Student: How Would You Respond?

Think about being a 23 year old student who was in his or her first few weeks of medical school with the only experience in medicine as an occasional patient with a minor illness or having experienced the reactions to significant illness in the family. You are challenged in these early days of becoming a doctor to sit across from a real patient lying in a hospital bed and told to take a medical history with no immediate assistance by an instructor. When the history is completed, the instructor will discuss with you about your experience. You have already been instructed regarding the composition of the history though prior education of the details of how you should react to all situations which develop during the interview can never be complete. Therefore, when faced, at the time of the interview, with a decision of what to do or say next, what would be your response?  As a student, how would you handle the following three scenarios?  As the student's instructor, after the student tells you what happened, how would you support and further educate the student regarding the event?  By the way, as an instructor, I have been informed about each of these three scenarios later as brought to my attention by students looking for advice.  ..Maurice.

THREE SCENARIOS:

1. You are interviewing a 68 year old apparently competent woman patient with pneumonia and her 45 year old son is in the room who repeatedly interrupts your attempts to have his mother give the history herself by immediately responding with what he knows to each question. What would you do and what would you say?

2. You are interviewing a 33 year old red headed female flight attendant who is to have repeat right shoulder surgery by a different orthopedic surgeon because as she says the initial surgeon "botched the job". She says that she was left with more  pain and limitation of motion of the right shoulder after the first surgery. She tells you what she knows about the surgery and her subsequent symptoms and then asks you directly "What do you think about how my surgeon treated me?" What would you then say to her?

3. You are interviewing a 28 year old female 3rd year medical student from a medical school in another state. She is very sick with leukemia and appears very weak, pale with multiple bruise-lie spots on her skin and is short of breath with repeated spells of coughing, raising bloody sputum as she tries to move in bed. She doesn't seem to be able to cope with her illness now and is very restless and depressed.  She talks about her fear of dying and seems to be asking you, a first year medial student, to somehow give her some emotional support even though he had never met you before.  You, yourself, are very upset about what you see and know. There is a "lump" feeling in your throat and you are beginning to feel nervous and weepy with tears welling up in your eyes. What would you do at this point and what would you say?

Overcoming the Inevitable in Medicine: Doctors Simply Doing Their Best Under the Circumstances

There is the story of the two campers whose tent is about to be invaded by a hungry bear. Despite both knowing that a bear can outrun a human, when one camper noted that the other was putting on his running shoes and tightening the shoe laces, the camper asked the other "why are you doing that?" The other camper responded "I don't have to outrun the bear, I just have to outrun you!"

I think there are a lot of times in medicine when doctors are faced with the task of simply doing their best under the circumstances.  It is not that they are necessarily wholly incompetent, it is just that diseases, not the doctors, can have a way of controlling the outcome of the illness.  Physicians faced with such diseases in their patients such as cancers and other illnesses may rarely want to give up. They may decide to continue specific treatments to rid the disease, denying the obvious that the disease is overtaking the treatment.  Sometimes the patient or families encourage the physician in this regard. This is not at all an uncommon scenario presented to hospital ethics committees for consultation. 

There should be a time, however, when the doctor realizes and accepts the inevitable and begins approaches which are the best treatment and benefit for the patient under the circumstances. This may involve energetic palliative care, care to relieve suffering but treatment that no longer attempts to cure.  One cannot always think that doctors can outrun the inevitable but, like the camper, must find alternate ways to accomplish the best under the circumstances.   Any objection from my visitors?  ..Maurice.

Graphic: Hungry Bear from KRQE.com via Google Images.

IVF Ethics: Should an Embryo be Rejected Because It's Potentially "Sick"?

The more science provides folks techniques to manage infertility such as through invitro fertilization and then implantation and the more science also provides tools to determine before the embryo is implanted whether or not the embryo is "potentially sick" because it is carrying a serious genetic defect (preimplantation genetic diagnosis), society is faced with further ethical and legal dilemmas. Such a dilemma can be developed from the example above: should prospective parents who desire to have a child by undergoing invitro fertilization be required under law to first have their embryo diagnosed for a genetic defect and if a serious genetic defect is found, they be compelled to reject implantation? Could it be argued that such attempt at diagnosis and subsequent rejection be considered under law and ethics as in the potential child's "best interest"?  And, perhaps in the best interest of the future generations if this embryo was allowed to mature, be born and survive long enough to have its own children? On the other hand, is the general ethical and legal principle of parents "acting in the best interest of their child does not mean choosing the 'best child'"? The expression in quotes is the title of a rebuttal by L.S.Flicker in response to a view set by Malek and Daar discussed in the current April 2012 issue of  American Journal of Bioethics. But what is your thought on this subject?  ..Maurice.

Does End-of-Life, Hospice, Comfort Care Represent "Murder, Euthanasia, Killing"?

Surprisingly, after over 30 years of hospice care available for those who are terminally ill, the public and even physicians have interpreted end-of-life care, hospice and comfort care patient treatment as "murder, euthanasia and killing", Palliative medicine, treatment to relieve pain and discomfort, in patients who have no further treatment to resolve their disease is an established certified sub-specialty and yet physicians who perform this specialty are working under a cloud of such misperceptions. Read about this issue in Amednews (American Medical Association News).

Do you look at treatment by physicians, with the terminally ill patient's consent, to relieve the pain and suffering "murder, euthanasia or killing" just because the patient's life might be ended a bit sooner than if they were left untreated? Or might you look at pain unrelieved by the treatment of a doctor as "torture"? ..Maurice.

Spending A Lot of Money on Your Sick Dog or Cat: Is that Ethical?

From today's New York Times Opinion page: "Veterinary medicine has made big leaps in recent years, which is great news for ailing dogs and cats — but raises some tough questions for humans. With the availability of treatments like bone-marrow transplants and heart stents, it is now easy to spend $10,000 to $25,000 on medical procedures for a pet.

Knowing that many humans die of preventable illnesses, or even considering that many dogs and cats are euthanized in overcrowded animal shelters, can a person justify spending that much money to prolong one animal’s life? If so, is it ethical to have a pet if you cannot afford such treatments?"

I would add, "...and even if you could afford it, is it in the best interest of humans who could benefit from the money for its use in research and treatment of human diseases?  Is there a point where the life of a pet cat or dog becomes of less value than preserving the life and existence of it's owner or other humans in general?   

Go and read about this ethical issue and read the full commentaries by the 6 contributors to the discussion and the responses from the public.  Here is the introductions by each of the contributors:

 "When our 6-year-old Labrador was dying, the vet said, “There’s nothing we can do.” We weren’t prepared to give up so easily."

"Even if a treatment option is promising, people must consider the cost and caregiving burdens."

"When you acquire a pet, you sign up to care for it for the duration of its life — but not 'at any cost.'"

"The first question is: Will the procedure improve the quality of life for the pet, or prolong suffering?"

"Spending $10,000 on chemotherapy for your golden retriever is no more unethical than spending it on a two-week vacation in Tuscany."

"There is no shame in euthanizing a pet, if it is done out of love. Nor is there shame in spending money to prolong a pet's life."

Come back and write your opinions here.  ..Maurice.

Graphic: From Dogasaur blog

How Much Truth Should the Doctor Tell the Patient in View of the NOCEBO EFFECT?

 The "Nocebo Effect" is described in the Wikipedia article by the name Nocebo and begins as follows:

"In medicine, a nocebo reaction or response refers to harmful, unpleasant, or undesirable effects a subject manifests after receiving an inert dummy drug or placebo. Nocebo responses are not chemically generated and are due only to the subject's pessimistic belief and expectation that the inert drug will produce negative consequences."  

It has been through research using placebos to establish that such a negative reaction exists.  The real clinical and ethical importance of such a concept is with regard to informed patient consent with regard to potential medicine side-effects or in presenting to the patient a full description of the complications of any form of treatment.

 The  Nocebo Effect as discussed in an article titled "To Tell the Truth: The Whole Truth, May Do Patient Harm: The Problem of the Nocebo Effect for Informed Consent written by Rebecca Erwin Wells and Ted J. Kaptchuk  in the American Journal of Bioethics March 2012.  The Abstract of the article follows:

The principle of informed consent obligates physicians to explain possible side effects when prescribing medications. This disclosure may itself induce adverse effects through expectancy mechanisms known as nocebo effects, contradicting the principle of nonmaleficence. Rigorous research suggests that providing patients with a detailed enumeration of every possible adverse event—especially subjective self-appraised symptoms—can actually increase side effects. Describing one version of what might happen (clinical “facts”) may actually create outcomes that are different from what would have happened without this information (another version of “facts”). This essay argues that the perceived tension between balancing informed consent with nonmaleficence might be resolved by recognizing that adverse effects have no clear black or white “truth.” This essay suggests a pragmatic approach for providers to minimize nocebo responses while still maintaining patient autonomy through “contextualized informed consent,” which takes into account possible side effects, the patient being treated, and the particular diagnosis involved.

How much of the "good news" of a drug or other treatment or disease prognosis and how much of the "bad news", that is, side-effects of the drug, complications of the surgery or other procedures or disease outcomes (in view of the documented "nocebo effect" ) would you want to know from your doctor?

For those who want to read more on the issue "Is It OK for the Doctors to Lie?" go to my earlier thread on the topic and take a quiz about lying if you were the doctor in various situations.   ..Maurice.

Graphic: From the Wikipedia article.

Dying and Donating Your Organs but by Whose Criteria? Yours?:An Ethical and Legal Challenge All Should Consider

Stanley Terman,  M.D., PhD. who is Medical Director and CEO of Caring Advocates has written to this blog in January 2008  a commentary on the issue "Should Physicians Provide Information  so Patients Can Hasten Dying":

 http://bioethicsdiscussion.blogspot.com/2008/01/should-physicians-provide-information.html

Now Dr. Terman has offered us all an interesting addition to his previous suggestion to "Natural Dying" (stopping life-sustaining treatment and food and fluid if those treatments would be extraordinary and disproportionate, for example at some point along the downward trajectory of a terminal illness that may include unbearable pain, or lingering for many months or years if suffering from dementia.)

 In addition, he suggests voluntary vital organ procurement for donation, an act that would end the patient's life at a time when the process of Natural Dying has become clearly irreversible, while waiting for the patient to die would result in damaging the organs so they could no longer be gifts of life.Even though Dr. Terman’s suggestion may provoke some ethical or legal challenges, both he and I think it would be useful to obtain some feedback from people from a variety of backgrounds who may face such decisions on a personal level. (I personally have not as yet taken a position about it.) Dr. Terman tells me that we can expect his responses to your comments here. This issue is important enough that this suggestion and the link to Caring Advocates be offered to public for the purpose of furthering discussion.  So here it is on my bioethics blog for my visitors’ consideration and discussion. ..Maurice.

 

When asked by the Mayor of the Munchkins about the Wicked Witch of the East (on whom Dorothy’s house fell), the local Coroner answered: She is “morally, ethically, spiritually, physically, absolutely, positively, undeniably and reliably…” as well as “really and sincerely” dead. [L. Frank Baum’s, The Wizard of Oz, 1900.] Back then in “Oz,” death simply meant the cessation of heart and lung functioning. Today, modern medical technology can prolong a person’s biologic existence after major organs are so diseased they cannot function on their own, without “life-support” or “life-sustaining treatment.” The result has led to choices and conflict about which Mr. Baum could never have dreamed. 

Since 1968, we have been abiding by an ethical concept called the “Dead Donor Rule.” This means that physicians will never harvest organs from live patients. The political purpose of this rule is to give people confidence that if they cannot speak for themselves, others will not give up on them because they want to harvest their organs. Clinically, however, some physicians and ethicists consider it a fiction that patients are really “dead” by definition. They point out many ways in which such patients are still alive, although very sick, absolutely unconscious, and totally dependent on machines to remain… (yes, alive). Others argue that the neurological criteria for “brain dead” are sound in one important sense: clinical experience shows that patients who fail the test never regain consciousness. 

A further problem arises if a state or an institution uses a different set of criteria, one based on the functioning of the heart rather than the brain. Here, physicians take the patient off life-support and then they wait a certain amount of time to see if -- without medical intervention -- the heart will start again by itself; that is, without medical intervention. If the heart does not re-start itself, then the process is considered irreversible so death is inevitable, and then a doctor can declare that the patient is “dead” –according to local protocol and the current local definition of death. Note: In case you didn’t know, you are “legally dead” if and when a physician declares that you are “clinically dead.”

Here are two potential problems: First, does it really make any sense to say that the patient is dead based on “irreversibility” when the heart can, and in fact may be restarted with medical interventions? The reality is that such hearts are often donated to other patients and are then restarted. Second, how long should physicians wait to see if the heart can restart itself? Some people find this part scary. There is tension here between A) waiting long enough to give the donating patient a chance to live, and B) not waiting too long so that the organs become unusable because they were deprived of oxygen. Hence, the Institute of Medicine recommends waiting 5 minutes. Yet the Children’s Hospital in Denver waits only 75 seconds. Strictly speaking, that means a patient would be “dead” in Denver but still “living” elsewhere based on this criteria. By the way, these criteria have two names: “Donation after Cardiac Death” and “Donation after Circulatory Death.”

Suppose there is a way for you to decide, to describe, and to memorialize your own criteria so that others will know at what point you would NOT want life-sustaining treatment, and would therefore be willing to die? In that case, it would be YOU -- not a state, or an institute, or a hospital (which could change its definition between now and when you become unconscious and reach this end-stage disease) -- that would determine when you would let nature takes it course so that you could die and before that, donate your organs. 
Note that the decision that it is time for Natural Dying is not a decision to die, but to let the underlying disease takes it course when further treatment -- including food and fluid -- are deemed by the physician and the proxy/agent, to have become extraordinary and disproportionate.  Then... if the patient passes the point of no return, why should we let his/her body dehydrate so the organs are not usable, when they could be gifts of life to several patients? From what you have learned so far:

Question 1: Would you have more confidence in your own criteria, or would you rather depend on the potentially changing criteria that others will have established, when “that time” comes? The living will that determines “WHEN” can importantly choose a way to die called “Natural Dying.” This means to stop not only stopping all life-sustaining treatment including tube feeding but also assisted feeding and assisted drinking. Of course, you would always receive all the comfort care you would need to die peacefully by medical dehydration. This includes agents to reduce your thirst. (Hunger is rarely a problem.) Most people die within two weeks.

Question 2: Can you imagine conditions such as untreatable, unbearable pain and suffering, or advanced dementia, or a permanent coma -- where you would opt for “Natural Dying”? 

Now suppose your medical condition reached the state where you were ready for “Natural Dying,” and that, as a completely independent decision, you also decided to donate your organs.

Question 3: If you are conscious when you begin your total fast, then after several days of fasting, you will fall deeply asleep. After that point, you will not be able to change your mind to resume eating and drinking… So would you be willing to consent (in advance) to donate your organs? (Anesthesia will be provided to make sure you do not experience any pain.)  

Question 4: If your end-stage condition was devastating brain trauma or Advanced Dementia, you could have previously authorized your future physician and your proxy/agent to jointly determine “WHEN” you meet your own criteria for “Natural Dying.” Once they decide, your dying will be inevitable… So would you be willing to consent (in advance) to donate your organs? (Anesthesia will be provided to make sure you do not experience any pain.)   

Question 5: Overall, which set of criteria would you be more comfortable with: one established by a state, or institute or hospital…  or one that you decided for yourself?

Question 6: If someone suggested that your consent to donate organs when you reach your own criteria for “Natural Dying” violates the “Dead Donor Rule,” would you agree or disagree? Could you offer an argument to support your view?

Question 7: If someone suggested that your consent to donate organs when you reach your own criteria for “Natural Dying” is a form of euthanasia, would you agree or disagree? Could you offer an argument to support your view? 

Question 8: Do you have any other comments or questions?

(Note: the Natural Dying Living Will is available from a non-profit organization, whose website and email address are www.CaringAdvocates.org  and CaringAdvocates.aol.com)                 

                 

Play The Doctor: Four Clinical Situations

A physician interviewing or examining a patient may find him/herself in a professional clinical situation that the doctor had not experienced previously or even thought about and at once must decide how to respond to the situation in a manner which is ethical and professional and hopefully constructive and even of therapeutic value.  I have challenged my second year medical students to a discussion about how they would handle each of the four clinical situations  listed below.  Now I would like to challenge my blog visitors to do the same. Pretend that you are the doctor of the scenario and suddenly faced the patient's response. What would you do next? ..Maurice.

• 1) You ask the father of a child patient whether there are guns in the household and the father becomes angry and says "it's none of your business!"  
• 2) You are a male physician and your female patient of a few visits now says "I have taken a liking to you.  Can we go out tonight together for supper." 
• 3) You are trying to take the patient's medical history and the patient repeatedly returns to talking about different symptoms which his cousin is experiencing.  
• 4) You are attempting to perform a physical exam on a young but adult patient  and every time you touch the patient, the patient is repeatedly squirming around and giggling and responding "I'm very ticklish."   

Doctors "Should Do No Harm" but How About Carrying a Gun?

Is there any profession which is so dedicated to non-violence and "to do no harm" to others and particularly to those they serve? I am thinking about a priest or reverend or rabbi or others supporting their God.  I am also thinking about a physician. I found an interesting website (Brainblogger) and article regarding doctors and their access to guns either within or outside their office. There are also present a number of visitor comments and it seems that the majority find acceptance with regard to doctors having guns for self-protection and protection of their offices.  

But, what about the professional ethics of carrying a gun with the intent to shoot and most likely kill someone as a response to a threat to ones own life? Should doctors have some higher duty "to do no harm" if such harm could be prevented by not having a gun readily available?  ..Maurice.

p.s. On the other hand.  Here is another view of doctors and guns which has been seen on various websites but I don't vouch for all the statistics presented. However, I guess there are different ways of looking at the doctors and guns issue.

Doctors
(A) The number of physicians in the U.S. is 700,000.

(B) Accidental deaths caused by Physicians per year are 120,000..
(C) Accidental deaths per physician is 0.171 (17%).
Statistics courtesy of U.S. Dept of Health and Human Services.

Now think about this:
Guns
(A) The number of gun owners in the U.S. is 80,000,000. (Yes, that's 80 million !)
(B) The number of accidental gun deaths per year, all age groups, is 1,500.
(C) The number of accidental deaths per gun owner is .0000188 (.00188%)
Statistics courtesy of the F.B.I.
So, statistically, doctors are approximately 9,000 times more dangerous than gun owners.
Remember, 'Guns don't kill people, doctors do.'
FACT: NOT EVERYONE HAS A GUN, BUT ALMOST EVERYONE HAS AT LEAST ONE DOCTOR.
Please alert your friends to this alarming threat. We must ban doctors before this gets completely out of hand!!!!!

P.S. - Out of concern for the public at large, I have withheld the statistics on lawyers for fear the shock would cause people to panic and seek medical attention.

What is the Difference Between What is "Good" and What is "Bad"?

Perhaps, since what is a "good" for one person may be a "bad" for another, perhaps the question why should society bother to distinguish the "good" from the "bad" in the first place? Is it essential for society to define the differences in order to set standards acceptable to society with regard to individual behavior to prevent chaos: a conflict between persons who find one behavior to be acceptable and the other persons who find it unacceptable? And yet, one might wonder whether society, perhaps through political decisions and laws, are setting too many standards, too many decisions as to what is good and what is bad, perhaps more than what is really needed.  Actually, I shouldn't be blaming society in general since each individual in society may live their life with their own stereotypes of other's behavior or their own life experiences or possibilities as either good or bad. And these stereotypes may not be based on facts but more on feelings or moral beliefs.  What do you think? ..Maurice.

What's On Your Mind?: Medicine and Ethics

In the past 8 years, I have covered many, many topics regarding bioethics, ethics in general and ethics specifically as related to medical education and medical practice and I have many, many visitors who have contributed to the threads I have developed.  But, still, there may be a host of topics which I have not considered and which has troubled some visitor.  On this thread, I would like to hear about those topics which could be further developed or started as new. Google's Knol, a site where I was attempting to answer the ethics concerns of visitors there over the last few years is now being dismantled by Google. So, let's hear from you here if you have an idea or question. ..Maurice.

Gender Inequality and the Case of Contraception

Equality between genders.  Is that what our western culture should attempt to attain?  Would this be the most fair and just way for our civilization to move forward in the 21st century? There are attempts at beginning equality in employment, with women catching up to men in terms of responsibility and salary.  In medicine, my field, medical school student gender proportions are running close to 50-50.  In nursing, men have a long way to catch up.  In the management of home life along with care of the children, men are said to be more participatory these days than in the past allowing women to leave the house.

But also these days, women have been the political and philosophic or religious targets regarding issues of their potential for conception of new members of the family and the sustaining of pregnancy to delivery.  Currently, these issues have arisen with perhaps more civil and uncivil agitation than in the past with regard to contraception and abortion.  In the United States, these issues deal with the declared rights of women for control over their own bodies before and after pregnancy.  State laws are being written to suppress any such considered rights with requirements that can lead to severe penalties  applied to the women and their physicians if the requirements are not followed.   The goal of some creating such laws applied to women is to prevent contraception and diminish the opportunity for abortion.  Some laws are designed to subject women to severe legal penalty for various behaviors and acts during pregnancy which may harm a fetus.  It may require a woman's medical record to be scrutinized by government to assure that a woman is following  the rules.

And yet, in this area of potential restrictions regarding pregnancy as applied to women there appears to be no interest in gender equality.  Men have so far been immune from these laws which appear to favor conception and deny contraception for women or deny a pregnant woman control over her body. Specifically,  a husband who has a vasectomy for contraception purposes has so far not been under the watchful eye of the politicians  or their activists.  (There currently however is one exception in which a law proposed in Missouri by women lawmakers would make vasectomy for contraception purposes illegal.  It may not be formally debated or signed into law perhaps because of resistance by the male lawmakers.) And definitely men still have control over what happens to their bodies.

I wonder how my blog visitors feel about gender (either gender) inequality in general and the current gender inequality with regard to conception.  Write and let me know. ..Maurice.   

Patient Modesty: Volume 48

Yes, I do want to continue this thread despite its many year length. Why? Because the issues which have been presented here by my visitors over the years have not been resolved or even significantly beginning to be resolved and I do think that the issues presented regarding patient physical modesty and medical caregiver gender selection, even if only an issue for a small population of patients is still meritorious and need mitigation and resolution.  Every patient, even from a small population, should be treated humanely and given all the support they need during their interaction with the medical system.  If we, as professionals speak about "medical care" to ourselves, to patients and others, I do think that we should "care".  ..Maurice.

Graphic: "Helping Hands" from a Google resource site

Cyberchondria: "Doc, I Know My Diagnosis, Tell Me if I am Right"

With the widespread access to the Internet and all the "medical information" sites throughout, it is not surprising that "cyberchondria" (patient worries about diagnoses that they obtained by researching the Internet) is becoming a common experience for physicians to encounter.  Read the article in Amednews.com (American Medical Association News) about cyberchondria and return and let's talk about it.  What are the "goods" and what are the  "bads" aspects of this Internet educational opportunity?  ..Maurice.

A Doctor's Decision: Whether or Not to "Call the Cops"

A most interesting scenario was posted on Medpedia by Scott M. Dyck which I am, in part, reproducing here but you might want to go there to review the responses there but also feel free to make your comments here. If you were the doctor in this case, what would you do? ..Maurice.

You are a general practitioner and a mother comes into your office with her child who is complaining of flu-like symptoms. Upon entering the room, you ask the boy to remove his shirt and you notice a pattern of very distinct bruises on the boy's torso. You ask the mother where the bruises came from, and she tells you that they are from a procedure she performed on him known as "cao gio," which is also known as "coining." The procedure involves rubbing warm oils or gels on a person's skin with a coin or other flat metal object. The mother explains that cao gio is used to raise out bad blood, and improve circulation and healing. When you touch the boy's back with your stethoscope, he winces in pain from the bruises. You debate whether or not you should call Child Protective Services and report the mother. 

Doctor vs Computer: Can a Computer Make a Better Diagnosis?

I found this visitor question on a discussion forum:" i was debating this with some doctors who say that it would be impossible to program a computer to make diagnoses as well as they can. i find this pretty ridiculous. whatever thought process/string of questions they would use to analyze the situation are the same that the computer would be programmed to use. the compute:r would then analyze all available information, ask questions, analyze the answers and assign probabilities. in fact, it seems like this would be way simpler than some of the things computers have already been programmed for. what do u think?"


So what do I think? 

My opinion, as a doctor, is that  what is input into a computer for calculation is the most important  part of the process of making a diagnosis and deciding on a treatment program to benefit the patient.   No amount of computer power or access to data storage will substitute for the physician's input of the history and the physical findings of the patient.  A computer posing questions to a patient and the patient responding will never substitute for a direct doctor-patient communication.  There are many subtleties, nuances  of a history which can never be accessed by a computer, such as body language and verbal expressions  and there is no way for a computer to perform a complete and worthy physical examination.  A robot used in surgery still requires a doctor behind it and no robot will attain the skills to inspect, auscultate, palpate and percuss and then interpret  the findings.  To me, how complete and understood is the input of data both from a patient telling a history and the doctor performing a physical is the basis for the diagnosis.   Poor input will always lead to poor output.  And, finally, it will always take a doctor to analyze the results of the computer to confirm its diagnosis.  I would agree that the doctor with knowledge and with experience and then working together with the computer can be most productive of  the correct diagnosis.

So.. what do you think?

..Maurice.

Patient Modesty: Volume 47

We continue here the discussion regarding how the concerns about healthcare provider gender selection by patients and ways for the patient to be more comfortable with those who attend them can be brought to the attention of all those who provide service and maintain the status quo in the healthcare system.  ..Maurice.


ADDENDUM (1-16-2012)  On this date, PT, a long-time writer to this thread on Patient Modesty, wrote the following comment which includes a potentially valuable suggestion for a method for those who want to change the current medical system regarding patient modesty and caregiver gender selection.  This is what he wrote:
Alan said

" Rosa parks was a single woman who started
a movement with a single act of resistance,Malcolm X
took another path and my style is more like Rosa parks
than Malcolm."


My style is more like Genghis Khan until I
realized that the pen is mightier than the sword. My idea
to solve this issue is a 40 step process, meaning I have
put together 40 different avenues of approach over a
period of about 10 months.

Here is the first avenue, visit www.change.org
to start a petition. Now I suggest you start perhaps at a
hospital or clinic that you in the past had concerns with.
Others around the world will join the petition
and to be effective use multiple facilities in each city. Keep
in mind this is a medium to bring our concerns forward. The
first of many mediums we will use as I suggested in volume
46 of Dr. B's blog.


PT 


NOTICE: AS OF TODAY FEBRUARY 20, 2012 "PATIENT MODESTY: VOLUME 47" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 48

Graphic: From Google image resource modified by me with Picasa3.

Do Oaths and Rules Make a "Good" Doctor?

Do oaths and rules make an ethical and caring physician?  

In the realistic and present day world of medical practice, the way medicine is practiced both in terms of emphasis or de-emphasis of oaths, medical school teachings and established legal and professional requirements are going to be different between one physician and another. There are going to be shortcuts and at times excesses depending on the situation and even the mood of the physician. Doctors are going to take chances or they will strictly follow what they believe are standard operating procedures ("standards of practice"). Yes, the Oaths are there, the laws and professional requirements and all the tools for professional behavior as provided by the medical schools are there but in the end, each doctor in their own professional environment will obey them as they see fit at the time. And it is up to their patients and their colleagues to finally grade the doctor. 

Do oaths and rules make an ethical and caring physician?  My conclusion is "probably not". I think it takes more than that. And, if you agree, what "more" is necessary? Let's read your thoughts on the subject. .Maurice.

Should Doctors be Allowed to Strike?

Currently, there is a strike by 10,000 physicians at public hospitals in a state of India in an attempt to get better salaries and work opportunities similar to those in other federal hospitals in India. The government has suspended 40 doctors, and 390 others have been arrested for failing to perform their duties.

Over the years there have been physician strikes elsewhere in the world and in the United States for various reasons including the high cost of malpractice insurance.  A 2004 article in the American Journal of Bioethics by Autumn Fiester argues the ethics against walkouts by physicians, in this case the issue has been the increasing malpractice insurance cost rates not keeping pace with physician reimbursements.

   

My question to the visitors to my blog is whether physicians have a right to strike and if so for what reasons and  if they do, is such individual physician termination of services, without any replacement provided ethical? ..Maurice.

Patient Modesty: Volume 46

Continuing on with the discussion regarding issues of physical modesty in the context of medical care, there continues to be debate throughout these Volumes as to who is responsible for the contested inequalities in attention to these issues and what is necessary for the resolution of these issues.  Is there a conflict between the male and female gender, working apart, in attaining their own individual modesty goals or should both genders look to each other's physical modesty needs and desires and stand and work together to change the medical care system to meet all their goals? I suspect the latter is the wisest.  Perhaps the best suggestion for both genders to become active to the same cause and to get together on a website to develop tools for advocacy.  I would suggest checking in at Suzy's site where the goal is to do just that.  Here is her description of the Mission Statement and Goals:

MISSION STATEMENT:
We believe that each patient is an individual and as such has specific preferences and needs including what accommodations they require to maximize comfort when their modesty must be compromised in the medical experience. Our mission it to act as a liaison between patients and providers in establishing, understanding, and executing the policies and procedures essential to that end. When appropriate we will act as advocates for patients to achieve that goal through interaction, education, and referrals to both patients and providers.

GOALS: Our goal is to help patients achieve dignified and respectful healthcare through education and information. Everyone has different needs and expectations of their healthcare providers, and we provide choices and options in obtaining those needs. We understand that modesty, privacy, and respect are primary needs when facing procedures and we promote educating providers in the sensitivity of those needs.

ADDENDUM (12-23-2011)

 On 12-23-2011, Belinda wrote the following comment : Going back the the "Naked" article, it would seem that now is the time to write protocols for exams with dignity at the forefront with equal accessibility as needed for any kind of exam making draping practices uniform. It would give patients and idea of what to expect and do as much to relieve the awkwardness of such an exam. Any thoughts on this?

I responded with the following:

Belinda, an EXCELLENT suggestion! In fact, to make the suggestion even more productive.. how about the visitors here (even you PT) together create a final consensus list, a series of suggested protocols for attending to all the patient modesty issues experienced in medical care. The development of the list can written to this blog or Dr. Sherman/Doug Capra's or on Suzy's blog.

But not just writing this protocol list to our blogs.. the final consensus list should be sent to Dr. Atui Gawande who wrote the article "Naked" in the New England Journal of Medicine and which was the basis for our entire series of Volumes on patient modesty. As some of you may know, Dr.Gawande is now a very well respected individual for his analysis and writings about a host of important medical issues that need fixing or change. By this project on our part, this may be the most direct way, through Dr.Gawande, to get something moving rather than repeated moaning and yearning on our blogs. How is that for an idea? Again, thanks Belinda for a suggestion to get us all "off our butts" (so to speak). 



..Maurice.
Graphic: "Man and Woman Apart and Together"-Classic icons modified by me with ArtRage.

NOTICE: AS OF TODAY JANUARY 11, 2012 "PATIENT MODESTY: VOLUME 46" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 47

Should Patients Have Online Access to Their Medical Records?

Should all patients be given online access to their medical records? The British healthcare system is currently considering such a possibility. With electronic medical records progressively becoming the norm throughout the medical world, this access would be feasible but would it be wise? Certainly, there would be advantages to the patient who would readily see the written result of the office visit and could then, if necessary, confront the physician with corrections, additions and questions and in a timely fashion. But what are the negatives to such an idea beyond potential loss of patient privacy due to inappropriate or illegal computer access? For example, would this mean that the medical record would have to be written in words understandable by any patient rather than in more concise and professionally understandable terminology and thus perhaps degrade professional communication? Would such access more easily give rise to patients starting malpractice actions due to misunderstandings of what was written to the record? Could patient's be pressured by others (insurance companies or employers as examples) into providing access to the electronic records since they would be more readily available? What do you think? ..Maurice.

Do We Own Our Own Germs?: Ethics and Law in Research

From the current New York Times Sunday Review: IMAGINE a scientist gently swabs your left nostril with a Q-tip and finds that your nose contains hundreds of species of bacteria. That in itself is no surprise; each of us is home to some 100 trillion microbes. But then she makes an interesting discovery: in your nose is a previously unknown species that produces a powerful new antibiotic . Her university licenses it to a pharmaceutical company; it hits the market and earns hundreds of millions of dollars. Do you deserve a cut of the profits?
In on ongoing legal challenge to the patent law which allows isolated human genes to be patented and which was previously overturned, the Court of Appeals for the Federal Circuit of the United States returned a ruling earlier this year that these genes were not simply a product of nature, which would not be eligible for a patent, but indeed could be patented. So..who has the legal rights to that rare and valuable germ growing in your nose or that gene which was part of your body but the one that was recovered and used for, as an example, a genetic test for cancer? And beyond the law.. what are the ethics? What is the good vs bad, what is the right vs the wrong?

..Maurice.

When is Privileged Communication Not Privileged? The Law and Ethics.

Privileged communication is "an exchange of information between two individuals in a confidential relationship."

I present now three scenarios and look toward some wise visitors to this blog to provide me with some answers from the legal point of view but also a view of the ethics. ..Maurice.

Suppose a patient admits to his physician that he is emotionally upset and is having gastro-intestinal symptoms because he killed his wife and buried her body in the back yard and told others that she was on a vacation. Suppose a client who is about to be questioned by the police, admits to his lawyer that he killed his wife and buried her body in the back yard. Would the professional standard in each case see the admission as privileged communication and allow the professional to withhold the information to the police or courts that the patient or client admitted? Suppose the patient with symptoms and that same story went to his physician who was both a physician and a lawyer licensed to practice and revealed the killing but desired the professional as a lawyer to provide professional legal advice and, if necessary, defend his case. Could privileged communication still be preserved?

Patient Modesty: Volume 45

Doug Capra, a regular contributor to this thread, wrote a comment on November 1 2011 which I inadvertently didn't publish but which I think is valuable for our consideration of two issues related to the patient modesty discussions here. Read it and then read my analysis below. ..Maurice.

Relative to the current discussions -- In past posts, I've referenced an articled called "Not Just Bodies" which is based upon a study of the strategies and/or defense mechanisms doctors use to deal with body issues == which include not just nakedness and modesty, but also horrible accidents and diseases. The profession knows well about these issues and addresses them. A major problem, as I see it, is this: Some of the strategies they use protect them psychologically but do little for or actually psychologically harm the patient. Some doctors never really "get over" this issue but just put up fences to protect themselves. There are also studies out there using medical students showing how they deal with this issue. There are some related studies about nurses. I think a myth within the profession is that these issues can easily be hidden from the patient by covering up using these strategies. I question that. I think many patients pick up on this and it may affect their healing and/or psychological health. Most of us, medical professional or not, are often unaware of the face we are actually "showing" to others. It takes quite a bit of self-reflection and knowledge to be aware of this. My other concern is what I've started to call the "deprofessionalization" of medical care in this country -- for cost saving reasons. I'm not so concerned with what are called mid-levels (PA's and NP's) But the use of all kinds of various initialed (cna, cma, pt's, ma, etc.) nurse assistants, some with little maturity and/or training, in this country is frightening. Some have no actual scope of practice, work under the doctor's license, and can do whatever the doctor is willing to risk. It's this trend that bothers me most and IF, and I emphasize the IF, there's a tendency for people with sexual perversions (or other psychological defects) to enter the medical field, it would be in this area. And these are the people these days doing most of the bedside care and, more and more, even some invasive procedures.By Doug Capra

First, I agree that physicians, in order to emotionally not react or show to the patient that they are not unprofessionally reacting to the patient's nudity, may take on a bland, emotionally neutral affect which demonstrates to the patient a sexually inert physician. And since the physician is sexually inert, he or she expects the patient to be likewise. And particularly, if the patient doesn't verbally complain, the physician thinks that the current behavior is fully acceptable.

I also agree with Doug regarding a certain degree of inadequate screening of the motivations of those entering the medical field and particularly those whose time and money and life investments are truly minimal and perhaps sexual interest values may play a role beyond the desire to be a care provider for the sick.

So who can be called a "peeping Tom", the title of this Volume's graphic, is a matter open to discussion. Perhaps we all are "peeping Toms" or "Little Bo Peeps" at one time or another, but it never should be at the physical or emotional expense of any patient. And that is why I think that discussion and dissemination of the issues of patient physical modesty is so important in the consideration of the best patient care. ..Maurice.

NOTICE: AS OF TODAY DECEMBER 20, 2011 "PATIENT MODESTY: VOLUME 45" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 46