Bioethics Discussion Blog: June 2006





Sunday, June 25, 2006

Patient Responsibility: "Consider Participating in Medical Education"

Continuing on with the topic of patient responsibility which was mentioned in the Comment section of the last post on the “Tired Doctor”, there is an article titled “A Responsible Patient” in the April 2003 issue of "Virtual Mentor. In the article, the American Medical Association's Code of Medical Ethics, Opinion 10.02 , regarding patient responsibilities is quoted as

“to include, but not limited to the responsibility to:
1. Be truthful and express their concerns clearly to their physicians.
2. Provide as complete medical history as possible .
3. Request information or clarification when they do not fully understand their health status or treatment.
4. Cooperate with agreed-upon treatment plans and appointments.
5. Take personal responsibility when they are able to prevent the development of disease.
6. Consider participating in medical education by accepting care from medical students, residents, and others”

I was particularly intrigued by item 6 “Consider participating in medical education by accepting care from medical students, residents, and others”. I wondered whether patient’s entering a clinic or hospital for medical or surgical treatment really enter expecting they should consider being possibly altruistic by accepting care from “medical students, residents and others” as part of contributing to medical education.

Medical training hospitals routinely may have a statement about medical education, usually in small print, somewhere on their admission papers for the patient to sign but do patients really understand what is going on? Is there specific or verbal communication by the hospital or the patient’s personal physician about what is going on? How do patients feel about being interviewed, examined or cared for as part of medical education if they learn about this before the experience or only afterward?

As teachers of first and second year medical students, we routinely and directly ask patients if they would approve having a medical student interview and examine them, explaining what the student would be doing. If the patient, for whatever reason, rejects the offer, the patient is not criticized but we go on and try to find another patient. Since I don’t participate in medical education in the later years, I am not fully aware of the timeliness or degree of informed consent that is given to patients. But I suspect that it is not the same as what we do in the first two years.

I,personally, would be greatly interested in comments by physicians and patients about this subject. One particular point that I would be interested in knowing is whether physicians, themselves, would accept examination and care by those still formally learning. ..Maurice.

Wednesday, June 21, 2006

The Tired Doctor and Frivolous Phone Calls

An old joke:

The tired doctor was awakened by a phone call in the middle of the night.

"Please, you have to come right over," pleaded the distraught young mother. "My child has swallowed a contraceptive."

The physician dressed quickly; but before he could get out the door, the phone rang again.

"You don't have to come over after all," the woman said with a sigh of relief. "My husband just found another one."

Though this is just a joke, it does provide the lead-in for the discussion of frivolous calls to doctors and most disturbingly when the calls are at night. There is no doubt that often those calls which contribute to the establishment of a tired doctor are calls particularly at night that disturb the doctor’s sleep. The question is when is a phone call from a patient frivolous and when is it not? Are any phone calls to a physician “unworthy of serious attention”? If the answer is “yes” then one may ask: how can a physician evaluate a patient’s call? And finally, should patients themselves be responsible to screen their own call before placing it? Or if the patient makes the call, one should assume the call was already screened for importance. On the other hand, should every call received by the physician be taken seriously and some definitive action should be taken by the physician. I am not going to try to respond to these questions for you now but instead I would like to read the experience and views of physician and patient visitors to my blog. ..Maurice.

Monday, June 19, 2006

Tired Doctors: Solution?: Outsourcing In House and Out of House

The issue seems simple but it really is complex as hinted at by a letter to the editor of the New York Times by a physician Martin J. Blaser, M.D. and published June 16, 2002.
Dr. Blaser wrote in response to an editorial about “Sleep-Deprived Doctors”:

Surely most patients would prefer a fully alert doctor to one who is sleep-deprived. However, consider a different question: Would you prefer a tired doctor who knows you well to one who has never seen you before? The complexity and the stakes involved in this issue are high.

Also, the values we cherish -- including being available to people in need and the ability to take responsibility -- are inculcated in training programs where doctors are taught that ''the buck stops here.'' Will Americans be better off with a group of shift workers who, not fully understanding the natural history of illness, order more tests, and pass care to the next level of specialist? Or with doctors whose schedule is determined by the demands of the clock, not the needs of the patient?

The question of “outsourcing in house” including the use of hospitalists is one medical practice that might need further evaluation. Another,as summarized at the website of Healthcare Financial Management Association today deals with outsourcing out of house, actually to another country, perhaps one where it is daytime while it's night and time to sleep in the U.S.:

Outsourcing Radiology Abroad Eases U.S. Radiologists’ Stress, Night Call

It’s just a matter of time before more specialists rely on outsourced assistance, predicts the Los Angeles Times, which examined the trend of radiologists working in Switzerland, England, France, Australia, and the Middle East making and confirming diagnoses for patients in the U.S. Hospitals are using the outsourcing to relieve stress and night hours for radiologists here; however, there is also the potential for cost savings. Although the contract radiologists abroad are American trained, board certified, and licensed from the state where the images are taken, critics of the outsourcing worry that the practice is damaging quality of care, that lines of accountability are unclear, and that hospitals will be held liable for malpractice committed abroad.

Do you think that “tired doctors” deserve a rest and how best can this be done so that the care of the patient is better served? ..Maurice.

Thursday, June 15, 2006

More on Prisoner Interrogation and the Physician’s Role

The Physicians for Human Rights (PHR) has in the past weeks released their views of a recent directive by the Defense Department regarding the role of physicians in interrogation of prisoners and their views of the recent American Medical Association’s stand on the issue. The Physicians for Human Rights organization is said to “mobilize the health professions to advance the health and dignity of all people by protecting human rights. As a founding member of the International Campaign to Ban Landmines, PHR shared the 1997 Nobel Peace Prize.” The following press releases were provided to me by the Physicians for Human Rights. If there are opposing views, from my visitors, to those presented here, my Bioethics Discussion Blog is a place to discuss them ..Maurice.

Physicians for Human Rights Denounces New Pentagon Instructions on Medical Support for Interrogation

Physicians for Human Rights (PHR), a health professional organization that has served as a leading voice against torture and abuse of detainees in US custody, today denounced new Defense Department guidelines on the role of health personnel in interrogations, calling them “an assault on medical ethics, the professional integrity of military health personnel, the Geneva Conventions, and on US military tradition and discipline.”
[Moderator’s note: Here is the link to the complete U.S. Dept. of Defense ”Medical Program Support for Detainee Operations” directive: so that you can read it for yourself]

"The DoD directive released today by Assistant Secretary of Health Affairs, William Winkenwerder, Jr., puts doctors and other health professionals in the untenable position of assisting in the infliction of harm,” said Leonard Rubenstein, Executive Director of Physicians for Human Rights. “This policy takes the United States further away from the most basic medical ethical and legal standards”
These new guidelines directly involve certain military health personnel, particularly mental health professionals, in the interrogation of detainees, making them active parts of the Behavioral Science Consulting Teams (known as “BSCTs”). “Military medical leadership ought to protect the ethical commitments and honor of our dedicated military health personnel,” said Brigadier General Stephen N. Xenakis, MD (USA—RET), an Advisor to Physicians for Human Rights. “Instead, they are subverting the essence of the Hippocratic Oath and compromising the integrity of the health professions as a whole.”
"The Pentagon policy also explicitly allows clinical information from medical records to be used in interrogation, in violation of core ethical principles protecting the confidentiality of information provided by patients to their health care providers,” said Rubenstein.
Rubenstein noted that the guidelines conflict directly with new policies issued last month by the American Psychiatric Association (APA) and World Medical Association (WMA), which prohibit psychiatrists and physicians, respectively, from directly supporting individual interrogations in any way. The WMA amended part of the Declaration of Tokyo, setting forth medical ethics regarding prisoners and detainees, to provide that “physicians should be particularly careful to ensure the confidentiality of all personal medical information” and that “[t]he physician shall not use nor allow to be used, as far as he or she can, medical knowledge or skills, or health information specific to individuals, to facilitate or otherwise aid any interrogation, legal or illegal, of those individuals.” The American Medical Association is a member organization of the WMA.
"The WMA and APA position recognizes that even lawful interrogation is an inherently adversarial and coercive process,” Rubenstein said, “and that there can be no ethical role for a health professional in the inevitable, ensuing infliction of stress and harm to a subject’s health and dignity. The only way to protect the health professional’s essential function as healer is to protect them from the interrogation process altogether, as the WMA and APA have done.”
The threat to health professional ethics extends even further, Rubenstein explained. The Pentagon guidelines do not follow universally recognized standards of medical ethics to guide the conduct of the BSCTs or any other health personnel, nor do they require the BSCTs to comply with international humanitarian and human rights law endorsed or ratified by the United States, such as the Geneva Conventions or the Convention Against Torture. Instead, BSCT health professionals are authorized to engage in any interrogation-related activity that complies with “applicable” US law.
"The problem with that standard,” Rubenstein warns, “is that the Bush Administration has interpreted US law on psychological torture in a way that violates the Convention Against Torture, as was recently reported by the UN Committee Against Torture. The Administration has further denied the applicability of the Geneva Conventions to many detainees and, according to news reports, has sought to delete the most basic tenets of the Conventions from the sections of the revised Army Field Manual that govern interrogations. What’s more, the Administration has sought to undermine the enforcement of the ‘McCain Amendment,’ passed by Congress last year to reaffirm the absolute ban on cruel, inhuman and degrading treatment by all US personnel. The net result is that health personnel participation in psychological forms of torture are not prohibited by these guidelines because they do not violate the Administration’s interpretations of US law.”
The Pentagon directive also instructs health professionals to violate ethical standards regarding hunger strikes, Rubenstein added, by instructing them to force-feed detainees who protest against their conditions of confinement by denying nutrition. Earlier this year, PHR and 250 leading doctors from around the world condemned the brutal force feeding methods used by military personnel in a campaign to break the will of hunger strikers at Guantanamo Bay.
The American Medical Association has also clarified that medical ethics generally prohibit force feeding hunger strikers. In a March 10, 2006 statement, the AMA said that the Association “has shared with U.S. military officials its position on hunger strikes or feeding individuals against their will. Specifically, the AMA endorses the World Medical Association's Declaration of Tokyo, which states:
‘Where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially. The decision as to the capacity of the prisoner to form such a judgment should be confirmed by at least one other independent physician.'"
"The new Pentagon directive flies in the face of these established ethical guidelines, Rubenstein said, “and open the door to painful and abusive force-feeding methods intended to discourage detainees from calling attention to inhumane conditions of confinement through this form of protest. It is beyond ironic for the Pentagon to justify its unethical force-feeding policy by claiming concern about the health and well-being of detainees.”

PHR Welcomes American Medical Association's Adoption of Rules Against Physician Involvement in Interrogation; Pentagon Must Commit to Adhere to AMA's Guidelines

Today in Chicago, the American Medical Association's (AMA's) House of Delegates adopted ethical guidelines that make it unethical for physicians to participate in the interrogation of detainees, such as those held at Guantanamo Bay and other US facilities. The new ethical guidelines appear to conflict directly with the rules released last week by the Pentagon for guiding the involvement of military physicians and other health personnel in interrogations. The guidelines, drafted under the guidance of Assistant Secretary of Defense for Health Affairs, William Winkenwerder, find no ethical obstacle to physicians playing an active role in the interrogation process.
"The new AMA policy goes a long way toward protecting the ethical commitments and integrity of all military medical personnel," said Leonard Rubenstein, Executive Director of Physicians for Human Rights. "While the AMA rule leaves a bit more room for interpretation than do the other medical association policies - something the AMA can and should quickly remedy - we believe this policy can only be read as an unambiguous rejection of the Pentagon's use of military physicians to support individual interrogations, as BSCT members or in any other capacity."
The AMA's action is the latest in a recent series of forceful statements from the medical community that repudiate the Pentagon's efforts to use medical knowledge and skill in the interrogation process, which, in even lawful interrogation, is inherently coercive and adversarial. In rejecting a role for physicians in individual interrogations, the AMA joined the American Psychiatric Association (APA) and the World Medical Association (WMA), both of which adopted explicit policies last month absolutely prohibiting physicians from participating in the interrogation process.
"The AMA acted today to defend the basic principles of medical ethics and to protect the men and women bravely serving our country as military health personnel," stated Brigadier General Stephen Xenakis, MD (USA-Ret), an advisor for Physicians for Human Rights. "Since 2001, the civilian leadership at the Pentagon has been engaged in a full frontal assault on the basic standards of medical and military ethics, from the Hippocratic Oath to the Geneva Conventions. All the major medical associations are now standing together to demand that this administration respect the core values of both the health professional and the soldier."
The new ethical policy adopted by the AMA prohibits physicians from directly participating in interrogations, from helping to plan and develop interrogation strategies on individual detainees, and from intervening in specific interrogations. This prohibition is needed, according to the new policy statement, to protect "the physician's role as healer" and to preserve trust in the medical profession.
Like the AMA, the new American Psychiatric Association policy prohibits psychiatrists from direct participation in interrogations, including "asking or suggesting questions, or advising authorities on the use of specific techniques of interrogation with particular detainees." The WMA rule, adopted with the support the AMA at last month's meetings, similarly provides that physicians may not "use, or allow to be used, as far as he or she can, medical knowledge or skills, or health information specific to individuals, to facilitate or otherwise aid any interrogation, legal or illegal, of those individuals."
The Pentagon's guidelines, however, require certain health personnel, particularly psychiatrists and psychologists on Behavioral Science Consultation Teams (BSCTs), to participate directly and extensively in the interrogation of individual detainees, and they facilitate the unethical disclosure of confidential medical information.
"The Pentagon must immediately revise its guidelines and rescind all regulations permitting the use of physicians and psychologists in individual interrogations and as part of the BSCTs." Rubenstein added that the AMA, APA and other medical associations can be expected to press for elimination of the BSCT role in view of their new policies banning direct physician involvement in interrogations.
Elaborating on the new limits imposed by the AMA on physicians in interrogations, Rubenstein emphasized that "no participation in individual interrogations is authorized by the new AMA rule. Physicians are only permitted under the rule to help develop interrogation strategies for 'general training purposes,' provided those strategies do not threaten or cause harm, are humane, and do not violate detainees' rights. We are deeply concerned even with this level of involvement," Rubenstein said, "because of the ambiguity of that qualifying language. It's simply not reasonable to require a physician to determine, in the abstract, whether a particular interrogation strategy will or will not be used in a way that inflicts harm, or whether it is clearly 'humane' or legal. Given the nature of interrogation, we believe it best, as the APA and WMA policies do, to insulate physicians entirely from the design of interrogation strategies, and we hope the AMA will fine-tune its policy accordingly."
Rubenstein also suggested that the AMA also should continue to refine its policy on confidential medical information to provide greater protection against disclosure to interrogators. "In stark contrast to the Pentagon guidelines," he said, "the new AMA rule significantly restricts physicians from disclosing information they obtain from detainees when providing medical care. We urge the AMA to go one step further, as the WMA has done, in requiring physicians to do what they can to prevent interrogators themselves from gaining direct access to detainees' medical information."

In the wake of the three suicides of detainees over the weekend that were being held at the US detention facility in Guantanamo Bay, Cuba, PHR strongly called for the Pentagon to grant access to Guantanamo and other facilities to independent medical and human rights experts and to publicly commit to vigorously enforce the McCain Amendment's prohibition against cruel and inhumane treatment of detainees, including the use of psychological torture. The group also reiterated its standing call for the Pentagon to end the force feeding of hunger strikers at the facility, a practice that is against the Declaration of Tokyo, the World Medical Association's prohibition of force feeding of voluntary hunger strikers.

Wednesday, June 14, 2006

Physicians' ResponsibilityTo Whose Trust: Patients vs Society

Matthew K. Wynia, MD, MPH, FACP, Director, The Institute for Ethics American Medical Association, a physician ethicist, posted today comments to a bioethics listserv which really covers a number of issues which I have written to this blog (doctors conflict of inteest, patient trust in physicians, what should be written in patients' charts) and including the last post here regarding the issue of physicians attending the prisoners at Guantanamo Bay. His comments are reproduced below with his permission. Of course, Matt writes for himself and is not necessarily representing the views of AMA in this posting. I would be interested to read what my visitors think about his views. ..Maurice.

Physicians – and all professionals – have an inherent dual role in society. We care primarily for our individual patients, and we promise that we will put their interests first. And because we do so, they confide in us, stand naked in front of us, allow us to touch and even cut them and, in sum, they trust us with their lives.

At the same time, we promise the community as a whole that we will use our skills and knowledge also to protect social goods and values. We will not take bribes to prescribe controlled substances – even when our patients want them. We will not write inappropriate work or school excuses, instead try to help our patients re-integrate into the community. To protect the public, we report into the public health system when a patient has a contagious disease, etc. Because of these promises, we are given a state-sanctioned license that allows us to touch and cut, and provides us with a number of unique social privileges (such as control over the use of narcotics, and sick days).

In brief, physicians earn patients’ trust by promising to look out for their best interests, but we earn the social right to do so by promising society that we will, as a group, take seriously our civic roles. This balancing act is not easy, but it is core to the effective functioning of medical professionalism in society.

Often, our obligations to the community (the state, if you will) and to individual patients are in perfect concert. But sometimes they are not. In some such cases, we must stand up to our patients’ demands, and refuse (for example) to ‘fudge’ information on a form that might allow a patient to get a handicapped parking permit, or social security benefits. This isn’t always easy, given the personal relations we have with patients and our well-known promise to always put their interests first, but it is part of maintaining our professional integrity. In other cases, we should stand up to the community or state and stand by our patients. Such was the case in the event of managed care ‘gag clauses’, for example, which would have prevented physicians from discussing medically appropriate but uncovered services with their patients. The profession said that even though such contracts might be legal, they were unethical and should not be adhered to. That’s also part of maintaining professional integrity.

The question of whether or not to put information in the medical record because to do so might harm one’s patients is actually an old one – but not one to which an easy answer is obvious. A number of doctors do, in fact, keep ‘shadow records’ or they just don’t write some information into the record and rely instead on memory But there are a lot of problems – both ethical and practical – associated with this practice. Legally, the record is supposed to be complete, and a doctor can be held accountable for inaccurate or incomplete record keeping in a variety of ways. On the other hand, ethically, it would be wrong to write down information if you were convinced that doing so would end up harming your patient.

In this specific instance, newer military policies have made increasingly clear that interrogators – inlcuding any health professionals involved (eg, psychologists) – are not supposed to have access to detainee medical records. And if any non-treating personnel do access detainee records, this event must be documented and justified in writing. The hope is that under these new rules abuses will not recur and it is now safe for military health professionals to record full information in detainee records… but it is very hard to know what the actual practices are, or were, since no independent investigation has yet occurred.

As a side note, I think there will need to be a full and independent investigation into medical practices at GTMO and elsewhere before military medicine can fully restore its credibility in this regard. I believe that many military medical personnel would welcome such an oppourtunity to clear the air. But it’s unlikely to happen under the current administration, which is sad. The military medical personnel I’ve come to know over the last few years are by and large some of the most integrity-oriented people I’ve ever met, and they would be extremely well-served by an independent, open review. But they are also very well aware of the importance of civilian control over the military, and the civilians in charge of the military today appear to have something to be afraid of in ordering an independent review of the medical policies and practices they’ve tried to implement at GTMO and in Iraq, Afrghanistan and other unnamed detention sites around the world.

Tuesday, June 13, 2006

AMA Takes a Stand: Physicians NOT to be Involved in Interrogation of Prisoners

I have previously posted about the ethical issues related to physicians’ conflict of interest by “wearing two hats”. Currently in the news is the issue of physicians who are involved in caring for those imprisoned in Guantanamo Bay by the U.S.Government. The basic requirement to preserve the ethics of the profession of medicine is that physicians must not engage in interrogation or contribute to the interrogation of prisoners.

Matthew K. Wynia, MD, MPH, FACP, Director, The Institute for Ethics at the American Medical Association has provided me and other subscribers to a bioethics listserv the following policy, developed and recommended by American Medical Association (AMA) Council on Ethical and Judicial Affairs and which was adopted yesterday by the American Medical Association, regarding physicians and interrogation. The AMA now has officially taken a stand, which is similar to that of the World Medical Association and the American Psychiatric Association. ..Maurice.

For this report, we define interrogation as questioning related to law
enforcement or to military and national security intelligence gathering,
designed to prevent harm or danger to individuals, the public, or national
security. Interrogations are distinct from questioning used by physicians to
assess the physical or mental condition of an individual. To be appropriate,
interrogations must avoid the use of coercion-that is, threatening or causing
harm through physical injury or mental suffering. We define a "detainee" as a
criminal suspect, prisoner of war, or any other individual who is being held
involuntarily by legitimate authorities.

Physicians who engage in any activity that relies on their medical knowledge and
skills must continue to uphold ethical principles. Questions about the
propriety of physician participation in interrogations and in the development of
interrogation strategies may be addressed by balancing obligations to
individuals with obligations to protect third parties and the public. The
further removed the physician is from direct involvement with a detainee, the
more justifiable is a role serving the public interest. Applying this general
approach, physician involvement with interrogations during law enforcement or
intelligence gathering should be guided by the following:

(1) Physicians may perform physical and mental assessments of detainees to
determine the need for and to provide medical care. When so doing, physicians
must disclose to the detainee the extent to which others have access to
information included in medical records. Treatment must never be conditional on
a patient's participation in an interrogation.

(2) Physicians must neither conduct nor directly participate in an
interrogation, because a role as physician-interrogator undermines the
physician's role as healer and thereby erodes trust in the individual
physician-interrogator and in the medical profession.

(3) Physicians must not monitor interrogations with the intention of intervening
in the process, because this constitutes direct participation in interrogation.

(4) Physicians may participate in developing effective interrogation strategies
for general training purposes. These strategies must not threaten or cause
physical injury or mental suffering and must be humane and respect the rights of

(5) When physicians have reason to believe that interrogations are coercive,
they must report their observations to the appropriate authorities. If
authorities are aware of coercive interrogations but have not intervened,
physicians are ethically obligated to report the offenses to independent
authorities that have the power to investigate or adjudicate such allegations.

Sunday, June 11, 2006

Truth Telling in Medicine: “Tell all the Truth but Tell It Slant”

I have posted many times in the past about truth. Truth is an important component of the fiduciary responsibility of the physician to his or her patient. But as with the physician’s prescription of a medication for treatment of a patient's illness, the maximum dose is not often the appropriate dose to prescribe, should the dose of truth administered to a patient be titrated too? But is a little truth not really truth at all?

With the words of Aristotle, “Poetry is finer and more philosophical than history; for poetry expresses the universal, and history only the particular”, I have looked to poetry for help in this ethical issue. I found the poem by Emily Dickinson titled “Tell All the Truth” which reads:

Tell all the Truth but tell it slant
Success in Circuit lies
Too bright for our infirm Delight
The Truth's superb surprise

As Lightening to the Children eased
With explanation kind
The Truth must dazzle gradually
Or every man be blind

I am not sure the poem has helped me in considering telling the truth in medical practice. Do doctors really know the real “truth” that they may pass on to their patients? Certainly there are unknowns. When the patient asks the physician “how long do I have to live?”, can the doctor know the truth to answer the patient? If the doctor doesn’t know the truth, should he or she simply say to the patient “I don’t know”? If you were a patient, would you want the doctor to tell you “the truth and the whole truth” or just a bit of the truth? If you were the doctor would you “slant” the truth as Emily Dickinson suggest? Any answers? ..Maurice.

Thursday, June 08, 2006

Is Ethics Immutable or Can Ethics Change?

I would like to expand the ethical issue discussed in the comments about the
last post. to a discussion about an aspect of the discipline of ethics itself which I never previously written. In the Comment section of the last post, I wrote:

Getting a bit more academic about ethics: Is ethics as a discipline really immutable? Isn't ethics fundamentally a consensus of society's "outlooks" as to what is right and not simply and totally based on the "straight timber" rigid teachings of specific people over the centuries? Isn't there something as democratic ethics? If not, then why not? I realize that what I am writing may sound to an ethicist as intellectually immature, but I never have held myself out as an ethicist and for the education of myself and my blog visitors, it might be valuable to discuss this point. ..Maurice.

Ethicist Bob Koepp, then responded as follows:

Maurice -
You're asking a very difficult question about the objecivity of ethics. There are many very thoughtful people who would disagree, but I happen to think that ethics concerns objective truths about this world. I don't think we can turn to any authorities to tell us what is ethically right or wrong. And I don't think that consensus, even democratically reached consensus, is what determines the answer. All we can do is think, as clearly and critically and honestly and we are able, about how we should live. And then we should have the humility to admit that, in all probability, our best thoughts on the subject are not the last word.

My response to Bob: If objective truths can only be established by subjective means, then why can't we all vote on the issue of what is ethically right or wrong.
Anyone else have a view? ..Maurice.

Wednesday, June 07, 2006

Changing the System: Medical Mistakes and Unprofessional Behavior

My visitor who wrote the e-mail I last posted, sent me a follow-up e-mail continuing with the concern about medicine's current tendency to hide, cover-up or fail to report medical error and unprofessional behavior. The visitor wrote:

The system must change. Doctors must feel free to chart mistakes. When a doctor feels pressure to avoid documenting the result of poor care there is a problem. When a doctor feels pressure to lie about providing medical interventions that were not provided there is a problem. When other doctors feel the need to support lies, either to protect a less skilled doctor or to avoid getting dragged into a messy court case, there is a problem. When nurses do not feel free to report unprofessional behaviour or medical mistakes there is a problem. At my local hospital nurses were told to stop complaining about a doctor who was behaving strangely. They were told they would lose their jobs if they continued to complain. The result? The doctor died of a drug overdose in a hospital washroom moments after overseeing an operation. The problem was so bad it was common knowledge around town that this doctor was not performing well, 3 months before he died. Even if the system doesn’t care about the quality of care patients are given, in this type of situation, the system should at least care about helping the doctor. This doctor had two young children and a wife. The problem of covering up mistakes or unprofessional behaviour stems from the fear of being sued or looking bad. As human beings we should be able to rise above a cycle of lying and suing and move toward providing a safe healthcare environment.

The Heath Council of Canada is looking at a New Zealand model of no-fault healthcare insurance to encourage a more open, honest system of reporting problems. Or for an example of how long it can take a patient to get the medical system to take a complaint seriously, and the damage inflicted on other patients when the goal is to cover up problems, check out this example. If I recall this problem was not addressed until a patient went to the press for help.

You may have noticed that this topic of medical error and unprofessional behavior has been a repeated subject on my blog. There is reason to keep this problem on the top burner when medical ethics is being discussed because of its widespread presence and its profound impact on patient care. Perhaps my visitors can contriubte suggestions to help with its solution. ..Maurice.

Monday, June 05, 2006

The Dark Side of Medicine: Writing Lies into the Medical Record

Resuming the topic of how the public views the practice of medicine, particularly issues that deal with the patient's medical record, I recently received the following e-mail from a visitor:

I was searching after reading my medical records and realizing that doctors lie on records via entering false information or excluding details. I was shocked to discover how records can be used to create the ‘truth’ rather than represent the truth. This knowledge has totally removed any faith I had in the medical community. It’s really creepy to fully grasp that doctors will do this. Even the specialist, who I completely trusted, left a detail off the OR records to protect a GP and must have allowed the GP to enter a false note in the records. There is no way the specialist would have missed the fact that the note was false. As a patient there isn’t a thing I can do to prove the records contain lies. I’m not even sure if it would matter if the lies were exposed because any group that functions like this is not going to change its ways from one complaint. It’s mind blowing to see the dark side of medicine and wonder how often records are used to protect doctors while causing great damage to the patient via loss of faith. Obviously the medical community has a major problem. The GP involved would likely suffer no negative feelings about lying but the specialist did not strike me as the type who could just lie and forget about it. Discovering that the medical community places value in ‘creating’ the truth over just telling the truth and letting the chips fall where they fall is disgusting.

Realistically, it is only rarely (really only as part of a court action or other legal documentation) that physicians are required to swear "the truth and only the truth" regarding what they have written in their patients' charts. The assumption is that what is written by the physician is the truth or at least is a faithful representation of what the physician knows about the patient in terms of history, physical examination, testing results, diagnosis and what the physician presented to the patient in terms of informed consent for treatment. The chart is not a novel but should be a clear documentation of the patient's care and therefore should be as accurate as clinically possible and truthful. To find a chart not meeting this standard should be highly discouraging to us all about the professional behavior. ..Maurice.

Saturday, June 03, 2006

Politics Will Be Politics: Mayor Bloomberg’s Address to Medical School Graduates

If you are interested in reading what a New York mayor could be telling the graduating students of a medical school, well, courtesy of the mayor’s office, I am posting the entire talk below. It is interesting to see how this politician views examples of science whose conclusions he finds arise not out of science but indeed out of politics itself. It is also interesting to see how a politician can’t avoid putting his own local political two cents into an address of graduating physicians from a different city and state. Oh well, politicians will always be politicians. ..Maurice.

From the New York City Mayor’s Office Website

May 25, 2006

Address to Graduates of Johns Hopkins University School of Medicine
Baltimore, MD [By New York City Mayor Michael R. Bloomberg]

Good afternoon. Thank you, Dr. Miller, for that kind introduction, and for this wonderful recognition.

I've been given special degrees before, but being made an honorary doctor by real doctors in front of future doctors is the ultimate and may be about the best news my mother has ever heard. Considering the anemic academic record I amassed during my undergraduate years here at Hopkins, this really reaffirms my belief that anything in life and at JHU is possible.

Let me begin this afternoon by assuring you of two things.

First: I'm going to be brief. And second: I'm not going to play the guitar and sing "I did it my way" like I'm told the commencement speaker did last year. Not that there's anything wrong with that, but I think you graduates have undergone enough punishment to get your degrees…and for humanitarian reasons, I won't pile on.

Still, before I impart some indispensable words of wisdom to you, I want to say something about another important group. I'm talking about the parents who are sitting out there this afternoon, beaming proudly and not even thinking about what it cost to get to this day - or about what happens if you become an academic and have to move back home to make ends meet. So let's give them a big hand. They deserve it!

Now, like all good scientists, I've done some research in preparation for this occasion. And I've learned a lot about today's distinguished graduates. Here's what I found out:

Some of you will practice medicine or do research; others will manage fancy Mexican restaurants in Federal Hill.

Some of you took anatomy with Doctor Rose; others actually enjoyed anatomy with Doctor Rose.

Some of you have studied here for four years; others have for six, seven, or eight - and I think one MD/PHD started just around the time The Dome was built!

All of you, though, shared a few experiences:

Those first-year lectures in the beautiful, windowless confines of the Wood Basic Science Building basement.

The glamorous and nutritious take-out dinners from "Taste of China."

And I know you all share a deep, personal satisfaction that whatever happens in your professional life, you probably won't ever again live in Reed Hall.

But you also share something quite serious. Two things, in fact. Each one of you has had two important principles deeply embedded in you through your association with this amazing institution: An unwavering allegiance to the power of science and a profound commitment to use that power to help people. And this is a good thing, because now more than ever, these two fundamental concepts are being ignored, or are under attack.

Today, we are seeing hundreds of years of scientific discovery being challenged by people who simply disregard facts that don't happen to agree with their agendas. Some call it "pseudo-science," others call it "faith-based science," but when you notice where this negligence tends to take place, you might as well call it "political science."

You can see "political science" at work when it comes to global warming. Despite near unanimity in the science community there's now a movement - driven by ideology and short-term economics - to ignore the evidence and discredit the reality of climate change.

You can see "political science" at work with respect to stem cell research. Despite its potential, the federal government has restricted funding for creating new cell lines - putting the burden of any future research squarely on the shoulders of the private sector. Government's most basic responsibility, however, is the health and welfare of its people, so it has a duty to encourage appropriate scientific investigations that could possibly save the lives of millions.

"Political science" knows no limits. Was there anything more inappropriate than watching political science try to override medical science in the Terry Schiavo case?

And it boggles the mind that nearly two centuries after Darwin, and 80 years after John Scopes was put on trial, this country is still debating the validity of evolution. In Kansas, Mississippi, and elsewhere, school districts are now proposing to teach "intelligent design" - which is really just creationism by another name - in science classes alongside evolution. Think about it! This not only devalues science, it cheapens theology. As well as condemning these students to an inferior education, it ultimately hurts their professional opportunities.

Hopkins' motto is Veritas vos liberabit - "the truth shall set you free" - not that "you shall be free to set the truth!" I've always wondered which science those legislators who create their own truths pick when their families need life-saving medical treatment.

There's no question: science - the very core of what you have been living and breathing these past several years - is being sorely tested. But the interesting thing is this is not the first time that graduates of the School of Medicine have faced such a challenge. When the institution was founded more than a century ago, medicine was dominated by quacks and poorly-trained physicians. In that world, Johns Hopkins and its graduates became a beacon of truth, and trust and helped to revolutionize the field.

Today, in just a few hours you will each evoke that same respect - and with it, you will each bear the same responsibility: To defend the integrity and power of science.

Now, the second ideal that has been ingrained in you by Hopkins is a commitment to use science to help people. That's true at the Medical School and it's true across Wolf Street at the Schools of Public Health, and Nursing. In fact, it is a calling that is at the very essence of the entire East Baltimore campus.

When Johns Hopkins developed the original principles by which the hospital should operate, he specifically decreed that it should "treat the indigent sick of the city… without regard to sex, age, or color."

It may sound obvious that the goal of every doctor and scientist is to use knowledge to improve the lives of others, but this cannot be taken for granted anymore. Look at some of the recent federal and state governmental, medical, and scientific policies and then tell me that, in every case, the end goal is always about helping the patient. I don't think so!

I work at the city level, dealing with real world problems and delivering actual services. We have to put the care and treatment of our neighbors front and center. We can't let ideology get in the way of truth.

We have pursued a ground-breaking agenda built on facts, and on a commitment to those who need it most. A patient-driven program that cares about outcomes, not incomes. Let me give you some examples:

We have taken aim at tobacco - the country's biggest killer - by raising cigarette taxes, running hard-hitting ad campaigns, helping smokers quit, and wiping out smoking in bars, restaurants, and other workplaces.

We have taken aim at AIDS by focusing on reducing risky behavior, improving the quality of care, and expanding testing - because knowledge is power.

We have taken aim at diabetes - the only major health problem in our country that's getting worse - by beginning to address childhood obesity and working to create the nation's first-ever population-based diabetes registry.

And we have taken aim at unintended pregnancies by increasing access to high-quality reproductive health care services for all our citizens. Last June, we became the first city in America to run a public campaign to raise awareness and increase access to Emergency Contraception.

None of these initiatives is steeped in ideology, but they are all brimming with common sense. To me, that's really the essence of good public health policy, and it's the same approach that I hope you will carry with you wherever you go, whether it's into research, practice, teaching, or the private sector.

If you think about it, the cardinal rule of medicine - "Do no harm" - really aims too low. To improve health means being rigorous, being inquisitive, keeping up to date with scientific progress, and always pursuing the truth. It also means thinking beyond just medicine, and addressing the broader social, political, and economic issues that affect health: Housing, education, discrimination, and most of all, poverty.

Addressing these issues will increase access to care and improve patient outcomes, but there's no doubt, it will take courage and strong leadership to make society confront them. Fortunately, as graduates of this institution, I believe you can be those leaders.

Let me conclude today with a story that I think illustrates everything I've been talking about.

Although New York City is now, by far, the safest large city in America, tragic crimes do continue. Last November, a young New York City police officer was gunned down during a traffic stop on the streets of Brooklyn. He was rushed to Kings County Hospital, where doctors heroically tried to save him. But despite their best efforts, the officer's massive heart wounds were too severe and he died on the operating table.

Moments later, Dr. Robert Kurtz - the hospital's Co-Director of Trauma Surgery, who also worked at Johns Hopkins Hospital during the late 1960s - joined me and our Police Commissioner to address the press. The doctor was exhausted, still in his scrubs, which were covered in blood.

First, he talked about his patient. He calmly and professionally explained how his team had tried to save the officer… how they had reopened the young man's chest after the first surgery had failed…how he had held the officer's heart in his hands. All to no avail.

This man's devotion to his patient was palpable, and powerful. And so was his commitment to the truth. At that moment, having seen too many gunshot victims in his ER over the years, he felt compelled to speak out forcefully and publicly, to tell the assembled politicians and press the truth about the problem of guns on our streets.

There's no question this single act did a great deal to spark a renewed commitment in our fight against illegal guns, a scourge that has created a true public health crisis in our city, and all cities. Dr. Kurtz could have left the advocacy to others. He could have said that wasn't his job. But leadership is part of his job, and part of the job of all doctors.

Now, like him, you must fight - both to heal, and to be heard. And, despite the obstacles that will be placed in your path, you must lead us to a stronger, safer, healthier world. I have no doubt that you will succeed.

Today, you celebrate. Tomorrow, your great work begins.

So get up early. Have that last 8A.M. beer at Jimmy's. And then welcome to the battle. It is one we not only can win; it is one we must win.

Congratulations on your graduation, and all the best in your lives and careers.

Ethics of "Blacklisting":Should Negative Comments about a Patient be Transferred to a New Doctor? If So, How?

Continuing on with the topic of trusting doctors and the medical profession,
here is a topic which I hadn't as yet covered on my blog but which must be of concern to many patients and perhaps one of the reasons why such distrust is expressed by patients in general. This topic was initially posted on my now inactive "Bioethics Discussion Pages" in 2002 and I got a few responses. I have reproduced the posting and responses below. I have a feeling that this topic should stimulate a few more comments on this blog. ..Maurice.

The Ethics of Transfer of Patient Information from One Physician to Another: Concern about "Blacklisting"


A visitor to these pages wrote me the following: "I am also interested in the ethics of the 'grapevine' phenomena in blacklisting patients via word of mouth..." It appears that she was concerned that when she has left one doctor and has requested that her records are sent to another doctor, the previous doctor may by talking to the new doctor also provide him/her with what the patient may consider personally negative and harmful information. This information may include the previous doctor's evaluation of the patient's personality, behavior, medical compliance, payment history, drug-use history and many other aspects of the patient's history including the physician’s conversations with former physicians that might not be present in the patient's written record. This additional information may lead the new doctor to change his/her approach to the patient's medical management but also may encourage the new doctor to refuse to accept the patient for treatment.

The concern is that when the patient authorizes transfer of his/her medical record should any other information be transferred orally? Should a physician be prohibited from revealing any information to another physician that is not in the patient's chart? Would it be more acceptable if this information were part of the written record? Should a patient be allowed to review his/her medical record and specifically dictate which portions should be transferred to the new doctor and which should not? Should a patient also specify what should or should not be orally communicated? Would this patient empowerment improve or hinder proper medical treatment?

Here is the question:

How much control should a patient have in the selection of what personal information is transferred by one physician to another?

Date: Fri, Sep 27, 2002 4:20 PM From: To:
Health care providers and patients can have bad experiences. If I were the provider I would be asking myself why is this patient transferring care? Is there anything I can do to resolve the issue? The answer for the most part must be a collaborative effort for both parties. The effort must be professionally addressed in the patients record and should be included in the transfer allowing the next provider to have a clear picture of the case. However, we have heard the term "cherry picking", and unfortunately this does happen in the presence of personality conflicts and the almighty dollar(or the lack of). I have observed some pretty fancy foot work in the past. Regardless it is our responsibility to handle difficult cases and follow them through until patient is in the care of another provider, and that includes thorough and accurate documentation (all of it).

Date: Wed, Sep 11, 2002 1:00 AM From: To:
It seems to me that the tough part of the issue is the *way* in which the new physician treats any "negative" information. I don't know a solution, of course, because compassion and tolerance can't (or shouldn't) be enforced.

As with any relationship, both parties (patient and doctor) must be considerate of one another. Transfer of medical information is necessary so that the patient isn't "starting over," so to speak, with the new doctor. Likewise, the new doctor should not have to be "surprised" by a new patient's difficulty with paying bills, difficulty with medical compliance or addiction to illicit substances (the knowledge of which, being important to medical care, should remain a "patient-doctor" priviledge whenever possible). But this also assumes that the new doctor will give the patient at least one chance.

As far as "personality" and "behavior" are concerned, information should be very objective and should only be passed along if it would probably affect *any* doctor's ability to administer proper care. In other words, it requires a certain degree of emotional self-awareness on the part of the prior physician; is the patient truly difficult to deal with, or does he simply push that particular physician's "buttons?" This last bit, self-awareness, should be a part of the training of any medical school program.

In any case, I think all communications from old doctor to new should be documented. And, especially if there are any negative connotations, the patient should be given control of whether or not the records are transferred. But I would say the whole record must be transferred--it's either all or nothing.

Thank you. Carl Wedell, Denver, CO, USA

Date: Thu, Sep 5,2002 11:35 AM From: To:
You need to be far more concerned about the woman who complained to you, and much less concerned about the "ethical issue". In some medical communities, this can(and has) escalated to an illegal medical blacklisting. She may have impending risk that could eventually cost the woman her life, or cause perrmanent harm, possibly sooner than she thinks. And she may have a very serious legal problem-- potentially a criminal law problem as a potential victim-- and not an issue that belongs in the "juristiction" of ethics at all. When the woman used the terms "the ethics of" and "blacklisting", the term "blacklisting" is the far more important term. This can be criminally illegal. It can also result in death or permanent harm in the longer term. If nothing else, she could be financially "ripped off", along with her insurer, in a trial-and-error effort to find suitable medical services. She could end up with a "medical records reputation" as a nusiance patient, and possible face higher insurance rates or difficulty getting insurance later on(and die eventually from "poor & uninsured" disease). Most Americans-- 95+%, and likely including this woman-- are literate and smart to use simple terms like "blacklisting" quite accurately. And whenever anyone does, it must be taken with extreme seriousness, since this term can refer to a criminal illegality. Whenever anybody, for any reason, makes a statement that indicates a possible criminal illegality of any kind-- and proof is not required, just the smallest probable cause-- it is a very very serious matter, and the worst must be assumed when potential bodily harm could result. This is as much the case in the world of medicine as it is when criminal risk might exist anywhere else, such as the back alleys of the world. When probable cause exists, medicine and its' people are not exempt from the scrutiny of law.

At the very least, this woman should make written statements, possibly in certified letters, and send copies to all concerned-- all the doctors involved and possible her local medical society. She should have these filed in at least one law office. If her statements indicate that a criminal complaint should be made, then a lawyer should advise her to do so, and assist her as much as possible. Regardless, she should be "on the record" with her statements in writing.

The doctors involved are "on the official record" in their medical records, which you can bet will look legally and "ethically" good for them(and not for the patient) in any dispute. If the woman gets "equally on official records" in a way that shows that the doctor's story is not the only story, that the doctor's way is not the only way, that the doctor's judgement is not the only or final judgement-- if the woman does this, then the doctors might decide to behave in "a different way". They might decide to work on their "behavior problems". When medicine and it's people are exposed to reality-- that they are subject to the scrutiny and judgement of others, including the law and those who pay their bills and support their livelihoods; that their judgments are far from final, that their authorities are not the most powerful or enforceable authorities(doctors in "my neck of the woods" don't like this at all)-- when medicine is faced with this "spotlight of scrutiny" from the bigger world outside their own, doctors will often "rethink their ethics and policies". If the woman "gets on the written record" with her own well worded statements, it may avoid more serious legal problems later on, and reduce the chance of physical harm. She might also end up with smaller medical bills without a loss of service!!

M O Harris III

Well, what do my blog readers think? ..Maurice.