Bioethics Discussion Blog: Play The Doctor: Four Clinical Situations





Tuesday, April 03, 2012

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."   


At Tuesday, April 03, 2012 11:30:00 PM, Blogger Hexanchus said...

OK, I'll play....

1. Nothing - it really isn't any of the doctor's business, and asking the question invites a possible confrontational response. Rather than ask, I think the physician should simply tell the parent(s) that he doesn't know whether or not they have firearms in the home, but in the event they might, he wants to provide them with some information on firearm safety - then hand them a pamphlet on the subject prepared by qualified firearms safety experts. Most physicians are no more qualified to provide advice on firearm safety than firearms instructors are qualified to provide medical advice.

2. A relationship between doctor and current (or past for a specified amount of time) patient is prohibited by law in every State that I know of - simply explain that to the patient. Carefully evaluate if it is likely to interfere with the doctor/patient relationship, and if it is, offer to help them find a new provider if that would make them more comfortable.

3. This can be a toughie.Firmly explain to the patient that your time together is limited and you need to focus on their specific issues, not their cousin's. Good conversational and communication skills can really help.

4. Again, good communication techniques are important. Their ticklishness could be a sign they are uncomfortable - ask them. Get them to focus on something like breathing. Lighter touch can be more prone to evoke a ticklish response - use a firmer touch if need be. Again, ask the patient what they think might help.

At Wednesday, April 04, 2012 4:49:00 AM, Anonymous Anonymous said...

#1. He's right, unless the kid has holes through him, it is none of your business. Apologize and move on.
I am one that feels a doctor should be providing health care, not looking further into my life than I choose to share.
#2 "I'm flattered, but I'm sorry, a doctor is not ethically allowed to date a patient." Move on.
#3 "You seem to keep coming back to the problems your cousin is having, instead of your own symptoms - can I ask why that is?" I'd think being direct might help. Maybe the patient is afraid they have the same problem or something. If ignoring it wasn't working, I'd be direct.
#4 Hard one. Say "I'm sorry" and just continue as best as possible?

At Wednesday, April 04, 2012 8:33:00 AM, Blogger Maurice Bernstein, M.D. said...

With regard to Clinical Situation #1, is there really any question that a physician can ask the patient or family that is "off-limits" if the physician's intent is to meet the professional obligation to provide information which prevents disease or injury, to attempt to understand the psychologic, social and biologic aspects of the patient in order to make a diagnosis and establish treatment and without any intent to purely satisfy simple curiosity or prurient or other non-patient directed self-interest? Wouldn't asking about the financial situation of the patient or family be pertinent to understanding the social aspects relative to symptoms or disease or their medical management? I don't mean requesting to look at the patient's tax return but to ask about order of magnitude income and significant debts?

With regard to questions about sex and sexuality of the patient, they are not "off-limits" either even when the patient's history is being taken as part of a comprehensive examination. In fact, we teach our medical students, standard in all medical school education, in such an examination, to ask the patient about which gender they have sex ("male, female or both"), what route ("oral, genital or rectal or what combination"), how often and how many partners to the present. Again, this is not done for self-interest but is relation to understand the patient's potentials for disease. Wouldn't asking about guns in the home when the physician is responsible for the health of a child be the beginning of a potentially valuable discussion regarding prevention of injury or death of a child if the father answered "yes"? ..Maurice..

At Thursday, April 05, 2012 5:07:00 AM, Anonymous Anonymous said...

Maurice, you and I are probably not going to agree here. But these days, I would find many questions off-limits from a medical provider.
I would answer questions about sex if they were directly pertinant to the problem I was having. I would not answer financial questions at all, unless whoever I was talking to was trying to help me apply for charity care. I would not talk about social/psychological issues with a doctor other than a psychologist.
I'm struggling for the right term here, but I think that for some of us at least, the physician providing advice on a patient's entire life isn't a relationship we want. Doctors and patients often don't have a close/special relationship these days, a patient sees the doctor for a few minutes.
I want advice on my physical medical problem from a physician, that's all. For other advice, I'll seek out a counselor, financial expert, or other appropriate expert.

At Thursday, April 05, 2012 2:28:00 PM, Blogger Hexanchus said...

I agree with TAM completely on this one Dr. B. IMHO physicians who engage in this type of questioning without a specific immediate medical reason are attempting to insert themselves into areas of people's lives that are strictly none of the physician's business.

And while some issues such as sexual related questions may be within a physician's area of training and expertise, things like financial information or advice on firearm safety rarely would be. To be it's not a valid comparison.

At Friday, April 06, 2012 9:56:00 AM, Blogger Maurice Bernstein, M.D. said...

"physicians who engage in this type of questioning without a specific immediate medical reason are attempting to insert themselves into areas of people's lives that are strictly none of the physician's business."

Hexanchus, as I had written, there should be a "specific medical" reason for asking the question and not one simply out of curiosity or self-interest by the physician. "Immediate", well, that needs to be defined. A better adjective would be "pertinent to the physician's responsibility" (or if you want to express it with your terms "physician's business"}. Remember, protection of patient against injury and disease along with interpretation of symptoms, diagnosis and treatment are the physician's business at all times in the doctor-patient relationship. And knowing the facts that can affect providing such responsibilities is the business of the doctor.

Now, what must be understood is that the physician also has the responsibility to ask questions only after prefacing them with an explanation to the patient regarding why and what value they are being asked. To do otherwise would be unfair to the patient.
On the other hand, the patient still has the freedom to avoid providing an answer for whatever reason the patient may have. And if an answer to the physician's question is provided, both the patient and the physician understands that the answer is not under legal oath. Thus, justice (equal fairness) is met to both parties: an attempt for the physician to meet his or her professional requirements and for the patient to retain his or her personal privacy. If both parties understand each others motives and goals then there should be no angry "it's none of your business!" response. ..Maurice.

At Friday, April 06, 2012 10:40:00 PM, Blogger Hexanchus said...

"protection of patient against injury and disease along with interpretation of symptoms, diagnosis and treatment are the physician's business at all times in the doctor-patient relationship"

Sorry, I don't buy that a physician has an unlimited right to ask these questions. It's only the physician's business to the extent that the patient agrees and permits. The patient has the final say as to what is the "physicians business" with respect to them. It's the patient that gets to decide what the limits are and the physician who needs to respect those limits.

I do agree with you that if the groundwork for the conversation is laid properly there shouldn't be an angry response. Physician describes the nature of what they want to ask and why, patient says yes or no, physician accepts patient's decision - calm, cool and rational with no histrionics on either side.

The sad truth is that for whatever reason, a lot of physicians don't lay that type of groundwork. Maybe it's the time pressure the physician is under....or the holdover paternalistic attitude that a significant number of physicians still have...or the demi-god complex some seem to develop. Further, at the first sign of resistance on the part of the patient, many physicians will attempt to browbeat or coerce a patient into going along with their recommendation instead of simply accepting the patient's position and moving on. This occurs all the time with respect to cancer screening, especially with women.

It boils down to communication issue, and sadly I don't think it's going to get any better unless/until physicians can have the time they need to lay the groundwork necessary to have a calm, rational discussion with the patient.

At Friday, April 06, 2012 11:01:00 PM, Blogger Maurice Bernstein, M.D. said...

"It's only the physician's business to the extent that the patient agrees and permits"

Hexanchus, I would rephrase your statement with "It is the physician's business but only to the extent that the patient agrees and permits". It is the physician's professional responsibility but obviously how complete that responsibility will be met is determined fully based on the understanding and cooperation of the patient. There is no doubt that the patient (or family member in the clinical situation under discussion) must also be a partner in fulfilling that responsibility. ..Maurice.

At Saturday, April 07, 2012 6:14:00 AM, Anonymous Anonymous said...

I agree with Hexanchus at 10:40 pm.
Just how far does the physician think he/she can go in "protection of patient against injury and disease"? Is it ok to ask if my husband is nice, if I have had the brakes on my car inspected lately, if I have a breed of dog likely to bite me, if my furnace has been inspected, and perhaps direct that I should not engage in any dangerous hobbies (horseback riding, skydiving for ex.) that I happen to enjoy?
These are all personal choices, nobody's business but my own.
So no, I do not think such things are the "physician's business at all times".
And even if I was "prepared", I would decline to discuss things other than my immediate medical problem.
I do not view the physician's role as all-encompassing in my life. That sounds like the days of Marcus Welby, not today.

At Saturday, April 07, 2012 8:56:00 AM, Blogger Maurice Bernstein, M.D. said...

TAM, perhaps we need a bit more Marcus Welby in our current medical system.

What questions doctors ask is what doctors are taught to ask. For example, it was the American Academy of Pediatrics that set the guidelines for pediatric physicians to ask about the presence of guns in the household. Many of the questions doctors ask were specifically taught by instructors like myself as part of a medical student's first and second years of training.

Finally back to guns in the household: Despite a "precedent-setting" law that went into effect in Florida, June 2011, "to prohibit doctors from asking their patients about gun safety in the home", a Florida federal judge blocked the act stating "Despite the State’s insistence that the right to ‘keep arms’ is the primary constitutional right at issue in this litigation, a plain reading of the statute reveals that this law in no way affects such rights...A practitioner who counsels a patient on firearm safety, even when entirely irrelevant to medical care or safety, does not affect nor interfere with the patient’s right to continue to own, possess, or use firearms.” The injunction against carrying out the law is still apparently in effect. The need to allow physicians to educate the parents was exemplified by a January 18 2012 article in the Orlando Sentinel "Every parent's worst nightmare played out Sunday night inside an Eatonville home.

A 7-year-old child picked up a gun that he apparently thought was a toy, pointed it at his 15-year-old cousin and accidentally shot and killed the older boy."

'nuff said. ..Maurice.

At Saturday, April 07, 2012 1:15:00 PM, Blogger Hexanchus said...

DR. B.,

Accidents like those you describe are indeed tragic. That still doesn't take away from the fact the vast majority of medical practitioners, unless they are a certified firearms safety instructor, are neither trained nor qualified to counsel anyone on firearms safety.

The law in Florida you refer to came to be because a pediatrician asked a parent about firearms in the home, and when the parent declined to answer the physician fired the patient. Yes it was a knee jerk reaction, but so was the act of the physician that started it.

As I said earlier, the role of the physician should be to offer referral to qualified resources on firearms safety if the patient is interested. If not, end of discussion. AAP guidelines are exactly that - they have no legal standing and can not and do not authorize the provider to do anything.

And whether or not a person has firearms in the home is not something that should be in their medical record.

'nuff said...

At Saturday, April 07, 2012 7:06:00 PM, Blogger Maurice Bernstein, M.D. said...

OK TAM, let's move along to Situation 4 with the ticklish young adult. I know you characterized it as a "hard one" Nevertheless, it is important to discuss the role of an implied apology by the doctor. When should the doctor say to the patient "I'm sorry"? Is a personal apology by the doctor appropriate for responding to a patient's self-described behavioral reaction? What I am getting at is that "I'm sorry" by the physician could be a misused expression. For example, if the doctor expresses to the patient "I'm sorry that you are sick"...or "I'm sorry that you are suffering" and so on as part of a sign of sympathy, doesn't that diminish its significance to the patient when "I'm sorry" should be used as part of a self-apology by the doctor. On the other hand, perhaps the doctor is apologizing for his or her palpation (touching) technique that would upset the patient.

In dealing with interaction with a patient, perhaps physicians should limit their use of the words "I'm sorry" unless the reason that they are personally "sorry" is clearly expressed to the patient. Otherwise, I think that the word becomes meaningless and perhaps other words should be used. ..Maurice.

At Sunday, April 08, 2012 4:19:00 AM, Anonymous Anonymous said...

OK, that's an interesting comment re. "I'm sorry". I guess I just meant it to express sympathy (maybe empathy too, I can be ticklish). I do appreciate sympathy and/or empathy expressed by physicians. "I'm sorry you're so ticklish, I'll do my best to minimize that" or something to that effect was what I meant. I did not mean it as an apology by the physician, who wasn't doing anything wrong.

At Sunday, April 08, 2012 9:24:00 PM, Blogger Maurice Bernstein, M.D. said...

With regard to situation #3, everyone should remember that physicians must be attentive to everything that the patient communicates. Taking a history should not be such a mechanical process that the doctor asks a question and the patient is expected to answer the question directly and succinctly. It often doesn't happen that way. How the patient handles the question can provide more information and an insight into other issues that should be considered and perhaps then covered by the doctor beyond any expected answer.

Take, for example, situation #1. Clearly, the father did not directly answer the doctor's question. However, the father's response should provide the doctor with insight regarding a family attitude beyond a direct answer to the doctor's question. The attitude being that privacy on certain issues may trump an attempt by the physician to provide education pertinent to the question. Therefore, it would be appropriate, for the doctor to follow up with a response as suggested by Hexanchus.
But, if the doctor did not directly ask, an understanding of the family privacy issue would have been missed.

In the case #3, I think that TAM's suggested response "You seem to keep coming back to the problems your cousin is having, instead of your own symptoms - can I ask why that is? could lead to an answer which provides the physician a valuable insight and lead to further considerations than that of Hexanchus "Firmly explain to the patient that your time together is limited and you need to focus on their specific issues, not their cousin's" which would clearly end any attempt to gain that insight into the patient's concerns.

Again, as one handles the question of how to respond in these clinical situations, attention should be paid in addition to aspects beyond what the patient specifically asks or answers. ..Maurice.

At Monday, April 09, 2012 5:49:00 AM, Anonymous Anonymous said...

The thing is, with the privacy issues, if the patient is so offended by what they (and I personally) view as inappropriate and invasive questioning, that may irretrievably damage the physican-patient relationship. The patient may simply never see that physician again. Or, they may be much more defensive of their privacy than they would have been, if they didn't feel that an inappropriate attempt to invade their privacy had been made.

At Monday, April 09, 2012 5:48:00 PM, Blogger Maurice Bernstein, M.D. said...

TAM, the issue is that the physician really doesn't know what, within the entire panoply of questions that physicians can ask for professional reasons, a patient will consider out of context, too private to answer and outright reject (perhaps with an expression of disgust or anger). Perhaps a physician even suggesting to the patient before hand that he or she is about to ask this kind of question will bring about the same expressions of offense by the patient.

Again, what is missing here is a sense by all patients that they are part of a team with the physician to accomplish the goal of identification of a problem and then prophylaxis and treatment as necessary. Generally, remember, it is the patient who seeks out the doctor for help and not vice versa.
All doctors nowadays, beyond the era of paternalism, knows full well that they need the patient on their team to reach their goals.


At Tuesday, April 10, 2012 8:48:00 AM, Anonymous Anonymous said...

I don't think many patients feel they are part of a team with the physician. I've been very lucky with health myself, but spent a vast amount of time with many physicians from taking family members around to many doctors and hospitals.
There were a few doctors that we got to know, who got to know us, and who were genuinely caring. Those doctors, yes, we felt part of a team.
But many we did not. Sometimes they were ok, but we only saw them for a few minutes - the patient could barely remember which doctor was which specialty, or their names. With the way practices work with hospitalized patients, you may see a different doctor from that practice each day - can't even keep them straight. You can't have real trust and teamwork when you don't know each other - you just hope for the best.
Or, quite a few were very arrogant. Talked down to the patient, and really resented questions. No teamwork there.
I still believe in this era, many questions are no longer appropriate. I don't want advice on my entire life. But if there is something specific a doctor really needs to know, I'd be more likely to respond if the doctor first gave a reason.
For example, "Some conditions can be worsened by stress, such as financial difficulties, marital difficulties, ill relatives... Even a good thing (marriage, moving) can be stressful. Can you tell me if there are any big changes or stress in your life recently?"
I would find that infinitely more respectful than "Do you have enough money these days? How is your relationship with your husband?" etc.
I once had a nurse ask "Where do you get your money from?". And I wasn't even the patient. Needless to say, she didn't get an answer. I just thought she was very rude. And the patient was well insured, and not dress in rags. Completely none of her business.
Things that don't directly apply to healthcare, such as gun safety, I still believe is none of the physician's business, unless there are some signs that some harm is being done.

At Tuesday, April 10, 2012 2:37:00 PM, Blogger Maurice Bernstein, M.D. said...

Here is another clinical situation which was written anonymously today to my blog tread "I Hate Doctors: Chapter 3".
I challenge my visitors here to become this lady's doctor in place of the one she described and how would you communicate with her about her lab tests and her concerns? Play the Doctor. ..Maurice.

I have EVERY symptom in the book of Hypothyroidism with the exception of my blood test and cholesterol being normal. I even have a goiter.

I am an ex- athlete who has never had problems maintaining my weight, attitude, or thoughts. All of a sudden I gained 100 pounds (106 to be exact). My hair was long and silky. Now I had to cut it because Its dry, brittle and breaks off. I've fainted (on more than one occasion), cant breath, My eyebrows are gone, and I'm cold all the time. I wake up in the morning and even after 8 hours of sleep I feel like I need MORE. I also feel as though I've been beaten up in my sleep. My mind struggles to keep up. Back hurts, headache. On the weekends I sleep 12 and 15 hours. And I have mood swings.

All I want is to be me again. To look like a woman again. I'm embarrassed to go out, trying uncomfortably to hold my stomach in and look comfortable. To be able to concentrate and to just genuinely smile. I literally just came from a doctor. Days ago I passed out cold while at work, and today there was blood in my urine. I dont have insurance. I'm a freelancer.

I gave a urine sample. The doctor didnt look at me when he came in. He walked in, said his name really quickly and buried his face in his computer. He asked me what was wrong. I started to tell him and he cut me off. Told me that some women have discharge right before theyre cycles come on. I told him that Ive had my cycle for 21 years and I know that but this is different. I spewed to him everything wrong. he finally looked up and said. Your thyroid blood tests are normal. Your urine test was clear. your not pregnant and you dont have BV. And goiters are benign. Then he says "have you tried weight watchers?" This man never knew me when I was, well.... ME.

I cried a little. Then got angry because I let him bring me to tears. He gave me a script for a yeast infection. I snatched it and left. I come from a family in the medical field. My father a health teacher, My mother a nurse, my sister in medical field, and my cousin in sports medicine. Why is it so hard to get a "doctor" to listen? If I dont do my job, I will get fired. And my reputation will be ruined. He's not the first to treat me that way. I'm screaming for help. I give up for now. When I get the energy I will try again.

Doctors dont understand that people need them. They look at everything as if its the matrix. Just 0s and 1s. A database of numbers and tests. Wont even look you in the eyes and open theyre ears to listen. Our bodies are ours. We know them. And if they cannot help, they should know who can. But never should it be that they wont help. Thats neglect. And a person like me who has to pay out of pocket, its a waste of money.

At Wednesday, April 11, 2012 5:13:00 AM, Anonymous Anonymous said...

Well that is a very interesting one to me. I have a dog who suddenly had dry hair, gained weight, lost energy and had skin issues (all symptoms of hypothyroidism in dogs). But his blood tests were normal. A university specialist finally said - if it walks like a duck, and quacks like a duck - and started him on thyroid medication. It was night and day, the dog is healthy again. Tests aren't perfect - perhaps the patient has a point.
Not saying she should necessarily have thyroid medication at this point. But I would ask over how much time she had the weight gain. I would also consider other conditions - sleep apnea maybe?
I would do a careful physical exam - do I find what she's complaining about (dry hair, no eyebrows, etc.)?
I would not suggest weight watchers (!) until medical conditions had been ruled out. I suppose one could say try to watch your diet so you don't feel worse - but I think she has figured out she is overweight, I doubt that would be helpful, and probably hurtful.
Perhaps she has low-grade hypothyroidism secondary to some other disease. If the patient really feels unwell, I would try hard to see if I could find a medical cause.
I suppose, especially if physical findings are not consistant, I would also look for signs of depression. Of course, if one is ill, and it's causing problems with one's life, it could be situational depression if present.

At Wednesday, April 11, 2012 8:11:00 AM, Blogger Maurice Bernstein, M.D. said...

TAM, what you wrote is all very good and all of this should be going on in the mind of the physician, but what is pertinent to the issue of this thread is how do you verbally, at the moment, respond to the patient. That is the "tricky" part. As with each of the 4 scenarios, it is the challenge how to put the doctor's immediate reaction to what the patient says into the appropriate words for further communication. What are those words? ..Maurice.

At Thursday, April 12, 2012 5:27:00 AM, Anonymous Anonymous said...

Oh, I'm sorry Maurice, I misunderstood. Let's see... I might say:
I think I understand that you feel you have really changed physically lately, and it's having a big impact on your life. I can see why you suspect thyroid disease, given the symptoms you are experiencing. But it is puzzling that your lab tests so far are normal. So I think we need to investigate further just what else might be causing this in case it isn't hypothyroidism. I'd like to do a thorough physical exam now, and then I'll probably have some more questions for you. Then, we can decide what to do next to try to figure this out and hopefully get you feeling better.

At Thursday, April 19, 2012 8:04:00 AM, Anonymous Anonymous said...

Well no more answers so far. Maurce, but I possibly get your feedback on that response? I am curious.

At Thursday, April 19, 2012 5:36:00 PM, Blogger Maurice Bernstein, M.D. said...

Perfect TAM! You wrote exactly what I would say and recommend for the patient's next doctor to say. Unfortunately, most doctors don't have the time and a few doctors don't have the humanism as part of their personality to express these 107 words as you wrote them. ..Maurice.

At Friday, April 20, 2012 5:36:00 AM, Anonymous Anonymous said...

Thank you very much.

At Wednesday, July 11, 2012 10:23:00 PM, Anonymous MC said...

TAM, can you become a doctor? Please??? Specifically, becoming MY doctor would be really, really good!

Seriously, what you wrote was spot on. Balanced, respectful and immediately sets up a 'team' working towards a common goal - to get the patient feeling better. I believe there is way too much emphasis in diagnostics, at the expense of the patients perspective of change. Just because a test result is within 'normal limits' doesn't necessarily mean it is normal for that particular person.

My question (and it's a serious one I'm genuinely seeking an answer to) is why do so many doctors dismiss what their patients claim to know about themselves? Is it because so many patients are clueless and usually wrong? Does this 'train' doctors to become dismissive of patients views and rely heavily on diagnostics alone?


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