Download - 01 Bioethics Lecture - Professional Behavior
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Professional Behavior
Tom Heston, MD
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Case Study 1
A physician over time becomes attacted to a
current patient
The physician and patient mutually agree to
end the physician-patient relationship
The physician now asks the former patient out
on a date, and they go on several additional
dates.
What do you think?
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Case Study 1
Relationship soured
Complaint made to the state medical board
Physician was disciplined by the state medicalboard and license was restricted for 2 years
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Principles
Physicians are in a position of power
Patients can be vulnerable to their influence
Physician power should only be utilized formedical purposes, not personal gain
Romantic relationships with a current patient isnot allowed
Some states prohibit the treatment of family,
friends, or employees
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Doctor-Patient Relationship
Both parties must agree
Physicians do not have a legal obligation toenter into a doctor-patient relationship with
anyone, however note that: Emergency departments must treat everyone
Physicians working in such settings have agreed to
provide treatment to all patients seeking care Ending the relationship: reasonable notice,
provide alternatives, maintain records
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Gifts From Patients
Small gifts acceptable
Large gifts should be refused
Patients may be vulnerable, and as a resultgive a provider a large gift.
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Impaired Physicians
Substance abuse
Physical disability
Mental illness Old age resulting in poor performance
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Principles to Follow
Self Regulation Surgeon with advanced arthritis stops operating
Elderly physician retires
Physicians have a duty to do their very best to selfregulate their medical practice
Physician Colleague Regulation
Must ensure that the impaired physician gets help
When discovered, all physicians have an ethicalobligation to ensure impaired physicians get help
Physicians are often in the best position toidentify impairment in a colleague
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Medical Malpractice
Error and mistakes occur. This alone does not
equal malpractice
Must prove the 4Ds: dereliction ofduty results
in damage directly to the patient
Dereliction: giving substandard medical care
Duty: a physician-patient relationship exists
Damages: actual damage to the patient occurred
Directly: damages were the result of dereliction
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Impact on Physicians
All physicians are at risk of getting sued
~10% per year in US historically
Top specialties: surgery, ob/gyn, anesthesiology
Malpractice is a tort, i.e. a civil wrong.
Compensation typically is financial.
Physicians occasionally, but rarely, accused ofa criminal malpractice violation
Result can be jail time
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Types of Damage
Compensatory
Reimbursement of medical bills
Reimbursement of lost wages
Pain and suffering
Punitive Damages
Designed to punish the offending party
Designed to set an example
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Deviation From the Standard of Care
Generally determined by LOCAL practice
Practice guidelines http://guideline.gov
Medical society guidelines
http://guideline.gov/http://guideline.gov/ -
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Informed Consent
Not simply a signature on a page
Fully Informed Procedure
Alternatives Benefits
Risks
Informed Refusal
This is a high-risk situation Frequently occurs in emergency room settings
Must fully document and ask patient to sign out AMA
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Patient Obligations
Fully inform the physician
Ask questions
Be honest Follow medical advice
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Medical Errors
Ethical duty to inform patients of an error if it
will impact the patients care.
Minor errors that will have no impact upon
care do not need to be reported to the patient
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Case Study 2
Patient with high blood pressure admitted tohospital
Order for Diovan misinterpreted as for
digoxin, possibly due to sloppy handwriting Patient overdosed on digoxin requiring a
prolonged stay
Patient successfully treated, being unaware ofsituation
What are the principles here?
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Case Study 2
Physician, pharmacist, and nurse all made a
mistake
Dosage difference for digoxin vs Diovan should
have been caught by pharmacist and nurse
Physician should have written more legibly
Harm occurred, even though patient unaware
although no long-term harm, the patient did have
a prolonged hospital stay
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Case Study 3
What is the role of the Risk Management
team in a hospital?
Patient advocacy?
Improve clinical care?
Ensure the ethical treatment of patients?
Minimize legal risk to the hospital?
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Case Study 3
Risk Management Teams are tasked with
reducing the legal risk to the hospital.
May or may not lead to improved clinical care
Sometimes, but not always, also reduces the
liability risk of physicians and nurses.
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Case Study 4
Adult patient with leukemia informed
(procedure, alternatives, benefits, risks)
regarding bone marrow transplantation
versus chemotherapy
Patient agrees to bone marrow
transplantation
Patient dies and lawsuit filed
What is the likely outcome?
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Case Study 4
Lawsuits can be filed for any reason
In states with no tort reform, outcomes are
unpredictable due to high emotion and low
level of medical expertise of non-professional
(lay public) jurors.
Theoretically, the physician should not lose
this lawsuit because of documented, full
informed consent, and the therapy being
within the standard of care
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Case Study 5
Patient with acute myocardial infarction
Angioplasty offered
The procedure and risks were fully explainedto the patient
Patient decides to go with medical therapy
alone Patient dies
What is the medico-legal situation here?
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Case Study 5
Consent was not done properly: the
alternatives and benefits were not discussed
Procedure and associated risk of procedure
explained, but...
Benefit of procedure not explained
Alternatives (and their risks) not explained
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Case Study 6
Resident disagrees with medical management
by attending physician
What should the resident do?
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Case Study 6
The resident should first discuss the case with
the attending, using evidence-based medicine
If no satisfactory response, then resident
should bring the issue to a higher local
authority
Do not go to the patient
Do not go directly to the state board
Go to a local, higher authority
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Case Study 7
Elderly women admitted to hospital with
gastroenteritis and dehydration
Does not complain of dizziness
Left alone to use the toilet, gets dizzy, and
falls
Sues hospital for negligence What are the legal principles here?
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Case Study 7
Patients are required to fully inform physician
of medical condition and physical complaints
Patients required to inform nurses about
dizziness when it affects nursing duties
Fall precaution policies in hospitals try to
prevent this situation from occurring.
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Case Study 8
Patient with osteomyelitis
You forget to reorder antibiotics, and the
patient misses 2 days out of his 6 week course
of antibiotics (2 days out of 42 total)
The patient does not experience any clinical
deterioration
Condition successfully treated by 6 weeks
What should you do?
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Case Study 8
This is a medical error but not malpractice (no
damage occurred)
You should inform the patient and reassure
them that they will be okay
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Case Study 9
Patient admitted with massive intracranial
bleed
Patient on a ventilator
Brain death confirmed
What do you do?
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Case Study 9
Inquire about organ donation
Death is determined by the physician, not the
family
Brain death = death
Cardiopulmonary arrest resistant to
rescussitation = brain death = death
Remove the ventilator after speaking with the
family
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Case Study 10
A parent brings a 5-year old child to the ER
You suspect child abuse
What do you do?
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Case Study 10
Report the situation to child protective
services
You are ethically and legally required to report
even a suspicion of abuse
You are legally protected even if it turns out to
not be abuse
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General Principles
The patient comes first
Open communication
Tell the patient what you knowExpect reciprocity from the patient
Try to remove barriers to communication
such as computers, other family members
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General Principles
Work on long-term relationships
Negotiate rather than order. Paternalism is
out.
Admit errors
Never pass-off care. Stay involved even
after referral to subspecialist.
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General Principles
Ensure you understand the patient first
Patients do not get to select inappropriate
treatments
Best answers serve multiple goals. Consider
both short-term and long-term issues.
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General Principles
Never lie.
Accept the health beliefts of patients
Expect to come across folk remedies
Explain your care in plain language
Accept and honor religious beliefs of patients,
participate if appropriate
Anything that improves communication is
good
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General Principles
Have a good bedside manner and be
respectful
A good rapport increases patient satisfaction,
compliance, and physician satisfaction
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References
Kaplan Medical USMLE Medical Ethics (2006)
Deja Review USMLE Step 1
http://sgoti.ws/JzMTiNhttp://sgoti.ws/JzNhxDhttp://sgoti.ws/JzNhxDhttp://sgoti.ws/JzMTiN