20120425 - usmle bioethics - professional behavior

Professional Behavior

Tom Heston, MD

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?

Case Study 1

• Relationship soured• Complaint made to the state medical board• Physician was disciplined by the state medical

board and license was restricted for 2 years

Principles• Physicians are in a position of power

• Patients can be vulnerable to their influence

• Physician power should only be utilized for medical purposes, not personal gain

– Romantic relationships with a current patient is not allowed

– Some states prohibit the treatment of family, friends, or employees

Doctor-Patient Relationship

• Both parties must agree• Physicians do not have a legal obligation to

enter 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

Gifts From Patients

• Small gifts acceptable• Large gifts should be refused• Patients may be vulnerable, and as a result

give a provider a large gift.

Impaired Physicians

• Substance abuse• Physical disability• Mental illness• Old age resulting in poor performance

Principles to Follow

• Self Regulation– Surgeon with advanced arthritis stops operating– Elderly physician retires– Physicians have a duty to do their very best to self

regulate their medical practice• Physician Colleague Regulation–Must ensure that the impaired physician gets help–When discovered, all physicians have an ethical

obligation to ensure impaired physicians get help– Physicians are often in the best position to

identify impairment in a colleague

Medical Malpractice

• Error and mistakes occur. This alone does not equal malpractice

• Must prove the 4Ds: dereliction of duty 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

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 of a criminal malpractice violation– Result can be jail time

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

Deviation From the Standard of Care

• Generally determined by LOCAL practice• Practice guidelines – http://guideline.gov• Medical society guidelines

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

Patient Obligations

• Fully inform the physician• Ask questions• Be honest• Follow medical advice

Medical Errors

• Ethical duty to inform patients of an error if it will impact the patient’s care.

• Minor errors that will have no impact upon care do not need to be reported to the patient

Case Study 2

• Patient with high blood pressure admitted to hospital

• 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 of situation

• What are the principles here?

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

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?

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.

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?

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

Case Study 5

• Patient with acute myocardial infarction• Angioplasty offered• The procedure and risks were fully explained

to the patient• Patient decides to go with medical therapy

alone• Patient dies• What is the medico-legal situation here?

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

Case Study 6

• Resident disagrees with medical management by attending physician

• What should the resident do?

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

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?

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.

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?

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

Case Study 9

• Patient admitted with massive intracranial bleed

• Patient on a ventilator• Brain death confirmed• What do you do?

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

Case Study 10

• A parent brings a 5-year old child to the ER• You suspect child abuse• What do you do?

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

General Principles

• The patient comes first• Open communication–Tell the patient what you know–Expect reciprocity from the patient–Try to remove barriers to communication

such as computers, other family members

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.

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.

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

General Principles

• Have a good bedside manner and be respectful

• A good rapport increases patient satisfaction, compliance, and physician satisfaction

References

• Kaplan Medical USMLE Medical Ethics (2006)

• Deja Review USMLE Step 1