Ethics and ProfessionalismThe Integrity of MedicineAbuse and Impairment

Richard L. Elliott, MD, PhD, FAPAProfessor and Director

Medical Ethics and ProfessionalismMercer University School of Medicine

Adjunct ProfessorMercer University School of Law

Goals Questions? Thus far: Tuskegee, IRBs, pharmaceutical industry

– Small group discussions (NOT exam material!) Today: Student abuse and impaired colleagues For session on malpractice: Studdert Friday: Exam 11 questions – Lectures, NOT cases,

Studdert Course evaluation – What can we do differently?

Two Stories from an Intern

One day at an Intern’s mid-morning breakfast, . . . Wounded Knee Massacre Senior resident asked me to tap a knee Had tapped bellies, spines, chests, never knee Didn’t know landmarks, procedure Many (!!) medical students, nursing students invited

to watch Improper technique led to extremely painful tap Resident told group “That’s what you get from a

psychiatrist.” Later learned he had never tapped a knee, was afraid

to ask attending

Abuse of Students Approximately 50% students report significant abuse Clinical

– Exposure to risk management problems• Informed consent• Improper procedure techniques• Breaches of confidentiality

Teaching– Humiliation

• 24% first year students, 55% 4th years viewed derogatory comments about patients as appropriate – patient abuse?

– Sexual harassment– See one, do one, teach one – always true?

Research– Authorship – failure to include or overinclusion

Copyright ©2006 BMJ Publishing Group Ltd.

Frank, E. et al. BMJ 2006;333:682

Proportion of medical students experiencing harassment or belittlement at entry to wards or in senior year

Who is more likely to abuse students?

Attendings, residents, and fellows during clinical years

Power differential makes some feel immune to the harm they cause?

Decline of Values During Medical School

Four studies show leveling or decline in moral reasoning during medical school

Idealism shifts to self-interest What does this mean for me? Fear and blame as motivators Enthusiasm turns to fatigue, frustration, burnout Coping with difficult patients Effects of role models

• Interns and residents as teachers• Most student abuse comes from house staff

Understanding the clinical dilemmas that shape medical students’ ethical development

Experiences constitute a “hidden ethics curriculum”

May or may not be consistent with desirable ethics content

Happens frequently– 61% of students witnessed clinical faculty acting

unethically at least occasionally What are ethically problematic situations? What should you do when faced with

problematic ethical situations involving teachers?

The Art of Pimping

To pimp: verb. To ask a series of progressively arcane and distantly related questions. The purpose is to establish or confirm power.– Historical, anatomical, physiological, clinical,

eponomical, characterological, hierarchical

Responses: bluffing, feigned erudition Brancati FL. The art of pimping. JAMA. 1989;262(1):89-90. Detsky AS. The art of pimping. JAMA 2009;301:1379-81

Responding to Abuse

Politely, professionally, privately Discuss with colleague?

– Was it abuse? Did you overreact? Discuss with faculty Report to Chief Report to Dean’s office Ombuds program? Offers confidentiality

Responding to Abuse

Change the system!– Do not do unto others as they have done

unto you– Be open to criticism that what you do might

be seen as abusive– Help colleagues be better role models and

teachers

Stress and impairment

Stress results when demands (stressors) exceed resources

Optimal stress comes from demands which slightly exceed resources and produces health growth

Any change (positive or negative) can produce stress

Medical student stressors

Rapid social changes Academic expectations Financial Lifestyle changes: exercise, sleep

patterns, recreation, eating Exposure to difficult medical challenges

– Death, disability, difficult patients, abuse

Resources

The usual resources and coping strategies may be overwhelmed

Social supports Income Time for leisure, physical activity, sleep,

healthy eating, faith

Stress and impairment

When optimal stress is exceeded, physical and psychological changes may occur and, when extreme, may lead to impairment

The Impaired Physician “unable to practice medicine with reasonable

skill and safety to patients because of physical or mental illness, including deterioration through the aging process or loss of motor skill, or excessive use or abuse of drugs including alcohol.” (AMA)

“inability to exercise prudent medical judgment and the ability to practice with reasonable skill and safety without jeopardy to patient care” (AAFP)

Examples of Impairment

Substance abuse Mental Illness Cognitive Personality traits

– Boundary violations Physical condition

– Motor– Visual

Impaired Physician -Epidemiology Overall

– 10-15% lifetime risk of becoming impaired Substance abuse – 90% of impaired

physicians– 8-10% lifetime risk– 2% current

Mental Illness – 8% of impaired physicians No greater than general population except

30-100 times greater risk of narcotic addiction, greater risk for suicide (vide infra)

Physician Mortality

1261 physicians, graduated 1948-1964, studied through 1998

Overall mortality 56% lower in men, 26% lower in women

Suicide 82% greater in men, 395% greater in women

DM Torre et al. Suicide compared to other causes of mortality in physicians. Suicide and Life-Threatening Behavior. 2005;35:146-53

Impaired Students/Residents

Medical students: 11% with excessive alcohol use during at least one 6-month period, 18% with alcohol abuse during first two years

30% residents report depression with suicidal ideation in previous two weeks

14% students reported suicidal thoughts in previous year

Only 22% of depressed students received treatment

Medical Student Impairment

N Engl J Med 353;25 December 22, 2005 2673 235 physicians disciplined by medical boards

matched with 469 physicians who graduated from the same school and year

Students who were described as having unprofessional conduct during medical school were 3 times more likely to be disciplined, with a risk of 26%.

Risk factors during medical school for future disciplinary action included irresponsibility (lack of accountability) and lack of capacity for self-improvement

Impaired Physician – Risk Factors Problem behaviors, low test scores, drug use

in medical school predict problems in residency and later

Sensation seeking and paternal history predict substance abuse in students

Sleep – drugs to sleep or stay awake Access – narcotics Stress – school, family, burnout Specialty – anesthesia, ER – x3 Pharmacological optimism, reliance on

intellect, strong willed, high “T”

Impaired Physician - Recognizing

Personality changes– Complaints from patients, staff, colleagues– Intoxication on and off duty– Erratic performance and behavior– Burn out – 50% of physicians– Absences, odd hours– Errors and unusual practices– Irritability, moodiness

Aid for the Impaired Medical Student (AIMS)

MUSM Medical Student Handbook – Provide assistance before irreversible harm– Protect rights of students to receive treatment in

confidence– To ensure recovered students can continue

education without stigma or penalty– To protect others affected by impaired students– Prevent future cases of impairment

Aid for the Impaired Medical Student (AIMS) II

Administered by AIMS Council (8 students, 4 professionals)

Referral to AIMS student representative Class representatives and professional

member review circumstances, interview student, recommend action

Professional member monitors follow-up

Impaired Physician - Interventions Key is recognition – colleagues must

overcome denial, reluctance, desire to be “discrete”

Personal vs. formal intervention Thorough assessment – high co-morbidity Physician-focused treatment (e.g., Ridgeway,

Caduceus) Anticipate relapse and determine

consequences Long term monitoring Address specific issues – (e.g., burnout)

Impaired Physician - Reporting

AMA “Physicians have an ethical obligation to report impaired, incompetent, and/or unethical colleagues in accordance with the legal requirements in each state”– August 29, 2005, AMA E-9.031

Reporting not mandatory in Georgia

Attitudes to Reporting Impaired or Incompetent Colleague

JAMA 2010;304(2):187-193 17% MDs had direct knowledge of impaired

or incompetent colleague in preceding year 2/3 reported Most common reason for not reporting:

– Someone else will– Nothing will happen

Less likely to report in high malpractice risk areas

Impaired Physician – Outcomes

Risk of relapse related to family history, opioid use, co-morbid psychiatric disorder

California – 73% drug free more than two years

Missouri Physician Health Program –90% recovery

Anesthesia – 56% success, 40% entered another specialty, 5% mortality within several years

Physician Health Program

Physicians Well-Being ProgramMedical Association of Georgia

339 Tenth Street, NWAtlanta, GA 30318-5681

(404) 875-1061 Fax (404) 875-3084 email AAGM8888@aol.com George D. Miller, MD, Medical Director Types of disease, illness, or conditions monitored:

– Chemical dependency – Mental health – Behavioral health problems – Sexual misconduct and/or boundary violations – Physical illness

Georgia PHP – Chemical Dependency

Length of contract: 5 years Random urine drug screen frequency:

– Year 1: 1 time per week – Year 2: 1 time per month – Year 3: 1 time per month – Year 4: 1 time per month – Year 5: 1 time per month

Support (self help) group requirements:– AA,,NA, Caduceus, Other: IDAA

Support (self help) group frequency:– Year 1: 3 times per week – Year 2: 3 times per week – To completion: 2 times per week

Therapy or treatment requirement: peer group required, other Tx as directed by provider

Work or practice monitor requirement: once weekly contact (minimum) Other provisions: monthly monitoring meeting with program representative

Georgia PHP – Mental Health Length of contract: 5 years Support (self help) group requirements:

professionally facilitated Support (self help) group frequency: as directed by

participant's psychiatrist of record Therapy or treatment requirement: as directed by

participant's psychiatrist of record Work or practice monitor requirement: weekly

contact Other provisions: as needed Other monitoring services provided: as needed,

committee monitor (quarterly), worksite monitor, therapeutic monitoring groups, hair analysis, naltrexone

Mandatory testing of competence at age 65?

240,000 physicians Are older physicians responsible for

more adverse outcomes? http://www.medscape.com/viewarticle/

848937?src=wnl_edit_bom_weekly&uac=37986BY&impID=873915&faf=1

Slides from this point on were not part of the presentations

USMLE #3

A 95-year-old woman in a nursing home has had advanced vascular dementia, severe dysphagia, and a 9-kg (20-lb) weight loss over the past 2 months. Her four children are divided regarding the decision to provide artificial feeding through a gastrostomy tube. There is no living will. The oldest son approaches the physician after a family meeting and says, “You should simply decide what is best for her and tell the others that’s what we should do.” Assuming the physician proceeds in this manner, which of the following best describes the physician’s action?

Best Interest Standard

Paternalism Preserving fairness in use of

resources Protecting patient autonomy Rationing care Truth-telling

USMLE #4

You are a psychiatrist and Mr. Moore is your patient. Mr. Moore has been talking to you for some time about his neighbor who, he believes, has it in for him. He tells you that he plans to get his revenge. He tells you he plans to kill his neighbor.

Tarasoff – Duty to Protect

Which is the best course of action?– Inform the police of this threat.– Inform the patient’s neighbor– Inform both the police and the patient’s

neighbor– Inform no one but focus on treating the

underlying illness

USMLE #6

You are preparing a clinical trial of different doses of a certain medication. This medication has already been proven to be clinically effective and is already approved by the FDA. You are only studying to see whether a higher dose of the medication will lead to enhanced benefit.

Tuskegee The Tuskegee Study of Untreated Syphilis in the Negro Male

– Do whites and blacks differ in disease course? Treatment planned, cut due to cost Participation of Tuskegee Institute, black nurse eased fears among men Macon County Medical Society, mostly black physicians, agreed to deny

treatment Treatment – arsenic, mercury, ASA, iron, spinal taps – perceived as far superior

medical care than usually received Later, men denied free care for syphilis at PHS clinics Study continued after Nuremberg and Declaration of Helsinki (1964) Expose 1972 ended the study $10 million settlement IRBs established Legacy of mistrust between blacks and whites in research

Where is Tuskegee Today? Vulnerable populations and research AIDS in Africa

– Is use of a placebo ethical? Children

– Proxy consents

Mortality and Vioxx

Data submitted to FDA concluded no significant risk

Intent-to-treat deaths in RCTs for Alzheimer’s– Subjects 34/1069– Placebo 12/1078 – Hazard ratio 2.99

JAMA 2008;299:1813

Policy on the rights of patients in medical education (BMJ)

For educational activities not part of clinical care:– Patients must understand that medical students

are not qualified doctors (and not "young doctors," "my colleagues," or "assistants"). • What about interns? Unlicensed physicians? Non-board

certified physicians? Do all patients understand the distinctions?

– Clinical teachers and students must obtain consent from patients before students take their case histories or physically examine them, making sure they understand the primarily educational purpose of their participation. • What is “primarily educational?” Students are valuable

history takers, examiners, etc.

BMJ Patients’ Rights II

Never perform examinations or present cases that are potentially embarrassing for primarily educational purposes without the patient's consent. When individual students are conducting such examinations a chaperone should usually be present.

Students should never perform examinations on patients under general anesthetia for primarily educational purposes without patients' consent. Patients who are unconscious or incompetent must be involved in primarily educational activity only with the explicit agreement of their responsible clinician and after consent from parents (children) or consultation with relatives (adults).