01 bioethics lecture - professional behavior

8/2/2019 01 Bioethics Lecture - Professional Behavior

1/39

Professional Behavior

Tom Heston, MD


2/39

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?


3/39

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


4/39

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


5/39

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


6/39

Gifts From Patients

Small gifts acceptable

Large gifts should be refused

Patients may be vulnerable, and as a resultgive a provider a large gift.


7/39

Impaired Physicians

Substance abuse

Physical disability

Mental illness Old age resulting in poor performance


8/39

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


9/39

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


10/39

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


11/39

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


12/39

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/


13/39

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


14/39

Patient Obligations

Fully inform the physician

Ask questions

Be honest Follow medical advice


15/39

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


16/39

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?


17/39

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


18/39

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?


19/39

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.


20/39

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?


21/39

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


22/39

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?


23/39

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


24/39

Case Study 6

Resident disagrees with medical management

by attending physician

What should the resident do?


25/39

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


26/39

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?


27/39

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.


28/39

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?


29/39

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


30/39

Case Study 9

Patient admitted with massive intracranial

bleed

Patient on a ventilator

Brain death confirmed

What do you do?


31/39

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


32/39

Case Study 10

A parent brings a 5-year old child to the ER

You suspect child abuse

What do you do?


33/39

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


34/39

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


35/39

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.


36/39

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.


37/39

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


38/39

General Principles

Have a good bedside manner and be

respectful

A good rapport increases patient satisfaction,

compliance, and physician satisfaction


39/39

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

01 bioethics lecture - professional behavior

Documents