Bioethics 2 Flashcards
Why is it important to respect what appear to me to be idiosyncratic beliefs?
Respecting the beliefs and values of your patient is an important part of establishing an effective therapeutic relationship. Failure to take those beliefs seriously can undermine the patient’s ability to trust you as her physician. It may also encourage persons with non-mainstream cultural or religious beliefs to avoid seeking medical care when they need it.
What are some ways to discover well known sets of beliefs?
Good resources for guidance in this area include patients and family members themselves, staff members with personal knowledge or experience, hospital chaplains, social workers, and interpreters.
What is the legal equivalent of patient autonomy?
Individual liberty
Where does ethics begin?
Where the law ends
What are the two primary types of potential civil actions against health care providers for injuries resulting from health care?
- Lack of informed consent
2. Violation of the standard of care
What is informed consent?
Before a health care provider delivers care, ethical and legal standards require that the patient provide informed consent
What happens if a patient cannot provide informed consent?
- A legally authorized surrogate decision-maker may do so
- In an emergency situation when the patient is not legally competent to give informed consent and no surrogate decision-maker is readily available, the law implies consent on behalf of the patient, assuming that the patient would consent to treatment if he or she were capable of doing so.
What information does the doctor need to share with the patient for the consent to be informed? What to note?
- The treatment’s nature and character and anticipated results
- Alternative treatments (including non-treatment)
- Potential risks and benefits of treatment and alternatives (including side effects)
NOTE: the information must be presented in a form that the patient can comprehend (i.e., in a language and at a level which the patient can understand), the doctor should assess the patient’s understanding, and the consent must be voluntary given
How does one determine what the standard of care is?
The standard of care emerges from a variety of sources, including
- Professional publications
- Interactions of professional leaders
- Presentations and exchanges at professional meetings, and among networks of colleagues
- Experts are hired by the litigating parties to assist the court in determining the applicable standard of care
Can I just Google what the law says?
The changing nature of the law prompts a caveat to legal researchers: material obtained through general legal searches may not be current and the state of the law should be confirmed with a practicing lawyer before relying upon it.
Can children give informed consent?
NOPE, except for specific conditions
What is substituted judgment? What to note?
Decision-making when a surrogate decision-maker is required to make the choice she believes the patient would have wanted, which may not be the choice the decision-maker would have chosen for herself in the same circumstance
If the surrogate is unable to ascertain what the patient would have wanted, then the surrogate may consent to medical treatment or non-treatment based on what is in the patient’s best interest
What happens if there are multiple children who have to make a decision for their parent?
Unanimity must be achieved
Should providers disclose medical errors to patients, and if so, how and when?
Despite a professional ethical commitment to honest communication, providers cite a fear of litigation and malpractice lawsuits as a reason for non-disclosure
Sometimes, an apology coupled with disclosure and prompt payment may decrease either the likelihood or amount of legal claim, and a number of state legislatures have recently acted to protect provider apologies, or provider apologies coupled with disclosures, from being used by a patient as evidence of a provider’s liability in any ensuing malpractice litigation
OVERALL: It is currently too early to know whether these legal protections will have any impact on the size or frequency of medical malpractice claims ==> it is advisable to involve risk management and legal counsel in decision-making regarding error disclosure
What is a DNAR?
Written document by a licensed physician in consultation with a patient or surrogate decision maker that indicates whether or not the patient will receive CPR in the setting of cardiac and/or respiratory arrest
Is a DNAR valid without an advance directive?
Yes
What does DNAR stand for?
Do-not-attempt-resuscitation
Why did DNARs come about?
In 1974, the American Heart Association recognized that many patients who received CPR survived with significant morbidities and recommended that physicians document in the chart when CPR is not indicated after obtaining patient or surrogate consent. This is based on the practical reality that performing CPR is an attempt to save life rather than a guarantee
Do you perform CPR if patients are unable to express what their wishes are?
- Refer to the advance directives
2. Ask a surrogate decision maker
How can you define the direct medical benefit of performing CPR?
Determining the potential for direct medical benefit can be challenging, especially when there is great uncertainty in outcome
- Examine the probability of an intervention leading to a desirable outcome. Outcomes following CPR have been evaluated in a wide variety of clinical situations
- Multiple factors, including both the distal and proximal causes for cardiopulmonary arrest, must be considered to determine whether or not CPR has the potential to promote survival
How should the patient’s quality of life be considered in determining direct medical benefit of CPR?
Should be considered with caution because it is subjective to the patient’s perspective and the patient’s values, preferences, and statements inform such assessments
Should you perform slow or show codes? Why?
NOPE
Because it undermines the rights of patients to be involved in clinical decisions, is deceptive, and violates the trust that patients have in health care providers
Should DNARs be respected in the OR or when the patient is under anesthesia?
Anesthesiologists and surgeons may be reluctant to accept DNR orders on patients undergoing surgery because of the scope of medical practice which constitutes “normal care” in the surgical environment.
Many authorities have suggested that the application of chest compressions is an unusual enough occurrence even in the OR setting, that it provides a medical and ethical boundary between CPR and normal anesthetic care
In the end, rediscussion of the DNAR should occur, whenever possible, prior to undertaking surgery and anesthesia
Is the outcome from CPR different in the OR than on the medical ward? Explain. Implication?
YUP
- In the OR, the event of arrest is always witnessed, and the proximate cause usually known, allowing rapid, effective intervention which is directed toward the specific cause of arrest
- Causes of arrest in the OR are often reversible effects of anesthesia or hemorrhage, and not usually due primarily to the patient’s underlying disease
Implication: patient and physicians may require correction of the perception that CPR in the OR is just as futile as CPR on the general medical ward
Can you require a patient to suspend their DNAR to be a candidate for surgery?
NOPE
What are the 4 roles of an ethics committee?
- To promote the rights of patients
- To promote shared decision making between patients (or their surrogates if decisionally incapacitated) and their clinicians
- To promote fair policies and procedures that maximize the likelihood of achieving good, patient-centered outcomes
- To enhance the ethical environment for health care professionals in health care institutions
Under what circumstances should I call the ethics consultant/service?
You should consider asking for a case consultation when two conditions are met:
- I perceive that there is an ethical problem in the care of patients
- Health care providers have not been able to establish a resolution that is agreed upon by the patient/surrogate and the clinicians caring for the patient
Why has AIDs had an enormous impact on health care delivery in the US?
Because it forced the medical community to openly address the needs of populations who have historically been marginalized in our society: gay men and IV drug users
What should you do if a patient refuses to be tested for HIV?
Testing for HIV, as for any other medical procedure should be done only with the informed consent of the patient. Testing without consent is unethical in this setting. The physician’s role in the care of this patient is ongoing support, education and guidance about her various options for care
When should you report a patient’s HIV status to the Public Health Department?
AIDS is a currently a reportable diagnosis in all 50 states of the union. Diagnosis should be reported to the department of public health.
However, HIV positivity without the diagnosis of AIDS is not reportable in all states. Currently, 30 of 50 states requires reporting of a positive test. It is important to find out the local states laws where you are practicing to know how to approach this problem (NC is one of those 30 states)
Should you prescribe protease inhibitors to a patient who is unlikely to follow through on the treatment regimen? Pros/Cons/Overall?
Protease inhibitors used in combination with nucleoside analogues have proven a powerful weapon in the fight against HIV.
CONS:
- The problem of resistance is a real concern in a patient who cannot take his medicines reliably so this would create resistant clones of virus which could then be passed on to others, or make the individual unable to benefit later if they were able to become compliant
- Costs of these medications on the health care system is so extreme that they should only be used by those who can fully benefit from them
PRO:
1. The principle of justice which espouses equitable distribution of resources amongst all available people in need, and if the patient wants the medications he should have equal access to them
OVERALL: there is no answer to this debate at this time. The only clear principle that should be followed here is that of non-abandonment. Whatever your choice is with the patient, the physician’s responsibility is to remain available to the patient and continue an ongoing therapeutic relationship and encourage him with information and guidance about his HIV disease and issues of addiction.
Should I give my recommendation to the patient during the informed consent? What to note?
YUP
And also explain my reasoning
How much information is considered “adequate” for a consent to be informed?
Ask yourself 3 questions:
- What would a typical physician say about this intervention?
- What would the average patient need to know in order to be an informed participant in the decision?
- What would this particular patient need to know and understand in order to make an informed decision?
What sorts of interventions require informed consent?
ALL
What are the 4 exceptions to the need for informed consent?
- If the patient does not have decision-making capacity, in which case a proxy, or surrogate decision-maker, must be found
- A lack of decision-making capacity with inadequate time to find an appropriate proxy without harming the patient, such as a life-threatening emergency where the patient is not conscious
- When the patient has waived consent
- When a competent patient designates a trusted loved-one to make treatment decisions for him or her. In some cultures, family members make treatment decisions on behalf of their loved-ones. Provided the patient consents to this arrangement and is assured that any questions about his/her medical care will be answered, the physician may seek consent from a family member in lieu of the patient
What about the patient whose decision making capacity varies from day to day?
Then try to assess when the patient is most lucid and if her decision is always consistent in those moments, use that
Can parents provide informed consent for their children?
NOPE, they provide informed permission
Are all members of the healthcare team equal? Explain.
NOPE
Relationships between professionals on the multidisciplinary team are by their nature unequal ones. Different knowledge and experience in specific issues both ethically and legally imparts unequal responsibility and authority to those care providers with the most knowledge and experience to handle them. But also because of differences in training and experience, each member of the team brings different strengths. Team members need to work together in order to best utilize the expertise and insights of each member.
Do I have to do whatever I am told by the attending physician, even if I disagree with their plans?
I should seek input from the attending, both about the reasoning to pursue the attending’s plan, and about the reasoning for rejecting my own
A respectful exchange of views may provide both parties with new information, and certainly serves to further education
What does “ethically” mean?
- Pertaining to or dealing with morals or the principles of morality; pertaining to right and wrong in conduct.
- Being in accordance with the rules or professional standards for right conduct or practice
What is meant by “respectful” exchange of views? What to note?
- Respectful behavior begins with both listening to and considering the input of other professionals
- Respect is demonstrated through language, gestures, and actions. Disagreement can and should be voiced without detrimental statements about other members of the team, and without gestures or words that impart disdain. Both actions and language should impart the message: “I acknowledge and respect your perspective in this matter, but for the following reasons I disagree with your conclusions, and believe I should do something else…”
NOTE: disrespectful behavior from a colleague does not justify disrespectful behavior in return
How can disagreements on the multidisciplinary team be handled? 3
- Discussion
- Consult other professionals who are not directly involved in the patient’s care team for objective input
- Ethics committee
What accounts for the rising awareness of maternal-fetal conflict?
Advances in medical technology have increased the physician’s ability to direct medical procedures towards the fetus
What principles are at play when medical therapy is indicated for one patient, yet contraindicated for the other (mother/baby)?
The ethical principles of beneficence (“be of benefit”) and nonmaleficence (“do no harm”) can come into conflict
When does a fetus or a newborn become a person?
When the fetus is viable aka capable of life independent of maternal corporeal support
Who is responsible for the health of the fetus?
US courts have ruled that a child has a legal right to begin life with a sound body and mind. Such a right may create a legal duty, on the part of a pregnant woman, to protect the health of her fetus. Failure to fulfill that duty could subject her to charges of fetal abuse, or render her liable for consequent damage to her child.
Can pregnant women refuse therapy?
YUP
What are 4 potential reasons for medical mistakes?
- Negligence
- Incomplete knowledge base
- Error in perception or judgment
- Lapse in attention
How do I decide whether to tell a patient about an error?
In general, even trivial medical errors should be disclosed to patients. Any decision to withhold information about mistakes requires ethical justification. If a physician believes there is justification for withholding information about medical error from a patient, his judgment should be reviewed by another physician and possibly by an institutional ethics committee. The physician should be prepared to publicly defend a decision to withhold information about a mistake from the patient.
Won’t disclosing mistakes to patients undermine their trust in physicians and the medical system?
Some patients may experience a loss of trust in the medical system when informed that a mistake has been made. Many patients experience a loss of trust in the physician involved in the mistake. However, nearly all patients desire some acknowledgment of even minor errors. Loss of trust will be more serious when a patient feels that something is being hidden from them.
What do I do if I see someone else make a mistake?
It is my obligation to make sure that the truth is revealed to the patient and this should be done in the least intrusive way:
- First, I need to clarify the facts of the case and be absolutely certain that a serious mistake has been made before taking the case beyond the health care worker involved
- If the other health care provider does not reveal the error to the patient, I should encourage her to disclose her mistake to the patient
- Should the health care provider refuse to disclose the error to the patient, I will need to decide whether the error was serious enough to justify taking the case to a supervisor or the medical staff office, or directly telling the patient
Is there an increased morbidity associated with higher survival rates of infants with low birth rates?
YUP (only 16% have no disability)
Do survivors and families think that aggressive care for very low birth weight infants is good?
Self-assessment research of a large group of adolescents, former extra-low birth weight infants, demonstrates that their view of their quality of life was “quite satisfactory” and when compared to a comparable age group of normal controls, there were few differences between the two groups in their perception of their quality of life
Is it possible to predict which infants will survive/be disabled despite aggressive medical/surgical care in the neonatal period?
There are no successful models to assess individualizable predictability of death or disability
What is the accepted legal and ethical basis for decision-making regarding the nature of medical care in the newborn infant? What to note?
The child’s best interest is legally and ethically primary and should be weighed over the family’s well-being or societal concerns.
NOTES:
1. There is considerable discussion in the literature about the utility of applying this standard to neonates based on their present or future best interest
- Much discussion is placed on the need to include the family’s interests when making life and death decisions regarding severely compromised infants
- In the interest of justice, societal concerns about excessive cost for aggressive care should be addressed at the policy level, rather than on an individual or case-by-case basis.
What is the basis for granting medical decision-making authority to parents? 2
- In most cases, a child’s parents are the persons who care the most about their child and know the most about him or her so parents are better situated than most others to understand the unique needs of their child and to make decisions that are in the child’s interests
- Since many medical decisions will also affect the child’s family, parents can factor family issues and values into medical decisions about their children
What if parents are unavailable and a child needs medical treatment?
Medical caretakers may provide treatment necessary to prevent harm to the child’s health
Should children be involved in medical decisions even though their parents have final authority to make those decisions?
Children with the developmental ability to understand what is happening to them should be allowed to participate in discussions about their care. As children develop the capacity to make decisions for themselves, they should be given a voice in medical decisions. Most children and adolescents lack full capacity to make complex medical decisions, however, and final authority to make medical decisions will usually remain with their parents.
What happens when an older child disagrees with her parents about a medical treatment?
If the medical caretaker judges a child competent to make the medical decision in question, she should first attempt to resolve the issue through further discussion. If that fails, the medical caretaker should assure that the child’s voice has been heard and advocate for the child. In intractable cases, an ethics consultation or judicial hearing should be pursued.
What are the 3 circumstances under which minors can make medical decisions for themselves?
- Emancipated minors
- Mature minor status (determined by the physician or judiciary system depending on the state)
- Specific conditions
What is a fiduciary relationship?
A relationship involving trust
How to ensure a good patient-physician relationship as a medical student?
Students must be honest about their role, letting the patient know s/he is a physician-in-training
Why do many patients appreciate the opportunity to work with medical students?
Students usually have more time to spend with a patient, listening to the patient’s history and health concerns, and may become more aware of personal concerns than other team members. Patients notice and appreciate this extra attention.
How much of herself should the physician bring to the physician-patient relationship?
Many patients may feel more connected to a physician when they know something of the physician’s life, and it may sometimes be appropriate to share information about family or personal matters. However, it is essential that the patient, and the patient’s concerns, be the focus of every visit.
Is a physician obliged to provide medical services in opposition to their personal beliefs?
NOPE
Can a physician try to convert a patient from one religion, belief, or opinion to another?
NOPE
What 5 factors can hinder physician-patient communication?
- Patients may feel that they are wasting the physician’s valuable time
- Patients may omit details of their history which they deem unimportant
- Patients may be embarrassed to mention things they think will place them in an unfavorable light
- Patients may not understand medical terminology
- Patients may believe the physician has not really listened and, therefore, does not have the information needed to make good treatment decisions
What 9 things can a physician do to facilitate open communication with a patient?
- Sit down and speak at eye-level
- Make sure the patient is comfortable
- Make eye contact
- Listen and not interrupt
- Show attention through nodding for example
- Allow silences while patients search for words
- Acknowledge and legitimize feelings
- Explain and reassure during examinations
- Ask explicitly if there are other areas of concern
What fraction of patients do not follow a physician’s treatment recommendations? How can this be improved?
1/3 to 1/2
Can be improved by shared decision making
What are two questions you can ask to support shared decision making and compliance?
- I can give you a medication to help with your symptoms, but I also suspect the symptoms will go away if you wait a little longer. Would you prefer to try the medication, or to wait?
- Sometimes it’s difficult to take medications, even though you know they are important. What will make it easier for you to take this medication?
What should I do if a patient gets angry and screams?
Say: I know that it has been hard to schedule this appointment with me, but using abusive language with the staff is not acceptable. What do you think we could do to meet everybody’s needs?
When is it appropriate for a physician to recommend a specific course of action or override patient preferences? Explain.
What is a caveat?
NEVER! When there is a high likelihood of harm without therapy, and treatment carries little risk, the physician should attempt, without coercion or manipulation, to persuade the patient of the harmful nature of choosing to avoid treatment
Court orders may be invoked to override a patient’s preferences:
- Minor patient
- Pregnant patient
- If harm is threatened towards oneself or others
- In the context of cognitive or psychological impairment
- When the patient is a sole surviving parent of dependent children.
BUT the use of such compulsory powers is inherently time-limited, and often alienates the patient, making him less likely to comply once he is no longer subject to the sanctions
What 2 things need to be done when a physician is required to report a patient’s condition?
- Reporting should be done in a manner that minimizes invasion of privacy
- Reporting should be done with notification to the patient
How to encourage a teenager to talk to you?
Say: sometimes teens have questions they would like to discuss with me. If that happens to you, it’s okay to tell your parents that you’d like an appointment. You and I won’t have to tell your parents what we talk about if you don’t want to, but sometimes I might encourage you to talk things over with them.
Why is it better to say physician aid in dying rather than physician assisted suicide? CON?
The use of this term ties the role of the physician to one that aids the patient in killing him or herself. However, implicit in the understanding of the word suicide is the notion of a premature death that is being hastened out of despair, therefore when mental illness impairs judgment, intervention to stop a suicide is ethically warranted because the person seeking suicide has lost his ability to carefully weigh the benefits and burdens of continued life
CON: it could include other practices that are clearly outside the legal bounds of the three states’ Death with Dignity Acts, e.g. a patient who receives assistance in ingesting the medication
What criteria must be met in Washington, Oregon, and Vermont for physician aid in dying?
- Eligible persons must be decisionally competent
2. They must have a limited life expectancy of about 6 months or less
Is physician aid-in-dying (PAD) the same as euthanasia?
No. While both physician aid-in-dying and euthanasia involve the use of lethal medications to deliberately end a patient’s life, the key difference is in who acts to administer the medications that will end the patient’s life. In physician aid-in-dying, the patient must self-administer the medications; the “aid-in-dying” refers to a physician providing the medications, but the patient decides whether and when to ingest the lethal medication. Euthanasia occurs when a third party administers medication or acts directly to end the patient’s life.
Is euthanasia legal?
NOPE
What are 3 practices that should not be confused with physician aid in dying?
- Withholding/withdrawing life-sustaining treatments: When a competent adult patient makes an informed decision to refuse life-sustaining treatment, their wishes are generally respected. The right of a competent adult patient to refuse life-sustaining treatments is supported by law.
- Pain medication that may hasten death: Often a terminally ill, suffering patient may require dosages of pain medication that have side effects that may hasten death, such as impairing respiration. It is generally held by most professional societies, and supported in court decisions, that this action is justifiable because the primary goal and intention of administering these medications is to relieve suffering, and the secondary outcome of potentially hastening death is recognized as an expected and acceptable side-effect in a terminally ill patient
- Palliative sedation: This term refers to the practice of sedating a terminally ill patient to the point of unconsciousness, due to intractable pain and suffering that has been refractory to traditional medical management. Such patients are imminently dying, usually hours or days from death. Palliative sedation may occur for a short period (respite from intractable pain) or the patient may be sedated until s/he dies. In the rare instances when pain and suffering is refractory to treatment even with expert clinical management by pain and palliative care professionals, palliative sedation may legally be employed.
What are the 5 arguments in favor of physician aid in dying?
- Respect for autonomy: Decisions about time and circumstances of death are personal. Competent people should have right to choose the timing and manner of death.
- Justice: Justice requires that we “treat like cases alike.” Competent, terminally ill patients have the legal right to refuse treatment that will prolong their deaths. For patients who are suffering but who are not dependent on life support, such as respirators or dialysis, refusing treatment will not suffice to hasten death. Thus, to treat these patients equitably, we should allow assisted death as it is their only option to hasten death.
- Compassion: Suffering means more than pain; there are other physical, existential, social and psychological burdens such as the loss of independence, loss of sense of self, and functional capacities that some patients feel jeopardize their dignity. It is not always possible to relieve suffering.
- Individual liberty vs. state interest: Though society has strong interest in preserving life, that interest lessens when a person is terminally ill and has strong desire to end life. A complete prohibition against PAD excessively limits personal liberty.
- Honesty and transparency: Some acknowledge that assisted death already occurs, albeit in secret. The fact that PAD is illegal in most states prevents open discussion between patients and physicians and in public discourse. Legalization of PAD would promote open discussion and may promote better end-of-life care as patients and physicians could more directly address concerns and options.
What are the 5 arguments against of physician aid in dying?
- Sanctity of life: Religious and secular traditions upholding the sanctity of human life have historically prohibited suicide or assistance in dying
- Passive vs. Active distinction: There is an important difference between passively “letting die” and actively “killing.” Treatment refusal or withholding treatment equates to letting die (passive) and is justifiable, whereas PAD equates to killing (active) and is not justifiable.
- Potential for abuse: Vulnerable populations, lacking access to quality care and support, may be pushed into assisted death. Furthermore, assisted death may become a cost-containment strategy. Burdened family members and health care providers may encourage loved ones to opt for assisted death and the protections in legislation can never catch all instances of such coercion or exploitation
- Professional integrity: Historical ethical traditions in medicine are strongly opposed to taking life. For instance, the Hippocratic oath states, “I will not administer poison to anyone where asked,” and I will “be of benefit, or at least do no harm.” The overall concern is that linking PAD to the practice of medicine could harm both the integrity and the public’s image of the profession.
- Fallibility of the profession: The concern here is that physicians will make mistakes. For instance there may be uncertainty in diagnosis and prognosis. There may be errors in diagnosis and treatment of depression, or inadequate treatment of pain. Thus the State has an obligation to protect lives from these inevitable mistakes and to improve the quality of pain and symptom management at the end of life.
What should I do if a patient asks me for physician aid-in-dying (PAD)? 8
- Explore the reasons for the patient’s request: discuss various ways of addressing the patient’s pain, suffering, hopes, and fears. If time permits, tell the patient that you would like to talk more about this at a subsequent appointment. That gives both you and the patient time to prepare for a fuller exploration of PAD as well as other palliative treatments, hospice, etc
- Evaluate for depression or other psychiatric conditions and treat appropriately
- Assess the patient’s decision-making competence
- Engage in discussion surrounding the patient’s diagnosis, prognosis, and goals for care
- Make sure to assess patient understanding.
- Evaluate patient’s physical, mental, social, and spiritual suffering and take into account the patient’s support system as well as personal and professional pressures and stressors
- Discuss all alternative options, such as palliative care and hospice
- Consult with professional colleagues regarding the patient’s situation( including palliative care specialists)
- Help the patient complete advance directives, DNR orders and POLST forms, as appropriate and ensure that preferences are followed
What are the 6 recognized obligations and values of a professional physician? Explain each.
- Altruism: A physician is obligated to attend to the best interest of patients, rather than self-interest.
- Accountability: Physicians are accountable to their patients, to society on issues of public health, and to their profession.
- Excellence: Physicians are obligated to make a commitment to life-long learning.
- Duty: A physician should be available and responsive when “on call,” accepting a commitment to service within the profession and the community.
- Honor and integrity: Physicians should be committed to being fair, truthful and straightforward in their interactions with patients and the profession.
- Respect for others: A physician should demonstrate respect for patients and their families, other physicians and team members, medical students, residents and fellows.
Is professionalism compatible with the restrictions sometimes placed on physician’s judgments in managed care?
One of the principal attributes of professionalism is independent judgment about technical matters relevant to the expertise of the profession. Today, many physicians work in managed care situations that require them to abide by policies and rules regarding forms of treatment, time spent with patients, use of pharmaceuticals, etc. In principle, such restrictions should be designed to enhance and improve professional judgment, not limit it. The presence of rules, policies and guidelines in managed care settings requires the physicians who work in these settings to make such judgments and to express their reasoned criticism of any that force the physician to violate the principles of professionalism.
What should I do when my preceptor introduces me as “Dr. Miller”?
It can be a difficult conversation to have with your preceptors, but it is best to discuss this matter in advance. Find out what his or her expectations are. If they feel strongly about introducing you as “doctor,” it remains your responsibility to explain tactfully that you cannot misrepresent yourself to patients. In the long run, patients’ trust will be secured if they realize you are both being straightforward. If the preceptor insists, you may need to find polite ways to reintroduce yourself to the patient, modeling for the preceptor that direct communication is often the best foundation for a strong physician (and student-physician) patient relationship. For example, you might say, “Yes, I am a physician-in-training from Wake Forest SOM!”
How should I respond when an intern asks if I want to practice a procedure on a patient who just died?
NOPE - simulation labs and cadaver labs are made for this
What if I see my resident or attending doing something “unethical”?
- Talk with your resident about what you observed. Everyone has a unique perspective and your resident may have a rationale for his behavior that was unknown to you. Approaching him honestly, with simple questions, may allow him the benefit of the doubt and open up a dialogue between you.
- If patient care is in jeopardy you may have an obligation to report the resident’s behavior if he refuses to discuss it with you directly but discuss with peers
I’m not sure how I feel about “using” vulnerable patients as teaching patients. Are we taking unfair advantage of people?
- It is necessary
- Care from a medical student is better than no care
- They should be treated with respect: ask permission before doing any observations, tests, or procedures
- Thank patients, acknowledging the crucial role they play in my education
- Students have more time to spend with the patient
I’m noticing what looks like addictive behavior in one of my classmates. What should I do?
Impaired students become impaired physicians. I am entering a profession that carries an obligation to its members for self-regulation. As a student, my classmate has an opportunity to seek help before serious harm comes to himself or herself, or to one of his or her patients. I can help him on his path to recovery.
Once licensed, you will have a legal obligation to report colleagues to the medical board if they are “unable to practice medicine with reasonable skill and safety to patients by reason of illness, drunkenness, excessive use of drugs, narcotics, chemicals, or any other type of material, or as a result of any mental or physical conditions.
Is a child able to refuse medical treatment?
NOPE - he/she is not competent
Can family members serve as interpreters?
NOPE - they do not qualify as professional licensed medical interpreter
