Do Oaths and Rules Make a "Good" Doctor?

Do oaths and rules make an ethical and caring physician?  

In the realistic and present day world of medical practice, the way medicine is practiced both in terms of emphasis or de-emphasis of oaths, medical school teachings and established legal and professional requirements are going to be different between one physician and another. There are going to be shortcuts and at times excesses depending on the situation and even the mood of the physician. Doctors are going to take chances or they will strictly follow what they believe are standard operating procedures ("standards of practice"). Yes, the Oaths are there, the laws and professional requirements and all the tools for professional behavior as provided by the medical schools are there but in the end, each doctor in their own professional environment will obey them as they see fit at the time. And it is up to their patients and their colleagues to finally grade the doctor. 

Do oaths and rules make an ethical and caring physician?  My conclusion is "probably not". I think it takes more than that. And, if you agree, what "more" is necessary? Let's read your thoughts on the subject. .Maurice.

Should Doctors be Allowed to Strike?

Currently, there is a strike by 10,000 physicians at public hospitals in a state of India in an attempt to get better salaries and work opportunities similar to those in other federal hospitals in India. The government has suspended 40 doctors, and 390 others have been arrested for failing to perform their duties.

Over the years there have been physician strikes elsewhere in the world and in the United States for various reasons including the high cost of malpractice insurance.  A 2004 article in the American Journal of Bioethics by Autumn Fiester argues the ethics against walkouts by physicians, in this case the issue has been the increasing malpractice insurance cost rates not keeping pace with physician reimbursements.

   

My question to the visitors to my blog is whether physicians have a right to strike and if so for what reasons and  if they do, is such individual physician termination of services, without any replacement provided ethical? ..Maurice.

Patient Modesty: Volume 46

Continuing on with the discussion regarding issues of physical modesty in the context of medical care, there continues to be debate throughout these Volumes as to who is responsible for the contested inequalities in attention to these issues and what is necessary for the resolution of these issues.  Is there a conflict between the male and female gender, working apart, in attaining their own individual modesty goals or should both genders look to each other's physical modesty needs and desires and stand and work together to change the medical care system to meet all their goals? I suspect the latter is the wisest.  Perhaps the best suggestion for both genders to become active to the same cause and to get together on a website to develop tools for advocacy.  I would suggest checking in at Suzy's site where the goal is to do just that.  Here is her description of the Mission Statement and Goals:

MISSION STATEMENT:
We believe that each patient is an individual and as such has specific preferences and needs including what accommodations they require to maximize comfort when their modesty must be compromised in the medical experience. Our mission it to act as a liaison between patients and providers in establishing, understanding, and executing the policies and procedures essential to that end. When appropriate we will act as advocates for patients to achieve that goal through interaction, education, and referrals to both patients and providers.

GOALS: Our goal is to help patients achieve dignified and respectful healthcare through education and information. Everyone has different needs and expectations of their healthcare providers, and we provide choices and options in obtaining those needs. We understand that modesty, privacy, and respect are primary needs when facing procedures and we promote educating providers in the sensitivity of those needs.

ADDENDUM (12-23-2011)

 On 12-23-2011, Belinda wrote the following comment : Going back the the "Naked" article, it would seem that now is the time to write protocols for exams with dignity at the forefront with equal accessibility as needed for any kind of exam making draping practices uniform. It would give patients and idea of what to expect and do as much to relieve the awkwardness of such an exam. Any thoughts on this?

I responded with the following:

Belinda, an EXCELLENT suggestion! In fact, to make the suggestion even more productive.. how about the visitors here (even you PT) together create a final consensus list, a series of suggested protocols for attending to all the patient modesty issues experienced in medical care. The development of the list can written to this blog or Dr. Sherman/Doug Capra's or on Suzy's blog.

But not just writing this protocol list to our blogs.. the final consensus list should be sent to Dr. Atui Gawande who wrote the article "Naked" in the New England Journal of Medicine and which was the basis for our entire series of Volumes on patient modesty. As some of you may know, Dr.Gawande is now a very well respected individual for his analysis and writings about a host of important medical issues that need fixing or change. By this project on our part, this may be the most direct way, through Dr.Gawande, to get something moving rather than repeated moaning and yearning on our blogs. How is that for an idea? Again, thanks Belinda for a suggestion to get us all "off our butts" (so to speak). 



..Maurice.
Graphic: "Man and Woman Apart and Together"-Classic icons modified by me with ArtRage.

NOTICE: AS OF TODAY JANUARY 11, 2012 "PATIENT MODESTY: VOLUME 46" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 47

Should Patients Have Online Access to Their Medical Records?

Should all patients be given online access to their medical records? The British healthcare system is currently considering such a possibility. With electronic medical records progressively becoming the norm throughout the medical world, this access would be feasible but would it be wise? Certainly, there would be advantages to the patient who would readily see the written result of the office visit and could then, if necessary, confront the physician with corrections, additions and questions and in a timely fashion. But what are the negatives to such an idea beyond potential loss of patient privacy due to inappropriate or illegal computer access? For example, would this mean that the medical record would have to be written in words understandable by any patient rather than in more concise and professionally understandable terminology and thus perhaps degrade professional communication? Would such access more easily give rise to patients starting malpractice actions due to misunderstandings of what was written to the record? Could patient's be pressured by others (insurance companies or employers as examples) into providing access to the electronic records since they would be more readily available? What do you think? ..Maurice.

Do We Own Our Own Germs?: Ethics and Law in Research

From the current New York Times Sunday Review: IMAGINE a scientist gently swabs your left nostril with a Q-tip and finds that your nose contains hundreds of species of bacteria. That in itself is no surprise; each of us is home to some 100 trillion microbes. But then she makes an interesting discovery: in your nose is a previously unknown species that produces a powerful new antibiotic . Her university licenses it to a pharmaceutical company; it hits the market and earns hundreds of millions of dollars. Do you deserve a cut of the profits?
In on ongoing legal challenge to the patent law which allows isolated human genes to be patented and which was previously overturned, the Court of Appeals for the Federal Circuit of the United States returned a ruling earlier this year that these genes were not simply a product of nature, which would not be eligible for a patent, but indeed could be patented. So..who has the legal rights to that rare and valuable germ growing in your nose or that gene which was part of your body but the one that was recovered and used for, as an example, a genetic test for cancer? And beyond the law.. what are the ethics? What is the good vs bad, what is the right vs the wrong?

..Maurice.

When is Privileged Communication Not Privileged? The Law and Ethics.

Privileged communication is "an exchange of information between two individuals in a confidential relationship."

I present now three scenarios and look toward some wise visitors to this blog to provide me with some answers from the legal point of view but also a view of the ethics. ..Maurice.

Suppose a patient admits to his physician that he is emotionally upset and is having gastro-intestinal symptoms because he killed his wife and buried her body in the back yard and told others that she was on a vacation. Suppose a client who is about to be questioned by the police, admits to his lawyer that he killed his wife and buried her body in the back yard. Would the professional standard in each case see the admission as privileged communication and allow the professional to withhold the information to the police or courts that the patient or client admitted? Suppose the patient with symptoms and that same story went to his physician who was both a physician and a lawyer licensed to practice and revealed the killing but desired the professional as a lawyer to provide professional legal advice and, if necessary, defend his case. Could privileged communication still be preserved?

Patient Modesty: Volume 45

Doug Capra, a regular contributor to this thread, wrote a comment on November 1 2011 which I inadvertently didn't publish but which I think is valuable for our consideration of two issues related to the patient modesty discussions here. Read it and then read my analysis below. ..Maurice.

Relative to the current discussions -- In past posts, I've referenced an articled called "Not Just Bodies" which is based upon a study of the strategies and/or defense mechanisms doctors use to deal with body issues == which include not just nakedness and modesty, but also horrible accidents and diseases. The profession knows well about these issues and addresses them. A major problem, as I see it, is this: Some of the strategies they use protect them psychologically but do little for or actually psychologically harm the patient. Some doctors never really "get over" this issue but just put up fences to protect themselves. There are also studies out there using medical students showing how they deal with this issue. There are some related studies about nurses. I think a myth within the profession is that these issues can easily be hidden from the patient by covering up using these strategies. I question that. I think many patients pick up on this and it may affect their healing and/or psychological health. Most of us, medical professional or not, are often unaware of the face we are actually "showing" to others. It takes quite a bit of self-reflection and knowledge to be aware of this. My other concern is what I've started to call the "deprofessionalization" of medical care in this country -- for cost saving reasons. I'm not so concerned with what are called mid-levels (PA's and NP's) But the use of all kinds of various initialed (cna, cma, pt's, ma, etc.) nurse assistants, some with little maturity and/or training, in this country is frightening. Some have no actual scope of practice, work under the doctor's license, and can do whatever the doctor is willing to risk. It's this trend that bothers me most and IF, and I emphasize the IF, there's a tendency for people with sexual perversions (or other psychological defects) to enter the medical field, it would be in this area. And these are the people these days doing most of the bedside care and, more and more, even some invasive procedures.By Doug Capra

First, I agree that physicians, in order to emotionally not react or show to the patient that they are not unprofessionally reacting to the patient's nudity, may take on a bland, emotionally neutral affect which demonstrates to the patient a sexually inert physician. And since the physician is sexually inert, he or she expects the patient to be likewise. And particularly, if the patient doesn't verbally complain, the physician thinks that the current behavior is fully acceptable.

I also agree with Doug regarding a certain degree of inadequate screening of the motivations of those entering the medical field and particularly those whose time and money and life investments are truly minimal and perhaps sexual interest values may play a role beyond the desire to be a care provider for the sick.

So who can be called a "peeping Tom", the title of this Volume's graphic, is a matter open to discussion. Perhaps we all are "peeping Toms" or "Little Bo Peeps" at one time or another, but it never should be at the physical or emotional expense of any patient. And that is why I think that discussion and dissemination of the issues of patient physical modesty is so important in the consideration of the best patient care. ..Maurice.

NOTICE: AS OF TODAY DECEMBER 20, 2011 "PATIENT MODESTY: VOLUME 45" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 46

Does the Fertilized Egg Equals Legal Person?

From today's New York Times:

"A constitutional amendment facing voters in Mississippi on Nov. 8, and similar initiatives brewing in half a dozen other states including Florida and Ohio, would declare a fertilized human egg to be a legal person, effectively branding abortion and some forms of birth control as murder. With this far-reaching anti-abortion strategy, the proponents of what they call personhood amendments hope to reshape the national debate."

By the time most of my visitors will have read this thread, the voters in Mississippi will have voted and the constitutional amendment will have passed with all its potential consequences or simply defeated and with some folks in Mississippi unsatisfied. Read the article describing the significance of this vote and return and discuss here what you think would be the consequences of such an amendment passing in other states or even become part of the United States Constitution. Should a fertilized human egg be a legal person and the intentional destruction of that person be consider a crime such as a homicide (murder)? ..Maurice.

Medical Bloopers 3: A Medical Communications Defect

The following medical charting errors may appear funny to the casual reader but if they or their cousins are written in medical charts, they not only appear ambiguous but may in some cases be harmful for the safe and effective medical management of patients. These "bloopers" are the results of rushed notations with no rereading by the writer of what was actually written.

This is actually the third in a series of such charting errors (the second in this series was an addition of 6 "bloopers" added to the original 19 and may be found at this link). There may be a few repeated from that second listing in this current presentation. Enjoy. ..Maurice.

Note: These "bloopers" come from a variety of sources and I don't know who to acknowledge for them.

By the time he was admitted, his rapid heart had stopped, and he was feeling better.

Patient has chest pain if she lies on her left side for over a year.

On the second day the knee was better and on the third day it had completely disappeared.

She has had no rigors or shaking chills, but her husband said she was very hot in bed last night.

The patient has been depressed ever since she began seeing me in 1986.

Patient was released to outpatient department without dressing.I have suggested that he loosen his pants before standing, and then when he stands with the help of his wife, they should fall to the floor.

The patient is tearful and crying constantly. She also appears to be depressed.

Discharge status: Alive but without permission.

The patient will need disposition, and therefore we will get Dr. Shapiro to dispose of him.

Healthy appearing decrepit 67 year old male, mentally alert, but forgetful.

The patient refused an autopsy.

The patient has no past history of suicides.

The patient expired on the floor uneventfully.

Patient has left his white blood cells at another hospital.

The patient's past medical history has been remarkably insignificant with only a 45 pound weight gain in the past three days.

She slipped on the ice and apparently her legs went in separate directions in early January.

The patient experienced sudden onset of severe shortness of breath with a picture of acute pulmonary edema at home while having sex which gradually deteriorated in the emergency room.

The patient had waffles for breakfast and anorexia for lunch.

Between you and me, we ought to be able to get this lady pregnant.

The patient was in his usual state of good health until his airplane ran out of gas and crashed.

Since she can't get pregnant with her husband, I thought you would like to work her up.

She is numb from her toes down.

While in the ER, she was examined, X-rated and sent home.

The skin was moist and dry.

Occasional, constant, infrequent headaches.

Coming from New York, this man has no children.

Patient was alert and unresponsive.

When she fainted, her eyes rolled around the room.

Malpractice vs Involuntary Manslaughter: What is the Distinction?

The current legal case being tried in court regarding the death of Michael Jackson by the alleged acts of Dr. Conrad Murray as involuntary manslaughter in contrast to the death being an act of malpractice brings up the question: what is the difference in legal terms between medical malpractice and involuntary manslaughter. And, perhaps, what is the difference in ethical terms? If the physician is found guilty, the physician is punished financially in the first case but by prison time in the second. An excellent article written by Eisenberg and Berlin in the American Journal of Radiology in August 2002 gives case examples and may tend to answer to the question posed in the title of my thread. An excerpt from the article follows:

The circumstances under which a physician's error of medical judgment triggers criminal prosecution are not totally clear. An English court of appeals ruled that to justify a criminal conviction, it must be proven that a physician acted with “gross negligence,” which is characterized by any or all of the following elements: indifference to an obvious risk of injury to health; actual foresight of the risk coupled with the determination nevertheless to run it; an appreciation of the risk coupled with a high degree of negligence in the attempt to avoid it; and inattention or failure to avert a serious risk.

A person whose behavior is “grossly negligent” may be liable for involuntary manslaughter if his or her conduct results in the accidental death of another person. Most jurisdictions hold that something more than ordinary negligence must be proven before the defendant can be found guilty of involuntary manslaughter. This usually requires that there be a substantial danger not only of bodily harm, but also of “serious bodily harm or death.” The defendant must have acted “recklessly,” a term defined as a “gross deviation from the standard of conduct that a law-abiding person would observe” in the same situation The court must consider all the circumstances surrounding the incident, including the social utility of any objective the defendant is trying to fulfill.

What, in my opinion, seems to be missing in the accusation of a physician with a crime of involuntary manslaughter rather than a professional error of malpractice is whether the physician's intent in diagnosis and management was to ignore any attempt toward the professional goal of beneficence (doing a "good" ) to his or her patient. If one could prove that such was not the intent and goal, shouldn't that be the overriding criteria to define a death as professional malpractice and not a crime? On the other hand, I look forward toward what how others to my blog thread look at this distinction. ..Maurice.