Medical Mistakes: The Patient as "Whistleblower" Reporting to the Government

The United States federal government in an attempt to prevent medical mistakes is considering a pilot program which will analyze these mistakes by doctors, pharmacists and hospitals. Medical mistakes not only can unnecessarily harm patients but end up costing everyone including the government money.  The interesting part of the program is that it  will be the patient (or, I suppose, also the patient's family) who will be the "whistleblowers" and notify the government of a suspected mistake.  To get an idea about the program read about it in a recent article in the  New York Times from which a few extracts follow. 

                                                      

  For each incident, the government wants to know “what happened; details of the event; when, where, whether there was harm; the type of harm; contributing factors; and whether the patient reported the event and to whom.”The questionnaire asks why the mistake happened and lists possible reasons:¶ “A doctor, nurse or other health care provider did not communicate well with the patient or the patient’s family.”¶ “A health care provider didn’t respect the patient’s race, language or culture.”¶ “A health care provider didn’t seem to care about the patient.”¶ “A health care provider was too busy.”¶ “A health care provider didn’t spend enough time with the patient.”¶ “Health care providers failed to work together.”¶ “Health care providers were not aware of care received someplace else.”A caution as noted in the article from an official of the American Academy of Orthopedic Surgeons:“However, patients may mischaracterize an outcome as an adverse event or complication because they lack specific medical knowledge.“For instance, a patient may say, ‘I had an infection after surgery’ because the wound was red. But most red wounds are not infected. Or a patient says, ‘My hip dislocated’ because it made a popping sound. But that’s a normal sensation after hip replacement surgery.” [Thus] it was important to match the patients’ reports with information in medical records.

                                                                                         

What do you think about you becoming the "whistleblower" to notify the government when you suspect your doctor made a mistake?  ..Maurice.

Graphic: From Google Images and modified by me with ArtRage

Doctors Maintaining "Clinical Distance": A Patient Value or None

The doctor looks at the patient who

Sits restlessly, coughs and is not smiling

The doctor's first thought

"Why is this patient coughing?"

Instead of

"This patient appears uncomfortable,

What can I do or say to relieve the discomfort?"

+++

What I have just described is a simple example of the professional behavior or perhaps misbehavior of maintaining "clinical distance".  It is the mindset of a technician to immediately look at the anatomy and pathology of the patient's symptoms rather than to look at the patient. Shouldn't the doctor's first interest be the observation and consideration of the patient as a whole human person who comes for consultation because of a personal problem and attempt to understand how the patient is feeling? But the fear of being contaminated by the patient's "feeling" may be more in the mind of the doctor than being exposed to whatever bacteria or viruses the patient is bearing and has become the basis for maintaining "clinical distance"; not measured in meters but in pain, in sorrow, in anxiety and fear.

But, shouldn't, at first, the doctor be more than a technician in the diagnosis and treatment of illness?  Shouldn't the doctor at first find and express some signs and acts of partnership with the patient's worries with responses of sympathy ("I care") and/or empathy ("I understand")?

In the current rush of medical practice where time is limited to attend to each patient and the fear by doctors of "becoming too emotionally involved" (contaminated), it is considered a wise practice to maintain that "clinical distance".  But is "clinical distance" really what makes a good medical professional? Does it provide a way to maintain physicians in less emotional distress, fatigue and more time to diagnose and treat and thus is of benefit and value to the patient?

On the other hand, maybe it is the basis of why some patients are dissatisfied with their doctors in many ways. Perhaps, we medical school teachers should more strongly emphasize to the students something more than the creation of a differential diagnosis list as the doctor-patient relationship begins and strive to shorten that "clinical distance". 

What is your opinion about maintaining vs shortening "clinical distance"?  Should the following be the doctor's first thought?

+++

The doctor looks at the patient who

Sits restlessly, coughs and is not smiling

The doctor's first thought

"This patient appears uncomfortable,

What can I do or say to relieve the discomfort?"

..Maurice.

Prohibition of Abortion in Rape: Who is Responsible for the Outcome?

Particularly these days, as a Presidential election is nearing, the politics of abortion is now in the forefront though it always has been a political and religious issue. Even, from an ethics point of view, the debate has been engaged as to whether a fetus was a person and what ethical, if not legal, rights was available for the fetus.. The issue of abortion is usually associated with either disease or injury on the part of the mother or in the case of an unwanted, unintended pregnancy.  Another area for consideration of abortion is in the case of rape with an associated pregnancy. Should abortion be an option for the mother if pregnant as a consequence of rape? There are political and religious views which deny such an option for the mother since rape should not lead to the punishment of the fetus for such a criminal act. Yet, one can argue that if the fetus of rape is unwanted by the mother and even by the rest of the family and abortion is not an option, who will be responsible for the continuing of the pregnancy and who will be responsible for the further life of the child when it is born?  Some might consider if the responsibility is put on the mother and family that this is simply an ongoing punishment of the mother and family for a crime they did not commit. If the rapist is not the one to assume the responsibility for the result of the crime, do the politicians and religions and others in society who hold that abortion is not acceptable in such a pregnancy, agree that then they are all responsible for the consequences of their dictum including the ongoing management, care and expense of the product of the rape?  Making political, religious or ethical decisions and failing to be responsible for the consequences should be open to scrutiny. What do you think?  ..Maurice.

Patient Modesty: Volume 50

This graphic modified by me from the graphic in an article in the July 30, 2010 New York Times sets an area of discussion on this Patient Modesty thread which we should settle by some consensus.  Those with such intense physical modesty concerns that would interfere with an efficient medical workup and treatment have been, after reading the responses to this thread, in my mind statistical outliers since I never have experienced such patients in my years of medical practice.  OK..that's one potential outlier. The other is the group of healthcare providers who have shown by their behavior and in many ways sexual and dominating actions creating emotional harm of their assigned patients.  I suspect (and hope) this group of providers are also statistical outliers.  I am not saying that such outliers whether patients or providers should be ignored but I think we must appreciate the majority of patients and providers who continue to attempt to improve health and service and not generalize the behaviors of the outliers to the entire population.  This is the topic that I would like further discussion upon as characterized by this Volume's graphic. ..Maurice.

NOTE: FOR THOSE VISITORS WHO HAVE NOT AS YET READ VOLUME 49 AND WOULD LIKE TO DO SO FOR CONTINUITY  (BUT NOT POST) MAY GO THERE WITH THIS LINK.

ADDENDUM; AS OF SEPTEMBER 10 2012, I HAVE STARTED A PETITION SIGNING DRIVE ON
ONE OF THE FREE PETITION WEBSITES TO ACCUMULATE SIGNATURES TO SEND TO THOSE OF RESPONSIBILITY IN THE MEDICAL SYSTEM REGARDING THE ISSUES AND CONCERNS AS PRESENTED IN THESE 50 VOLUMES OF PATIENT MODESTY. IF YOU WISH TO PARTICIPATE, GO TO THE FOLLOWING THEPETITIONSITE LINK.
http://www.thepetitionsite.com/799/493/745/medical-care-providers-must-attend-to-patient-modesty-issues-and-provider-gender-requests/

Graphic: see above linked source.

NOTICE: AS OF TODAY OCTOBER 14, 2012 "PATIENT MODESTY: VOLUME 50" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 51 

"No.. Not Yet":Answering the Patient's Request for "Off Label Use" of a Drug

In the United States, physicians can legally write a prescription for a drug to be administered to a patient with a disease not approved by the Food and Drug Administration (FDA) for use, so-called "off label use" if that drug has already been approved for use by the FDA  for some other disease.  Often, patients and their families faced with a serious disease and unresponsive to any beneficial action by the available drugs for that condition may, after learning from the media of "promising results" from preliminary drug studies for that disease insist that their physicians prescribe that drug.  The "promising results" may be more supposition based on elementary animal studies of the patient's disease and not as yet studied in humans with that disease.  Yet, such "results" are readily documented by the media and thus available for the public to consider and desire.

Physicians practice under the ethical obligations of their profession to be beneficent in their actions with the patient and to avoid harm.  Such beneficence would include to attempt to attain a goal of "cure" for the patient's disease.  But what if the "cure", at present, was only theoretical and not documented by valid testing in humans?  To "avoid harm" is another matter of concern since if approval of the drug was carried out in studies or experience with a disease other than that experiencing by the current patient, can the physician be sure that the drug will be equally safe?

The ethical issue is how should a physician respond to a vigorous and understandable request by a patient or family member for the doctor to prescribe a drug as "off label" for a critical illness, not responding to prior drugs, but a drug which has not been approved by the FDA for such use and whose benefit/safety value for that disease has not been proven but only suggested by the media?

Should what is read by the public on a website or newspaper or heard on TV be something to challenge the doctor?  And does the doctor have the time, knowledge and ethical strength to defend any refusal to follow the request and finally say "no.. not yet."  Or at a certain end-point of an illness, the refusal itself is unethical?   ..Maurice.

p.s.- For more on this topic: "The Ethics of Early Evidence---Preparing for a Possible Breakthrough in Alzheimer's Disease" by Lowenthal, Hull and Pearson in the Perspective Section of August 9 2012 issue of the New England Journal of Medicine.

Graphic: My photograph of medicine bottle and modified with ArtRage and Picasa3.

Refusing to Cast a Deaf Ear to the Ethics of Maintaining Deafness within a Deaf Family

You may not be affected by this topic but as one interested in the ethical issues within society, it is important that you don't ignore and cast a deaf ear on an ethics topic that relates to behavioral actions of other cultures attempting to maintain uniformity and comfort.

There is a view in the culture of the Deaf to maintain deafness within the deaf family. The options, which have been proposed in the literature  to accomplish this cultural requirement would be to 1) prior to implantation of a preserved embryo to first determine whether it had the genetic makeup to be deaf and, if so, proceed with implantation and 2) have the mother take a toxin during a normally started pregnancy to cause the fetus to be born deaf.  Of course, there is a third option: for the family to adopt a deaf child into that deaf family.

So without casting that deaf ear to this topic, do my visitors agree that there is nothing unethical in the culture of the Deaf to maintain that culture by acquiring a deaf child?  If the goal of maintaining the culture is ethical, then about the options presented, would my visitors consider them all ethical to meet that goal? If not, which ones and why? I will be interested to read your opinions.   ..Maurice.

Is Current "Teaching" Medical Students Really "Preaching" to Medical Students?

You know, I was thinking, medical school is all about preaching to the students their Commandments toward their future practice of the profession of medicine.  We are saying to them:
1. "Here are Your Tools for practice We have Chosen to be Given to You, Here is Your Medical Education We have Devised, Here are Your Standards of Practice
2.Here are Your Codes of Ethical Practice
3.You will be Monitored by Us to Graduation and by Others beyond for adherence to Continuing your Medical Education 
4. Your Adherence to Standards of Practice and Codes of Ethics
5.You may Select a Specialty of your Choosing and Comfort but Monitoring for Your Adherence will Continue." 

And if that isn't Preaching the gospel of Medicine, I don't know what Is? 

Should we, in medical school education, really be teaching students only about the options available for taking a history, for performing a physical exam, for making a diagnosis, for providing treatment and for the overall practice of medicine including the pros and cons of various behaviors within the responsibilities of a medical doctor rather than be setting a series of medical rules which have been carried down from one medical generation to another without empiric, statistical documentation of the value or harm of each dictum?

What do you think?  ..Maurice.

Graphic: Preaching from Fellowship Room via Google Images.

   

"The Truth, Whole Truth and Nothing But.." Followed by Words of Comfort

Now here is an Essay from the Hastings Center Report July-August 2012 issue which you can read free and in full by clicking on this LINK which I think brings out a modern and perhaps a common behavior by physicians which clearly is of ethical importance and should be considered by all patients.. The Essay, titled "Comfort Care as Denial of Personhood" by William J. Peace starts with the following abstract.  


Comfort care is an ethical good for the patient but should not be used to meet the needs or frustrations of the healthcare providers. Read the Abstract below but then go to the Essay LINK and read the entire Essay. Then return here and present your comments. Do you think that a physician's suggestion for "comfort care" could be premature and actually be an ethical wrong for the patient? ..Maurice.








 ABSTRACT

It is 2 a.m. I am very sick. I am not sure how long I have been hospitalized. The last two or three days have been a blur, a parade of procedures and people. I had a bloody debridement for a severe, large, and grossly infected stage four wound-the first wound I have had since I was paralyzed in 1978. I know the next six months or longer are going to be exceedingly difficult. I will be bedbound for months, dependent upon others for the first time in my adult life. As these thoughts are coursing through my mind, a physician I have never met and the registered nurse on duty appear at my door. As they put on their gowns I am weary but hopeful. Surely there is something that can be done to stop the vomiting. The physician examines me with the nurse's help. Like many other hospitalists that have examined me, he is coldly efficient. At some point, he asks the nurse to get a new medication.
What transpired after the nurse exited the room has haunted me. Paralyzed me with fear. The hospitalist asked me if I understood the gravity of my condition. He grimly told me I would be bedbound for at least six months and most likely a year or more. That there was a good chance the wound would never heal. If this happened, I would never sit in my wheelchair. I would never be able to work again. Not close to done, he told me I was looking at a life of complete and utter dependence. He went on to tell me I was on powerful antibiotics that could cause significant organ damage. He informed me I had the right to forego any medication, including the lifesaving antibiotics. If I chose not to continue with the current therapy, I could be made very comfortable. I would feel no pain or discomfort at all. Although not explicitly stated, the message was loud and clear. I can help you die peacefully.

Which Direction is Ethical? Should We Simply "Count the Cars"?

My question for this thread is who should set ethics? Who should establish "what is ethical and what is not"? Should it always be society as a whole to establish which direction is the right ethical direction with the decision based on observation of which direction the majority of society is moving?  Or is "what is ethical and what is not" really not a matter of statistics but should be decided upon independent criteria and beyond simply observing the direction set by the general public?

If so then should the decision  be based on what philosophers or other "thinkers" have set in the past and then carried on to the present and the future? In other words do ethical actions and behavior really change over the years? Or if they can and do change should what is ethical be based on how current philosophers look at current issues? What should be the role of religions to establish what is moral and what isn't? Are the religions and their members really the ones to define what is or is not ethical? Finally, should we disregard society, philosophers and religions and say that what is "good" and what is "bad" be defined only by those who are directly involved as actors or recipients in any activity or behavior?  Should it be only the participants who set the ethical standards. 

Who do you want to tell you what is ethical and what isn't? ..Maurice.

Graphic: Photograph taken by me today of the 405 Freeway in Southern California