The description of physical signs of illness in photographs by physicians with abnormal colour vision

BACKGROUND

Physicians with congenital colour vision deficiency (CCVD) have reported difficulties recognising certain physical signs of illness, for example, jaundice, red rashes and pallor, and interpreting coloured charts, diagrams and slide projections. However, there has been little study of the effects of CCVD on the performance of medical practitioners.

AIM

The aim of this study was to look for evidence of the effect of CCVD on the ability of physicians to recognise and describe physical signs of illness that have colour as either the main or an important feature.

METHOD

Twenty-three general practitioners with CCVD were shown 11 colour photographs depicting colour signs of illness and were asked to describe the signs they saw and rate their confidence in making their descriptions. Their responses were compared to those of 23 age-matched general practitioners with normal colour vision.

RESULT

General practitioners with CCVD compared to those with normal colour vision had less ability and confidence in detecting physical signs in the photographs and naming the colours.

CONCLUSIONS

The results of this study support other evidence that physicians with CCVD have difficulties detecting some colour signs of illness and naming the colours. Because of the use of photographs the extent of the problem in clinical practice is unknown but medical practitioners with CCVD should be aware of the possibility of failing to detect or correctly assess physical signs that are characterised by colour.

Two case reports of novel syndrome of bizarre performance of gastrointestinal endoscopy due to toxic encephalopathy of endoscopists among 181767 endoscopies in a 13-year-university hospital review: Endoscopists, first do no harm!

BACKGROUND

Although deficient procedures performed by impaired physicians have been reported for many specialists, such as surgeons and anesthesiologists, systematic literature review failed to reveal any reported cases of deficient endoscopies performed by gastroenterologists due to toxic encephalopathy. Yet gastroenterologists, like any individual, can rarely suffer acute-changes-in-mental-status from medical disorders, and these disorders may first manifest while performing gastrointestinal endoscopy because endoscopy comprises so much of their workday.

CASE SUMMARIES

Among 181767 endoscopies performed by gastroenterologists at William-Beaumont-Hospital at Royal-Oak, two endoscopies were performed by normally highly qualified endoscopists who manifested bizarre endoscopic interpretation and technique during these endoscopies due to toxic encephalopathy. Case-1-endoscopist repeatedly insisted that gastric polyps were colonic polyps, and absurdly “pressed” endoscopic steering dials to “take” endoscopic photographs; Case-2-endoscopist repeatedly insisted that had intubated duodenum when intubating antrum, and wildly turned steering dials and bumped endoscopic tip forcefully against antral wall. Endoscopy nurses recognized endoscopists as impaired and informed endoscopy-unit-nurse-manager. She called Chief-of-Gastroenterology who advised endoscopists to terminate their esophagogastroduodenoscopies (fulfilling ethical imperative of “physician, first-do-no-harm”), and go to emergency room for medical evaluation. Both endoscopists complied. In-hospital-work-up revealed toxic encephalopathy in both from: case-1-urosepsis and left-ureteral-impacted-nephrolithiasis; and case-2-dehydration and accidental ingestion of suspected illicit drug given by unidentified stranger. Endoscopists rapidly recovered with medical therapy.

CONCLUSION

This rare syndrome (0.0011% of endoscopies) may manifest abruptly as bizarre endoscopic interpretation and technique due to impairment of endoscopists by toxic encephalopathy. Recommended management (followed in both cases): 1-recognize incident as medical emergency demanding immediate action to prevent iatrogenic patient injury; 2- inform Chief-of-Gastroenterology; and 3-immediately intervene to abort endoscopy to protect patient. Syndromic features require further study.

The Age of The Surgeon: How Old Is Too Old?

N/a.

Evaluating Fitness to Perform in Surgical Residents after Night Shifts and Alcohol Intoxication: The development of a "Fit-to-Perform" test

OBJECTIVE

To develop a self-test to measure clinical fitness to perform in surgical residents, with alcohol-induced impairment as reference.

DESIGN

Observational, exploratory study to evaluate night shift-induced impaired performance in surgical residents followed by a randomized blinded, placebo-controlled, crossover study to evaluate impaired performance as a result of ethanol intoxication. Impairment was quantified using the Mini-NeuroCart, a psychomotor and cognitive test battery for assessment of subjective and objective measures of alertness, concentration, eye-hand coordination, mood, and self-assessed ability to perform. Surgical performance was tested in the randomized study with a laparoscopy surgical trainer.

SETTINGS

Level-I trauma hospital and a clinical research unit.

PARTICIPANTS

Surgical residents (n = 12 for the observational study, n = 18 for the randomized study).

RESULTS

High alcohol levels (0.6gL^-1) impaired adaptive tracking, reduced objective and subjective alertness, and increased slowness. Moreover, laparoscopy depth perception was impaired in the 0.6gL^-1 group. No significant within-subject correlation between subjective and objective measures of alertness was found. Performance of postcall surgeons was similar to, or even worse than, the performance of intoxicated surgeons.

CONCLUSIONS

The Mini-NeuroCart detected ethanol-induced performance effects that were similar to the effects of working a 14-hour night shift. Social (ethanol), personal (mood), and professional (laparoscopic skills) standards of fitness can in this manner be related to accepted deleterious effects of alcohol. The Mini-NeuroCart is, therefore, a potential noninvasive test for assessing "fitntness to perform" in healthcare professionals.

Predictors of fitness to practise declarations in UK medical undergraduates

BACKGROUND

Misconduct during medical school predicts subsequent fitness to practise (FtP) events in doctors, but relatively little is known about which factors are associated with such issues during undergraduate education. This study exploits the newly created UK medical education database (UKMED), with the aim of identifying predictors of conduct or health-related issues that could potentially impair FtP. The findings would have implications for policies related to both the selection and support of medical students.

METHODS

Data were available for 14,379 students obtaining provisional registration with the General Medical Council who started medical school in 2007 and 2008. FtP declarations made by students were available, as were various educational and demographic predictor variables, including self-report 'personality measures' for students who participated in UK Clinical Aptitude Test (UKCAT) pilot studies. Univariable and multivariable logistic regression models were developed to evaluate the predictors of FtP declarations.

RESULTS

Significant univariable predictors (p < 0.05) for conduct-related declarations included male gender, white ethnicity and a non-professional parental background. Male gender (OR 3.07) and higher 'self-esteem' (OR 1.45) were independently associated with an increased risk of a conduct issue. Female gender, a non-professional background, and lower self-reported 'confidence' were, among others, associated with increased odds of a health-related declaration. Only 'confidence' was a significant independent predictor of a health declaration (OR 0.69). Female gender, higher UKCAT score, a non-professional background and lower 'confidence' scores were significant predictors of reported depression, and the latter two variables were independent predictors of declared depression.

CONCLUSIONS

White ethnicity and UK nationality were associated with increased odds of both conduct and health-related declarations, as were certain personality traits. Students from non-professional backgrounds may be at increased risk of depression and therefore could benefit from targeted support. The small effect sizes observed for the 'personality measures' suggest they would offer little potential benefit for selection, over and above those measures already in use.

Oral health and the frailty syndrome

The frailty syndrome is an ever-growing area of study among older adults because of its association with an increased risk of falls, hospitalization, institutionalization, dependency and mortality. Frailty is neither a disease nor a disability but is better understood as a medical syndrome of multisystem dysregulation that results in a diminished ability to overcome everyday stressors. The prevalence of frailty in any given population can vary widely, in part because of the way in which it is defined and measured, but in general it is higher among women and in those with advanced age and declining health. Whilst it is largely understood that older adults will differ biologically, psychologically and socially, and that each of these domains can impact oral health, we are only beginning to investigate how the mouth is affected in frailty. Given that both hard and soft structures contribute to oral health and disease status among older adults with varying degrees of impairment and disability, frailty adds yet another dimension to be considered. This paper will discuss how frailty can influence and be influenced by oral disorders, as well as the potential relationship to oral neglect and the resultant consequences among this vulnerable population.

Do state physician health programs encourage referrals that violate the Americans with Disabilities Act?

The websites of many physician health programs provide lists describing signs of impairment or indications to refer physician-employees for evaluation and possible treatment. This study aimed (1) to determine how many of these descriptions likely provide physicians' employers with sufficient evidence to legally request mental health examinations under the general regulations of the Americans with Disabilities Act (ADA); and (2) to find out who they described. The authors applied US Equal Employment Opportunity Commission guidance documents and sought expert legal advice to evaluate the descriptions for their consistency with the ADA. They used directed content analysis to review and code these descriptions into categories. Very few, if any, of the 571 descriptions appeared to provide sufficient evidence for employers to request an examination under the ADA. About 14%, however, could refer to physicians attempting to defend themselves, assert their ADA rights, or otherwise complain about the hospital; and 27% either described physicians who complain or else had discriminatory effects in one of several different ways. Leaders within the medical field should ensure that their policies and state laws pertaining to physician impairment comply with and incorporate the language of the ADA. They should also reevaluate the functions of these policies, laws, and physician health programs, and the implications for patient safety, physician wellness, suicide, and other important issues.

Improving Anesthesiologists' Ability to Speak Up in the Operating Room: A Randomized Controlled Experiment of a Simulation-Based Intervention and a Qualitative Analysis of Hurdles and Enablers

PURPOSE

The authors addressed three questions: (1) Would a realistic simulation-based educational intervention improve speaking-up behaviors of practicing nontrainee anesthesiologists? (2) What would those speaking-up behaviors be when the issue emanated from a surgeon, a circulating nurse, or an anesthesiologist colleague? (3) What were the hurdles and enablers to speaking up in those situations?

METHOD

The authors conducted a simulation-based randomized controlled experiment from March 2008-February 2011 at the Center for Medical Simulation, Boston, Massachusetts. During a mandatory crisis management course for practicing nontrainee anesthesiologists from five Boston institutions, a 50-minute workshop on speaking up was conducted for intervention (n = 35) and control (n = 36) groups before or after, respectively, an experimental scenario with three events. The authors analyzed videos of the experimental scenarios and debriefing sessions.

RESULTS

No statistically significant differences between the intervention and control group subjects with respect to speaking-up actions were observed in any of the three events. The five most frequently mentioned hurdles to speaking up were uncertainty about the issue, stereotypes of others on the team, familiarity with the individual, respect for experience, and the repercussion expected. The five most frequently mentioned enablers were realizing the speaking-up problem, having a speaking-up rubric, certainty about the consequences of speaking up, familiarity with the individual, and having a second opinion or getting help.

CONCLUSIONS

An educational intervention alone was ineffective in improving the speaking-up behaviors of practicing nontrainee anesthesiologists. Other measures to change speaking-up behaviors could be implemented and might improve patient safety.

Primum Non Nocere: A More Proactive Workplace Drug Testing Regime for Australian Medical Practitioners?

This article considers whether Australian medical practitioners should be subject to a more proactive workplace drug testing regime in order to minimise the risk of harm to patients. It first canvasses the history of workplace drug testing in the United States, the United Kingdom and Australia, before exploring whether there is a need for more proactive drug testing of Australian medical practitioners. It then considers whether workplace drug testing adequately addresses drug-related risks to patient safety, and discusses some of the privacy issues associated with workplace drug testing regimes. The article concludes that although an argument can be advanced in favour of a more proactive workplace drug testing regime for all Australian medical practitioners, the implementation of such a regime would be costly and complicated. As a result, it should only apply to practitioners assessed as working in “high-risk” roles.

Medical Boards and Fitness to Practice: The Case of Teleka Patrick, MD

BACKGROUND

Medical boards and fitness-to-practice committees aim to ensure that medical students and physicians have "good moral character" and are not impaired in their practice of medicine.

METHOD

Presented here is an ethical analysis of stalking behavior by physicians and medical students, with focus on the case of Teleka Patrick, MD (a psychiatry resident practicing medicine while under a restraining order due to her alleged stalking behavior).

CONCLUSIONS

While a restraining order is not generally considered a criminal conviction, stalking behavior is clearly unprofessional and a marker of inappropriate character and fitness, yet the reporting obligations for such matters are complex. Medical schools and training programs that fail to assess, record, and report matters of moral conduct such as this potentially allow impaired students to graduate and enter the work force (unless a robust licensing process identifies them). Patrick's case should be a wake-up call for medical schools and medical boards to better integrate the professionalism domain into their operations. Further, the professionalism of students and doctors need to be integrated into the legal domain, so that those who are unfit to practice are, in fact, prevented from doing so. Guidance for integration is provided.

Dr Junkie. The Doctor Addict in Bulgakov's Morphine: What are the Lessons for Contemporary Medical Practice?

Historical, cultural and professional factors have contributed to stigma and secrecy regarding addiction in the medical profession and there are calls to improve education in this area. This paper argues that physician-penned literature plays an important role in raising awareness of substance misuse in the medical profession. Bulgakov's short story Morphine documents the decline of Dr Polyakov and illustrates a number of salient professional issues such as self-medication, abuse of authority and risks to patients. Physician-penned literature such as Morphine is of value in medical education as it offers a route into sensitive topics and an authoritative and insider perspective that is attractive to students and physicians alike.

Islam, mental health and being a Muslim in the West

The allegation that, 'Being Muslim means that you cannot be British' is often made. In view of this, we conducted a small survey (n=75) utilising purposive sampling on Muslims residing in the United Kingdom. Participants were recruited in a King's College London Islamic Society event in November 2014 in Guy's Hospital, London. 75/75 (100%) of the participants recruited responded. 69/75 (94%) of respondents either disagreed or strongly disagreed that, 'Being Muslim means that you cannot be British' (75/75 (100%) Muslim participants, 43/75 (57.3%) female participants, 32/75 (42.7%) male participants, mean Age 20.5 years, (Std. Dev. ±2.5)). This paper broadly seeks to answer two related questions. Firstly, 'What is the relationship between Islam and the West?' and secondly, 'What is the relationship between Islam and mental health?' In relation to the former, the rise of radicalization over recent years and the Islamophobia that has ensued have brought Islam and Muslims under intense scrutiny. Hence we feel it is both timely and important to offer a brief background of Islam and its relevance to the Western world. In relation to the latter, for many people religion and mental health are deeply and intimately intertwined. For example, religion can enable a person to develop mental health resilience and Islam has been reported to be a protective factor against suicidal behaviour. We conclude our paper by illustrating how the two questions are interrelated. We do so by offering an autobiographical narrative from a Muslim healthcare professional residing in the UK who developed a mental health problem precipitated by war in the country of his origin. His narrative includes descriptions of the role Islam that played in his recovery as well as his attempts to reconcile seemingly disparate aspects of his identity.

Alcohol and drug use among Danish physicians. A nationwide cross-sectional study in 2014

INTRODUCTION

The aims of this study were to describe Danish physicians' use of alcohol and drugs, their self-reported assessment of their use of alcohol and drugs, and their management of colleagues with substance use disorder in physician workplaces.

METHODS

During the spring of 2014, a nationwide cross-sectional study was conducted as an anonymous, electronic survey among a randomly weighted sample of 1) consultants and practicing specialists, 2) younger physicians (trainees) and 3) general practitioners in Denmark. A total of 4,000 physicians (approx. 1,333 from each group) were sampled and 1,943 responded (49%). The survey included the Alcohol Use Disorders Identification Test on alcohol use and the Drug Use Disorders Identification Test on drug use and related questions on health and psychological issues.

RESULTS

The three groups had an almost equal share of risky alcohol use (comprising hazardous, harmful and dependent use) of 17.2-20.3%. The highest proportion (24%) of risky alcohol use was found for both internal medicine and emergency medicine and the lowest for general practice (16%). Significantly more male physicians (25.1%) than female physicians (14.4%) reported risky alcohol use. Among physicians with risky substance use, 23.1% recognised their risky use.

CONCLUSION

The proportion of physicians with a risky use of alcohol and drugs was 19% and 3.0%, respectively. Significantly more male than female physicians reported risky alcohol use. Among physicians with a risky substance use, only one in four recognised this as problematic.

'I'm Not Calling Him!': Disruptive Physician Behavior in the Acute Care Setting

Results of a qualitative study of the experience of 15 acute care nurses with disruptive physician behavior and its impact on communication are reported. Findings will help educators and leaders prepare nurses by coaching and educating them on the importance of communication and patient advocacy.

A national study of medical students' attitudes toward self-prescribing and responsibility to report impaired colleagues

PURPOSE

The authors investigated medical students' attitudes about appropriate prescribing behaviors, their personal responsibility to report impaired colleagues, and what factors may influence these beliefs.

METHOD

The authors conducted a cross-sectional study of U.S. medical students in 2012 to assess attitudes about appropriate prescribing behaviors and responsibility to report impaired colleagues, and to explore relationships between prescribing beliefs and burnout, depression, and alcohol abuse/dependence. Chi-square test and multivariate logistic regression were performed.

RESULTS

Of 12,500 medical students invited to participate, 4,402 (35%) completed surveys. Believing it is appropriate to prescribe an antidepressant to self or spouse was rare (<10%) in comparison with believing it is appropriate to prescribe an antibiotic for oneself (34.5%) or a spouse (57.7%).In multivariate analysis, students with burnout were more likely to agree that each of the inappropriate prescribing behaviors was acceptable (ORs 1.15-1.51). Students with burnout were less likely to believe they had a personal responsibility to report colleagues with impairment due to alcohol or substance use (OR 0.87). Students personally experiencing symptoms of depression were less likely to believe medical students should report colleagues impaired by mental health problems (OR 0.72). Similarly, students with alcohol abuse/dependence were less likely to believe they had a duty to report colleagues impaired by alcohol/substance use (OR 0.55).

CONCLUSIONS

Suboptimal attitudes about prescribing and personal responsibility to report impaired colleagues are common among medical students. Suboptimal attitudes are associated with personal distress, further evidence of a link between personal distress and professionalism.

Special considerations in the care of the physician-patient: a lesson for medical education

In the field of medicine, there is strong emphasis on the healing of others, but not as much on the healing of self. It is therefore not surprising that physicians may be ill-equipped to not only care for other physicians, but to be treated as patients. Multiple studies indicate that relatively few physicians have their own primary physicians and often rely on self-treatment, rather than obtaining comprehensive care from other physicians. Through the lens of a personal struggle with serious illness, the author develops a discussion about potential barriers physicians face in seeking care, the downstream effects of physicians' perceptions of health care, and ways to make changes to prevailing physician health attitudes. Potential changes at the undergraduate, graduate, and continuing medical education levels are considered, in order to help physicians both to embrace their roles as patients and also better serve their colleagues who are under their care.

Failure all around. How do we identify and stop rogue practitioners?

Providers must do more to identify and stop rogue practitioners.

Alcohol and drug testing of health professionals following preventable adverse events: a bad idea

Various kinds of alcohol and drug testing, such as preemployment, routine, and for-cause testing, are commonly performed by employers. While healthcare organizations usually require preemployment drug testing, they vary on whether personnel will be subjected to further testing. Recently, a call has gone out for postincident testing among physicians who are involved in serious, preventable events, especially ones leading to a patient's death. This article will offer a number of counterarguments to that proposal and discuss an alternate approach: that health institutions can better improve patient safety and employees' well-being by implementing an organizational policy of "speaking up" when system operators notice work behaviors or environmental factors that threaten harm or peril. The article will conclude with a description of various strategies that facilitate speaking up, and why the practice constitutes a superior alternative to mandatory alcohol and drug testing in the wake of serious, harm-causing medical error.

Duty to speak up in the health care setting a professionalism and ethics analysis

Staff and students working in health care settings are sometimes reluctant to speak up when they perceive patients to be at risk for harm. In this article, we describe four incidents that occurred at our institution (Mayo Clinic). In two of them, health care professionals failed to speak up, which resulted in harm; in the other two, they did speak up, which prevented harm and improved patient care. We analyzed each scenario using the Physician's Charter on Medical Professionalism and prima facie ethics principles to determine whether principles were violated or upheld. We conclude that anyone who works in a health care setting has a duty to speak up when a patient faces harm. We also provide guidance for health care institutions on promoting a culture in which speaking up is encouraged and integrated into routine practice.

Duty hour reform in a shifting medical landscape

The circumstances that led to the death of Libby Zion in 1984 prompted national discussions about the impact of resident fatigue on patient outcomes. Nearly 30 years later, national duty hour reforms largely motivated by patient safety concerns have demonstrated a negligible impact of duty hour reductions on patient mortality. We suggest that the lack of an impact of duty hour reforms on patient mortality is due to a different medical landscape today than existed in 1984. Improvements in quality of care made possible by computerized order entry, automated medication checks, inpatient pharmacists, and increased resident supervision have, among other systemic changes, diminished the adverse impact that resident fatigue is able to have on patient outcomes. Given this new medical landscape, advocacy towards current and future duty hour reforms may be best justified by evidence of the impact of duty hour reform on resident wellbeing, education, and burnout.

Preparing for the worst

Unexpected deaths profoundly impact those left behind. And in the case of physicians, their deaths have financial and business implications they must address in advance. Professional planning allows physicians to address call coverage, management, and administration of the medical practice and helps ensure the orderly continuation of practice operations.

Primary care provider reflections on common themes from special issue on ethical quandaries when delivering integrated primary care

Comments on the articles by Hudgins, Rose, Fifield, & Arnault, (see record 2013-11498-002), Reiter & Runyan, (see record 2013-11498-003), Hodgson, Mendenhall, & Lamson (see record 2013-11498-004), and Kanzler, Goodie, Hunter, Glotfelter, & Bodart (see record 2013-11498-005), regarding the topic of common themes for the special issue on ethical quandaries when delivering integrated primary care. The current author provides brief reflections on each article.

Transformative learning in a professional development course aimed at addressing disruptive physician behavior: a composite case study

Disruptive physician behavior presents a challenge to the academic medical center. Such behaviors threaten the learning environment through increasing staff conflict, role modeling poor behaviors to trainees, and, ultimately, posing a risk to patient safety. Given that these physicians are often respected and valued for their clinical skills, many institutions struggle with how to best manage their behaviors. The authors present a composite case study of an academic physician referred to a professional development program for his disruptive behavior. They outline how transformative learning was applied to the development of concrete learning objectives, activities, and assessments for a curriculum aimed at promoting behavior change. Important themes include a safe group process in which the physician's assumptions are critically examined so that through experiential exercises and reflection, new roles, skills, and behaviors are learned, explored, and practiced. Timely feedback to the physician from the institution, colleagues, and administrators is critical to the physician's understanding of the impact of his or her behavior. Ultimately, the physician returns to practice demonstrating more professional behavior. Implications for medical education, prevention, and other professional development programs are discussed.