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Boudreau D, Wykretowicz H, Kinsella EA, Fuks A, Saraga M. Discovering clinical phronesis. Med Health Care Philos 2024; 27:165-179. [PMID: 38453732 DOI: 10.1007/s11019-024-10198-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 03/09/2024]
Abstract
Phronesis is often described as a 'practical wisdom' adapted to the matters of everyday human life. Phronesis enables one to judge what is at stake in a situation and what means are required to bring about a good outcome. In medicine, phronesis tends to be called upon to deal with ethical issues and to offer a critique of clinical practice as a straightforward instrumental application of scientific knowledge. There is, however, a paucity of empirical studies of phronesis, including in medicine. Using a hermeneutic and phenomenological approach, this inquiry explores how phronesis is manifest in the stories of clinical practice of eleven exemplary physicians. The findings highlight five overarching themes: ethos (or character) of the physician, clinical habitus revealed in physician know-how, encountering the patient with attentiveness, modes of reasoning amidst complexity, and embodied perceptions (such as intuitions or gut feeling). The findings open a discussion about the contingent nature of clinical situations, a hermeneutic mode of clinical thinking, tacit dimensions of being and doing in clinical practice, the centrality of caring relations with patients, and the elusive quality of some aspects of practice. This study deepens understandings of the nature of phronesis within clinical settings and proposes 'Clinical phronesis' as a descriptor for its appearance and role in the daily practice of (exemplary) physicians.
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Affiliation(s)
- Donald Boudreau
- Faculty of Medicine and Health Sciences, Institute of Health Sciences Education, McGill University, 1110 Pine Avenue West, H3A 1A3, Montreal, Canada.
| | - Hubert Wykretowicz
- Centre Hospitalier Universitaire Vaudois, Av. de Beaumont 23, 1011, Lausanne, Switzerland
| | - Elizabeth Anne Kinsella
- Faculty of Medicine and Health Sciences, Institute of Health Sciences Education, McGill University, 1110 Pine Avenue West, H3A 1A3, Montreal, Canada
| | - Abraham Fuks
- Department of Medicine, McGill University, 3647 Peel Street, H3A 1X1, Montreal, Canada
| | - Michael Saraga
- General Psychiatry, Centre Hospitalier Universitaire Vaudois, Route de Cery 60, 1008 Prilly, Lausanne, Switzerland
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Zaouaq K. Chapitre 1. La télémédecine et ses implications sur la relation médecin/patient. J Int Bioethique Ethique Sci 2023; 33:15-25. [PMID: 36894337 DOI: 10.3917/jibes.332.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
The practice of telemedicine is likely to raise ethical and legal problems that affect the doctor-patient relationship. Therefore, the respect of ethical principles is necessary, in addition to the involvement of the legislator, who must enact specific instruments capable of identifying all the problems caused by telemedicine and contributing to a certain humanization of the doctor-patient relationship.
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Kopp V. A Heresy of No Consequence: Duties and Virtues in Medicine and Professionalism. Perspect Biol Med 2023; 66:179-194. [PMID: 38662015 DOI: 10.1353/pbm.2023.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
In The Trusted Doctor: Medical Ethics and Professionalism (2020), Rosamond Rhodes presents a new theory of medical ethics based on 16 duties she considers central to medical ethics and professionalism. She asserts that her theory is "bioethical heresy," as it contradicts established "principlism" and "common morality" approaches to ethics in medicine. Rhodes advocates the development of parallelism between clinical and ethical decision-making and a systematic approach that emphasizes duties over principles and rules to facilitate the development of a "doctorly character" among medical decision-makers. Rhodes further asserts that her theory and approach necessitate the cultivation of virtues contained in Aristotle's Nicomachean Ethics. But Rhodes's insistence that "medical professionals," not just doctors, are covered by her theory is open to critique, as is her conflation of ethic and morals, especially around the question of the "doctorly character" upon which her duty-based theory hinges. This assessment argues that applicants to medical schools and allied health training programs be screened for specific virtues-honesty, diligence, curiosity, and compassion-to facilitate reinforcement of these pre-professionalized inclinations throughout the habituation processes of medical training. This would increase the probability of turning fear and hope to cure and care via reasoning and affective models performed within an ethical medical framework-even while what this ethical framework should reference remains under debate.
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Adashi EY, Cohen IG, Elberg JT. Transparency and the Doctor-Patient Relationship - Rethinking Conflict-of-Interest Disclosures. N Engl J Med 2022; 386:300-302. [PMID: 35061340 DOI: 10.1056/nejmp2114495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Eli Y Adashi
- From the Department of Medical Science, Warren Alpert Medical School, Brown University, Providence, RI (E.Y.A.); Harvard Law School and the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard University, Cambridge, MA (I.G.C.); and the Center for Health and Pharmaceutical Law, Seton Hall University School of Law, Newark, NJ (J.T.E.)
| | - I Glenn Cohen
- From the Department of Medical Science, Warren Alpert Medical School, Brown University, Providence, RI (E.Y.A.); Harvard Law School and the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard University, Cambridge, MA (I.G.C.); and the Center for Health and Pharmaceutical Law, Seton Hall University School of Law, Newark, NJ (J.T.E.)
| | - Jacob T Elberg
- From the Department of Medical Science, Warren Alpert Medical School, Brown University, Providence, RI (E.Y.A.); Harvard Law School and the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard University, Cambridge, MA (I.G.C.); and the Center for Health and Pharmaceutical Law, Seton Hall University School of Law, Newark, NJ (J.T.E.)
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Chantler C. Public repository of consultants' practice details should include competing interests. BMJ 2022; 376:o188. [PMID: 35063998 DOI: 10.1136/bmj.o188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Crosbie C, McDougall A, Pangli H, Abu-Laban RB, Calder LA. College complaints against resident physicians in Canada: a retrospective analysis of Canadian Medical Protective Association data from 2013 to 2017. CMAJ Open 2022; 10:E35-E42. [PMID: 35042693 PMCID: PMC8920540 DOI: 10.9778/cmajo.20210026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND An understanding of regulatory complaints against resident physicians is important for practice improvement. We describe regulatory college complaints against resident physicians using data from the Canadian Medical Protective Association (CMPA). METHODS We conducted a retrospective analysis of college complaint cases involving resident doctors closed by the CMPA, a mutual medicolegal defence organization for more than 100 000 physicians, representing an estimated 95% of Canadian physicians. Eligible cases were those closed between 2008 and 2017 (for time trends) or between 2013 and 2017 (for descriptive analyses). To explore the characteristics of college cases, we extracted the reason for complaint, the case outcome, whether the complaint involved a procedure, and whether the complaint stemmed from a single episode or multiple episodes of care. We also conducted a 10-year trend analysis of cases closed from 2008 to 2017, comparing cases involving resident doctors with cases involving only nonresident physicians. RESULTS Our analysis included 142 cases that involved 145 patients. Over the 10-year period, college complaints involving residents increased significantly (p = 0.003) from 5.4 per 1000 residents in 2008 to 7.9 per 1000 in 2017. While college complaints increased for both resident and nonresident physicians over the study period, the increase in complaints involving residents was significantly lower than the increase across all nonresident CMPA members (p < 0.001). For cases from the descriptive analysis (2013-2017), the top complaint was deficient patient assessment (69/142, 48.6%). Some patients (22/145, 15.2%) experienced severe outcomes. Most cases (135/142, 97.9%) did not result in severe physician sanctions. Our classification of complaints found 106 of 163 (65.0%) involved clinical problems, 95 of 163 (58.3%) relationship problems (e.g., communication) and 67 of 163 (41.1%) professionalism problems. In college decisions, 36 of 163 (22.1%) had a classification of clinical problem, 66 of 163 (40.5%) a patient-physician relationship problem and 63 of 163 (38.7%) a professionalism problem. In 63 of 163 (38.7%) college decisions, the college had no criticism. INTERPRETATION Problems with communication and professionalism feature prominently in resident college complaints, and we note the potential for mismatch between patient and health care provider perceptions of care. These results may direct medical education to areas of potential practice improvement.
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Affiliation(s)
- Charlotte Crosbie
- Department of Emergency Medicine (Crosbie, Abu-Laban), University of British Columbia, Vancouver, BC; Canadian Medical Protective Association (McDougall, Calder); Faculty of Education (McDougall), University of Ottawa, Ottawa, Ont.; Division of Plastic Surgery (Pangli), Faculty of Medicine, University of British Columbia, Vancouver, BC; Clinical Epidemiology Program (Calder), Ottawa Hospital Research Institute, Ottawa, Ont
| | - Allan McDougall
- Department of Emergency Medicine (Crosbie, Abu-Laban), University of British Columbia, Vancouver, BC; Canadian Medical Protective Association (McDougall, Calder); Faculty of Education (McDougall), University of Ottawa, Ottawa, Ont.; Division of Plastic Surgery (Pangli), Faculty of Medicine, University of British Columbia, Vancouver, BC; Clinical Epidemiology Program (Calder), Ottawa Hospital Research Institute, Ottawa, Ont
| | - Harpreet Pangli
- Department of Emergency Medicine (Crosbie, Abu-Laban), University of British Columbia, Vancouver, BC; Canadian Medical Protective Association (McDougall, Calder); Faculty of Education (McDougall), University of Ottawa, Ottawa, Ont.; Division of Plastic Surgery (Pangli), Faculty of Medicine, University of British Columbia, Vancouver, BC; Clinical Epidemiology Program (Calder), Ottawa Hospital Research Institute, Ottawa, Ont
| | - Riyad B Abu-Laban
- Department of Emergency Medicine (Crosbie, Abu-Laban), University of British Columbia, Vancouver, BC; Canadian Medical Protective Association (McDougall, Calder); Faculty of Education (McDougall), University of Ottawa, Ottawa, Ont.; Division of Plastic Surgery (Pangli), Faculty of Medicine, University of British Columbia, Vancouver, BC; Clinical Epidemiology Program (Calder), Ottawa Hospital Research Institute, Ottawa, Ont
| | - Lisa A Calder
- Department of Emergency Medicine (Crosbie, Abu-Laban), University of British Columbia, Vancouver, BC; Canadian Medical Protective Association (McDougall, Calder); Faculty of Education (McDougall), University of Ottawa, Ottawa, Ont.; Division of Plastic Surgery (Pangli), Faculty of Medicine, University of British Columbia, Vancouver, BC; Clinical Epidemiology Program (Calder), Ottawa Hospital Research Institute, Ottawa, Ont.
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Roberts LW. Our Patients, Our Teachers. Acad Med 2021; 96:1497-1498. [PMID: 34705742 DOI: 10.1097/acm.0000000000004363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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Davy R. 2021 Hope Babette Tang Humanism in Healthcare Essay Contest: Second Place Medical Student Essay: The Motherhouse. Acad Med 2021; 96:1558-1559. [PMID: 34705754 DOI: 10.1097/acm.0000000000004349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Ran Davy
- R. Davina is a medical student, University of Rochester School of Medicine and Dentistry, Rochester, New York;
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Cojab J. When We Needed His Wisdom More Than Ever. Acad Med 2021; 96:1579. [PMID: 34380929 DOI: 10.1097/acm.0000000000004355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Jimmy Cojab
- J. Cojab is an internist and clinical nutritionist, Hospital Angeles Lomas, Mexico City, Mexico;
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Witkop CT, Maggio LA, Harvey EJ, Torre DM. Seeing Complexity: Cultural Historical Activity Theory (CHAT) As a Lens for Shared Decision Making. Acad Med 2021; 96:1540-1545. [PMID: 33983138 DOI: 10.1097/acm.0000000000004157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Shared decision making, a collaborative approach between patient and provider that considers the patient's values and preferences in addition to the scientific evidence, is a complex clinical activity that has not realized its full potential. Gaps in education and training have been cited as barriers to shared decision making, and evidence is inconsistent on effective educational interventions. Because individual agents with their own social and behavioral contexts co-construct a shared decision, the educational approach may need to consider the role of patient agency and sociocultural influences. To address the inherent complexity in shared decision making, the authors identified cultural historical activity theory (CHAT) as a framework for analysis. Although certainly not the only relevant theory, CHAT offers an appropriate lens through which the multivoiced nature of shared decision making can be more clearly appreciated. In this article, the authors demonstrate the application of CHAT as a lens for researchers and educators to examine the complexity of shared decision making. The fictitious case presented in this article describes the use of CHAT with a patient who experiences 2 clinical encounters; during the second, shared decision making takes place. Elements of the case are threaded through the article, demonstrating a sample analysis of the interacting activity systems of the patient and physician and highlighting inherent tensions and contradictions. The authors propose CHAT as a tool for future research around the role of agency in shared decision making and other complex topics and as a framework for design of novel instructional strategies. Although not applicable to all topics and settings, CHAT has significant potential within health professions education.
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Affiliation(s)
- Catherine T Witkop
- C.T. Witkop is professor of preventive medicine and obstetrics/gynecology and associate dean for medical education, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: http://orcid.org/0000-0001-5366-2663
| | - Lauren A Maggio
- L.A. Maggio is professor of medicine and associate director of scholarly communication, Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: http://orcid.org/0000-0002-2997-6133
| | - Emily J Harvey
- E.J. Harvey is research and teaching associate, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences, and contractor, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland; ORCID: http://orcid.org/0000-0002-3685-6279
| | - Dario M Torre
- D.M. Torre is professor of medicine and associate director of evaluation and long-term outcomes, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: http://orcid.org/0000-0002-4924-4888
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11
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Davies EM, Bridges AJ, Chung EML. Does radiology require informed consent for radiation risk? Br J Radiol 2021; 94:20210620. [PMID: 34357789 PMCID: PMC8553186 DOI: 10.1259/bjr.20210620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/16/2021] [Accepted: 07/26/2021] [Indexed: 11/05/2022] Open
Abstract
Recent trends in medical decision-making have moved from paternalistic doctor-patient relations to shared decision-making. Informed consent is fundamental to this process and to ensuring patients' ongoing trust in the health-care profession. It cannot be assumed that patients consent to the risk associated with medical exposures, unless they have been provided with the information to make that decision. This position is supported by both the legal and ethical framework around Radiation Protection detailed in this commentary.
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Affiliation(s)
- Elizabeth M Davies
- University
Hospitals of Leicester NHS Trust, Infirmary Square,
Leicester, England, United
Kingdom
| | - Andrew J Bridges
- University
Hospitals of Leicester NHS Trust, Infirmary Square,
Leicester, England, United
Kingdom
| | - Emma ML Chung
- University
Hospitals of Leicester NHS Trust, Infirmary Square,
Leicester, England, United
Kingdom
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Lisak A, Efrat-Treister D, Glikson E, Zeldetz V, Schwarzfuchs D. The influence of culture on care receivers' satisfaction and aggressive tendencies in the emergency department. PLoS One 2021; 16:e0256513. [PMID: 34473754 PMCID: PMC8412260 DOI: 10.1371/journal.pone.0256513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 08/09/2021] [Indexed: 02/04/2023] Open
Abstract
Introduction Reducing aggressive tendencies among care receivers in the emergency department has great economic and psychological benefits for care receivers, staff, and health care organizations. In a study conducted in a large multicultural hospital emergency department, we examined how cultural factors relating to ethnicity interact to enhance care receivers’ satisfaction and reduce their aggressive tendencies. Specifically, we explored how care receivers’ cultural affiliation, individual cultural characteristics, and the cultural situational setting interact to increase care receivers’ satisfaction and reduce their aggressive tendencies. Method Data were collected using survey responses from 214 care receivers. We use structural equation models and the bootstrap method to analyze the data. Results Care receivers’ openness to diversity (an individual cultural characteristic) was positively related to their satisfaction that was associated with lower aggressive tendencies, only when they were affiliated with a cultural minority group and when the cultural situational setting included language accessibility. Conclusion Our results demonstrate that cultural affiliation, individual cultural characteristics, and cultural situational setting can affect care receivers’ satisfaction and aggressive tendencies in a multicultural emergency department context. In particular, high cultural openness of care receivers, and making information accessible in their native language, increased satisfaction and reduced aggressive tendencies among cultural minority care receivers in our study.
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Affiliation(s)
- Alon Lisak
- Department of Management, Ben-Gurion University of the Negev, Be’er Sheva, Israel
- * E-mail:
| | - Dorit Efrat-Treister
- Department of Management, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Ella Glikson
- The Graduate School of Business Administration, Bar-Ilan University, Ramat Gan, Israel
| | - Vladimir Zeldetz
- Department of Emergency Medicine, Soroka University Medical Center, Be’er Sheva, Israel
| | - Dan Schwarzfuchs
- Department of Emergency Medicine, Soroka University Medical Center, Be’er Sheva, Israel
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Abstract
BACKGROUND A 2009 systematic review demonstrated that ethical discourse was underrepresented in the plastic surgery literature; approximately one in 1000 articles contained ethical discussions. In the decade since, advances in plastic surgery and continued social progress have created new ethical dilemmas. However, it is unclear whether these developments have augmented the representation of ethics in the plastic surgery literature. A review of publications over the past decade can assess whether progress has been made and identify where deficits persist. METHODS The authors searched eight bibliographic databases to identify peer-reviewed articles discussing ethical issues in plastic surgery over the past decade. Independent reviewers extracted characteristics and ethical principles from included articles. RESULTS A total of 7097 articles were identified from the initial search and 531 articles were included for analysis. The principle of autonomy, present in 87.9 percent of articles, had the greatest representation, followed by beneficence (74.4 percent), nonmaleficence (72.3 percent), and justice (51.2 percent). Informed consent and face transplantation were the most prevalent topics discussed. Aesthetic surgery was the subdiscipline of plastic surgery with the greatest ethical discourse, representing 29.8 percent of all included articles. CONCLUSIONS In the past decade, there was approximately a five-fold increase in plastic surgery publications that include ethical discourse, indicating a growing awareness of ethical implications by the plastic surgery community. However, representation of ethical principles remained uneven, and specific subdisciplines of plastic surgery were substantially underrepresented. Plastic surgeons should adopt a more comprehensive approach when framing ethical implications in clinical and research settings.
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Affiliation(s)
- Ava G Chappell
- From the Division of Plastic Surgery, Department of Surgery, and Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
| | - Robert L Kane
- From the Division of Plastic Surgery, Department of Surgery, and Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
| | - Shannon M Wood
- From the Division of Plastic Surgery, Department of Surgery, and Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
| | - Annie B Wescott
- From the Division of Plastic Surgery, Department of Surgery, and Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
| | - Kevin C Chung
- From the Division of Plastic Surgery, Department of Surgery, and Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
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Zaidi Z, Razack S, Kumagai AK. Professionalism revisited during the pandemics of our time: COVID-19 and racism. Perspect Med Educ 2021; 10:238-244. [PMID: 33738767 PMCID: PMC7971352 DOI: 10.1007/s40037-021-00657-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 02/20/2021] [Accepted: 02/25/2021] [Indexed: 05/07/2023]
Abstract
In this article the authors review the current-day definition of professionalism through the lens of the two ongoing pandemics: COVID-19 and racism. The pandemics have led to contemporary practice-related questions, such as: does professionalism entail that health care providers (HCP) be compelled to treat patients without PPE or if patients refuse to wear masks? And what role do HCP play in society when confronted with glaring health disparities and police brutality? The authors propose using care ethics as a theory to view professionalism, as it takes into account broadly encompassing relationships between HCP and society, history and context. Professionalism viewed through a care ethics lens would require professionalism definitions to be expanded to allow for interventions, i.e., not just refrain from doing harm but actively interfere or take action if wrong is being witnessed. Principles related to the primacy of patient welfare need to be re-addressed to prevent systematic self-sacrifice which results in harm to HCP and burnout. Mature care should be a characteristic of professionalism ensuring that HCP care for the sick but be practically wise, highlighting the importance of balancing too little and too much care for self and others. Professionalism needs to be viewed as a bi-directional relational exchange, with society demonstrating solidarity with those providing care. Additionally, given the scale of health disparities, simply stating that HCP need to work towards social justice oversimplifies the problem. Professionalism needs to encompass incorporating critical action and critical pedagogy into health care training and the health care profession to demonstrate solidarity with those impacted by racism.
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Affiliation(s)
- Zareen Zaidi
- Department of Medicine, University of Florida College of Medicine, 32610, Gainesville, FL, USA.
| | - Saleem Razack
- Department of Pediatrics, McGill University Faculty of Medicine, Montreal, Canada
| | - Arno K Kumagai
- Department of Medicine, University of Toronto, Toronto, Canada
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15
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Reddick B. Fallacies and Dangers of Practicing Race-Based Medicine. Am Fam Physician 2021; 104:122-123. [PMID: 34383449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Bonzo Reddick
- Mercer University School of Medicine, Savannah, GA, USA
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16
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Hamilton KL, Kim R, Savetsky IL, Avashia YJ, Maricevich R, Rohrich RJ. Social Media Guidelines for Young Plastic Surgeons and Plastic Surgery Training Programs. Plast Reconstr Surg 2021; 148:459-465. [PMID: 34398100 DOI: 10.1097/prs.0000000000008170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
SUMMARY Social media are a powerful tool that creates a unique opportunity for the young plastic surgeon and trainee to share content, brand oneself, educate the public, and develop one's own professional voice early. The majority of all plastic surgery programs and particularly those that are highly ranked have social media opportunities for their residents, yet clear rules to guide implementation of social media programming in residency have remained unspecified. These guidelines and pitfalls can be used to inform a productive and professional entry into plastic surgery social media use for the resident and young plastic surgeon. Details regarding specific platform use to maximize exposure are provided. The core principles of patient safety and privacy, authentic photography, plastic surgery education and advocacy, and professionalism inform these guidelines. Pitfalls include establishment of an online physician-patient relationship, engaging in debate by means of online reviews, providing medical entertainment, and engaging in non-plastic surgery politics. Use of these guidelines will allow the young plastic surgeon and trainee to succeed by means of social media platforms in an ethical and professional manner.
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Affiliation(s)
- Kristy L Hamilton
- From private practice; the Dallas Plastic Surgery Institute; and the Division of Plastic Surgery, Baylor College of Medicine
| | - Roy Kim
- From private practice; the Dallas Plastic Surgery Institute; and the Division of Plastic Surgery, Baylor College of Medicine
| | - Ira L Savetsky
- From private practice; the Dallas Plastic Surgery Institute; and the Division of Plastic Surgery, Baylor College of Medicine
| | - Yash J Avashia
- From private practice; the Dallas Plastic Surgery Institute; and the Division of Plastic Surgery, Baylor College of Medicine
| | - Renata Maricevich
- From private practice; the Dallas Plastic Surgery Institute; and the Division of Plastic Surgery, Baylor College of Medicine
| | - Rod J Rohrich
- From private practice; the Dallas Plastic Surgery Institute; and the Division of Plastic Surgery, Baylor College of Medicine
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Affiliation(s)
- Gabrielle Mayer
- Resident physician, Internal Medicine, New York University Grossman School of Medicine, New York, New York; ; Twitter: @gabmayer; ORCID: https://orcid.org/0000-0001-8760-0241
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Abstract
While advances in science and technology continue to be at the forefront of the evolution of medical practice, the 21st century is also undergoing a unique and profound cultural shift that is changing the very nature of what it means to be a medical professional, namely humankind's transition to an information-based internet society. Medical care will increasingly depend on computer-generated probabilities guided and supported by a growing variety of individuals in health care-related professions, including statisticians, technologists, and information managers. Perhaps the biggest challenge to the profession will come from the erosion of professional autonomy, driven by smart machines, social networks, and internet search engines. As a result of these and other changes, physicians are facing a systematic loss of control, often without the direct input and leadership of the profession itself. In this commentary, the author urges the profession to adopt several strategies, including shifting its focus from reimbursement to the care patients value most, meaningfully addressing critical issues in health policy, becoming the definitive source for publicly available medical information, reimagining medical education, and overhauling the existing accreditation and licensing systems. Medical education must go beyond a focus on physicians whose professional identity revolves around being the exclusive source of medical knowledge. In the digitized 21st century, medical education should emphasize the centrality of the humanistic interface with patients such that the doctor-patient relationship is paramount in the complex medical world of machines and social media. Removing the roadblocks to successful professional reform is no small task, but the process can begin with a grassroots movement that empowers physicians and facilitates organizational and behavioral change. Failure to take action may well hasten the diminishment of patient care and the profession's trusted role in society.
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Affiliation(s)
- Steven A Wartman
- S.A. Wartman is president emeritus, Association of Academic Health Centers, Washington, DC
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19
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Abstract
Machine learning (ML) algorithms are powerful prediction tools with immense potential in the clinical setting. There are a number of existing clinical tools that use ML, and many more are in development. Physicians are important stakeholders in the health care system, but most are not equipped to make informed decisions regarding deployment and application of ML technologies in patient care. It is of paramount importance that ML concepts are integrated into medical curricula to position physicians to become informed consumers of the emerging tools employing ML. This paradigm shift is similar to the evidence-based medicine (EBM) movement of the 1990s. At that time, EBM was a novel concept; now, EBM is considered an essential component of medical curricula and critical to the provision of high-quality patient care. ML has the potential to have a similar, if not greater, impact on the practice of medicine. As this technology continues its inexorable march forward, educators must continue to evaluate medical curricula to ensure that physicians are trained to be informed stakeholders in the health care of tomorrow.
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Affiliation(s)
- Cornelius A James
- C.A. James is assistant professor, Departments of Internal Medicine and Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kevin M Wheelock
- K.M. Wheelock is an internal medicine house officer, Yale School of Medicine, New Haven, Connecticut
| | - James O Woolliscroft
- J.O. Woolliscroft is professor, Departments of Internal Medicine and Learning Health Sciences, and Lyle C. Roll Professor of Medicine, University of Michigan Medical School, Ann Arbor, Michigan
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Affiliation(s)
- Casey Jo Humbyrd
- C. J. Humbyrd, Chief, Penn Orthopaedics Foot and Ankle Service, The Hospitals of the University of Pennsylvania, Philadelphia, PA, USA
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21
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Bridges C, Duenas DM, Lewis H, Anderson K, Opel DJ, Wilfond BS, Kraft SA. Patient perspectives on how to demonstrate respect: Implications for clinicians and healthcare organizations. PLoS One 2021; 16:e0250999. [PMID: 33914815 PMCID: PMC8084197 DOI: 10.1371/journal.pone.0250999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/18/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Clinicians and healthcare organizations are ethically obligated to treat patients with respect, yet it is not clear what actions best demonstrate respect to patients. This exploratory qualitative study aimed to understand what actions on both an individual and organizational level effectively demonstrate respect for primary care patients. METHODS We conducted semi-structured telephone interviews with primary care patients in an integrated healthcare delivery system in Oregon and an integrated safety net health system in Colorado who were participating in a genomics implementation research study of a hereditary cancer screening program. We systematically coded interview transcripts using a coding framework developed based on iterative review of the interview guide and transcripts. We further analyzed the data coded with sub-codes relating to patients' experiences with respect in healthcare using a descriptive content analysis approach. RESULTS We interviewed 40 English-speaking (n = 30, 75%) and Spanish-speaking (n = 10, 25%) patients. Most interviewees identified as female (n = 35, 88%) and either Hispanic/Latino(a) (n = 17, 43%) or White or European American (n = 15, 38%). Interviewees identified two categories of efforts by individual clinicians that demonstrate respect: engaging with patients and being transparent. They identified five efforts by healthcare organizations: promoting safety and inclusivity, protecting patient privacy, communicating about scheduling, navigating financial barriers to care, and ensuring continuity of care. CONCLUSIONS Our findings suggest that patients' experiences of respect depend on efforts by individual clinicians as well as healthcare organizations. Our findings offer insight into how clinicians can build stronger partnerships with patients and how organizations can seek to promote access to care and patient safety and comfort. They also illustrate areas for future research and quality improvement to more effectively respect patients.
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Affiliation(s)
- Celina Bridges
- University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Devan M. Duenas
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington, United States of America
| | - Hannah Lewis
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington, United States of America
| | - Katherine Anderson
- Denver Health Ambulatory Care Services, Denver, Colorado, United States of America
| | - Douglas J. Opel
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington, United States of America
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Benjamin S. Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington, United States of America
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Stephanie A. Kraft
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington, United States of America
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, United States of America
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22
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Cox CE, Riley IL, Ashana DC, Haines K, Olsen MK, Gu J, Pratt EH, Al-Hegelan M, Harrison RW, Naglee C, Frear A, Yang H, Johnson KS, Docherty SL. Improving racial disparities in unmet palliative care needs among intensive care unit family members with a needs-targeted app intervention: The ICUconnect randomized clinical trial. Contemp Clin Trials 2021; 103:106319. [PMID: 33592310 PMCID: PMC8330133 DOI: 10.1016/j.cct.2021.106319] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The technologies used to treat the millions who receive care in intensive care unit (ICUs) each year have steadily advanced. However, the quality of ICU-based communication has remained suboptimal, particularly concerning for Black patients and their family members. Therefore we developed a mobile app intervention for ICU clinicians and family members called ICUconnect that assists with delivering need-based care. OBJECTIVE To describe the methods and early experiences of a clustered randomized clinical trial (RCT) being conducted to compare ICUconnect vs. usual care. METHODS AND ANALYSIS The goal of this two-arm, parallel group clustered RCT is to determine the clinical impact of the ICUconnect intervention in improving outcomes overall and for each racial subgroup on reducing racial disparities in core palliative care outcomes over a 3-month follow up period. ICU attending physicians are randomized to either ICUconnect or usual care, with outcomes obtained from family members of ICU patients. The primary outcome is change in unmet palliative care needs measured by the NEST instrument between baseline and 3 days post-randomization. Secondary outcomes include goal concordance of care and interpersonal processes of care at 3 days post-randomization; length of stay; as well as symptoms of depression, anxiety, and post-traumatic stress disorder at 3 months post-randomization. We will use hierarchical linear models to compare outcomes between the ICUconnect and usual care arms within all participants and assess for differential intervention effects in Blacks and Whites by adding a patient-race interaction term. We hypothesize that both compared to usual care as well as among Blacks compared to Whites, ICUconnect will reduce unmet palliative care needs, psychological distress and healthcare resource utilization while improving goal concordance and interpersonal processes of care. In this manuscript, we also describe steps taken to adapt the ICUconnect intervention to the COVID-19 pandemic healthcare setting. ENROLLMENT STATUS A total of 36 (90%) of 40 ICU physicians have been randomized and 83 (52%) of 160 patient-family dyads have been enrolled to date. Enrollment will continue until the end of 2021.
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Affiliation(s)
- Christopher E Cox
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Isaretta L Riley
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Deepshikha C Ashana
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Krista Haines
- Department of Surgery, Division of Trauma and Critical Care and Acute Care Surgery, Duke University, Durham, North Carolina, United States of America.
| | - Maren K Olsen
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States of America; Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States of America.
| | - Jessie Gu
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Elias H Pratt
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Mashael Al-Hegelan
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Robert W Harrison
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC, United States of America.
| | - Colleen Naglee
- Department of Anesthesia, Division of Neurology, Duke University, Durham, NC, United States of America.
| | - Allie Frear
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Hongqiu Yang
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States of America; Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States of America.
| | - Kimberly S Johnson
- Department of Medicine, Division of Geriatrics, Center for the Study of Aging and Human Development, Duke University, Durham, NC, United States of America; Durham Veterans Affairs Geriatrics Research Education and Clinical Center (GRECC), United States of America.
| | - Sharron L Docherty
- School of Nursing, Duke University, Durham, NC, United States of America.
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Wilkenfeld DA, Orbell SL, Lingler JH. Ethical Considerations in Communicating Alzheimer's Disease Neuroimaging Biomarker Test Results to Symptomatic Individuals. Neurotherapeutics 2021; 18:673-685. [PMID: 33860462 PMCID: PMC8423956 DOI: 10.1007/s13311-021-01047-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 12/11/2022] Open
Abstract
This article examines ethical issues associated with the return of AD neuroimaging results to cognitively symptomatic individuals. Following a review of research on patient and study partner reactions to learning the results of biomarker testing for AD, we examine ethical issues that will be of increasing significance as the field transitions to an era wherein disease-modifying treatments for AD become available. We first review the ethical justification for returning AD biomarker results to individuals who desire them. We then address a more novel question: whether, and to what extent, clinicians or clinical researchers should influence the decisions of individuals who are potentially reluctant to learn their AD imaging results. We argue that in many cases, it is ethically correct to explore, and sometimes alter, factors that may be inhibiting one's desire to know these test results. Our argument is grounded in the premise that having more complete information about changes that may be happening in one's brain will generally yield more informed participation in decisions about one's own care, thereby promoting autonomy. Finally, on the assumption that we have established that it is frequently ethically correct to try to communicate testing information, we examine considerations regarding (not whether but) how this is best accomplished, discussing the concept of responsible transparency. We suggest that both (1) explorations of why one may or may not want to learn results of AD biomarker imaging and (2) the responsible return of such test results is best accomplished using a transactional model of communication.
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Affiliation(s)
- Daniel A Wilkenfeld
- Department of Acute & Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh, PA, USA
| | - Staci L Orbell
- Department of Health and Community Systems, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jennifer H Lingler
- Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Health and Community Systems, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA.
- Alzheimer's Disease Research Center, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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24
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Dobbing C, Tomkins A. Sexual abuse by superintending staff in the nineteenth-century lunatic asylum: medical practice, complaint and risk. Hist Psychiatry 2021; 32:69-84. [PMID: 33118402 PMCID: PMC7820570 DOI: 10.1177/0957154x20967299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The nineteenth century witnessed a great shift in how insanity was regarded and treated. Well documented is the emergence of psychiatry as a medical specialization and the role of lunatic asylums in the West. Unclear are the relationships between the heads of institutions and the individuals treated within them. This article uses two cases at either end of the nineteenth century to demonstrate sexual misdemeanours in sites of mental health care, and particularly how they were dealt with, both legally and in the press. They illustrate issues around cultures of complaint and the consequences of these for medical careers. Far from being representative, they highlight the need for further research into the doctor-patient relationship within asylums, and what happened when the boundaries were blurred.
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25
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Abstract
Religion and spirituality in the United States have been shifting, and physicians are treating patients with increasingly diverse beliefs. Physicians' unfamiliarity with these beliefs poses critical challenges for medical education and practice. Despite efforts to improve medical education in religion/spirituality, most doctors feel their training in these areas is inadequate. This article draws on the author's conversations with providers and patients over several years in various clinical and research contexts in which religious/spiritual issues have arisen. These conversations provided insights into how patients and their families commonly, and often unexpectedly, make religious/spiritual comments to their providers or question their providers about these topics, directly or indirectly. Comments are of at least 9 types that fall within 4 broad domains: (1) perceiving God's role in disease and treatment (in causing disease, affecting treatment outcomes, and knowing disease outcomes), (2) making medical decisions (seeking God's help in making these decisions and determining types/extents of treatment), (3) interacting with providers (ascertaining providers' beliefs, having preferences regarding providers, and requesting prayer with or by providers), and (4) pondering an afterlife. Because of their beliefs or lack of knowledge, doctors face challenges in responding and often do so in 1 of 4 broad ways: (1) not commenting, (2) asking strictly medical questions, (3) referring the patient to a chaplain, or (4) commenting on the patient's remark. Medical education should thus encourage providers to recognize the potential significance of patients' remarks regarding these topics and to be prepared to respond, even if briefly, by developing appropriate responses to each statement type. Becoming aware of potential differences between key aspects of non-Western faiths (e.g., through case vignettes) could be helpful. Further research should examine in greater depth how patients broach these realms, how physicians respond, and how often medical school curricula mention non-Western traditions.
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Affiliation(s)
- Robert Klitzman
- R. Klitzman is professor of psychiatry and director, Master of Bioethics Program, Columbia University, New York, New York; ORCID: https://orcid.org/0000-0002-6827-8063
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26
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Abstract
The coronavirus disease 2019 pandemic has caused a breakdown in the healthcare system worldwide. The need to rapidly update guidelines in order to control the transmission in the population and for evidenced-based healthcare care has led to the need for timely, voluminous and valid research. Amid the quest for a vaccine and better therapies, researchers clamouring for information has led to a wide variety of ethical issues due to the unique situation. This paper aims to examine the positive and negative aspects of recent changes in the process of obtaining informed consent. The article outlines the various aspects, from history, previously described exemptions to consenting as well as those implemented during the pandemic and the current impact of virtual methods. Further, the authors make recommendations based on the outcome of suggested adjustments described in the literature. This article looks into increasing the awareness of physicians and researchers about ethical issues that need to be addressed to provide optimal care for patients while assuring their integrity and confidentiality.
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Affiliation(s)
| | - Olena Zimba
- Department of Internal Medicine No. 2, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Latika Gupta
- Department Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
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27
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Abstract
This paper introduces the model of Utilitarian Principlism as a framework for crisis healthcare ethics. In modern Western medicine, during non-crisis times, principlism provides the four guiding principles in biomedical ethics—autonomy, nonmaleficence, beneficence, and justice; autonomy typically emerges as the decisive principle. The physician–patient relationship is a deontological construct in which the physician’s primary duty is to the individual patient and the individual patient is paramount. For this reason, we term the non-crisis ethical framework that guides modern medicine Deontological Principlism. During times of crisis, resources become scarce, standards of care become dynamic, and public health ethics move to the forefront. Healthcare providers are forced to work in non-ideal conditions, and interactions with individual patients must be considered in the context of the crisis. The COVID-19 pandemic has forced healthcare to shift to a more utilitarian framework with a greater focus on promoting the health of communities and populations. This paper puts forth the notion of Utilitarian Principlism as a framework for crisis healthcare ethics. We discuss each of the four principles from a utilitarian perspective and use clinical vignettes, based on real cases from the COVID-19 pandemic, for illustrative purposes. We explore how Deontological Principlism and Utilitarian Principlism are two ends of a spectrum, and the implications to healthcare as we emerge from the pandemic.
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Affiliation(s)
- Laura Vearrier
- Department of Emergency Medicine, Center for Bioethics and Medical Humanities, University of Mississippi Medical Center, 2500 North State St., Jackson, MS, 39216, USA.
| | - Carrie M Henderson
- Department of Pediatrics, Division of Critical Care Medicine, Center for Bioethics and Medical Humanities, University of Mississippi Medical Center, 2500 North State St., Jackson, MS, 39216, USA
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28
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MacDougall DR. Must Consent Be Informed? Patient rights, state authority, and the moral basis of the physician's duties of disclosure. Kennedy Inst Ethics J 2021; 31:247-270. [PMID: 34565744 DOI: 10.1353/ken.2021.0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Legal standards of disclosure in a variety of jurisdictions require physicians to inform patients about the likely consequences of treatment, as a condition for obtaining the patient's consent. Such a duty to inform is special insofar as extensive disclosure of risks and potential benefits is not usually a condition for obtaining consent in non-medical transactions.What could morally justify the physician's special legal duty to inform? I argue that existing justifications have tried but failed to ground such special duties directly in basic and general rights, such as autonomy rights. As an alternative to such direct justifications, I develop an indirect justification of physicians' special duties from an argument in Kant's political philosophy. Kant argues that pre-legal rights to freedom are the source of a duty to form a state. The state has the authority to conclusively determine what counts as "consent" in various kinds of transactions. The Kantian account can subsequently indirectly justify at least one legal standard imposing a duty to inform, the reasonable person standard, but rules out one interpretation of a competitor, the subjective standard.
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29
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Minicuci N, Giorato C, Rocco I, Lloyd-Sherlock P, Avruscio G, Cardin F. Survey of doctors' perception of professional values. PLoS One 2020; 15:e0244303. [PMID: 33370373 PMCID: PMC7769469 DOI: 10.1371/journal.pone.0244303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 12/07/2020] [Indexed: 11/18/2022] Open
Abstract
Background New challenges in the medical field of the third millennium emphasise the "humanization of medicine" leading to a redefinition of doctors’ values, limits and roles. The study aims to assess whether there are different personality dimensions of physicians in relation to their perception of professional values and public expectations. Methods A questionnaire on the perception of professional values and the opinion on work in the medical field, work relationships and public expectations was administered to 374 doctors attending Continuing Medical Education courses. Results Two personality dimensions were identified: the first dimension (which we termed "Performance Attainment") is associated preeminently with values of competence, advocacy, confidentiality, spirit of enquiry, integrity, responsibility and commitment; the second dimension (which we called “Personal Involvement”) focuses on concern and compassion. The doctors that have more difficulty accepting judgements on their activity are those who think that “Performance attainment” is less important (β = 6.01; p-value = 0.007). Instead, the doctors who believe “public expectation of the health system” is not high enough, tend to think that “Performance Attainment” is more important (β = -6.08; p-value = 0.024). The less importance is given to the values of "Personal Involvement", the less is the doctor’s perception of having a leading role in respect to other health professionals (β = -2.37; p-value = 0.018). Conclusions Our results demonstrate that there are two different attitudes in terms of recognition and selection of the essential values to better practice the medical profession. Whether the doctors attach more importance to one dimension or the other, they do not differ in our analysis for how they answered the questions about relationships with patients, colleagues or family commitments in the questionnaire, even if they work in different areas. This suggests that in our research there is no single personal attitude that characterizes “a good doctor”.
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Affiliation(s)
- Nadia Minicuci
- National Research Council, Neuroscience Institute, Padova, Italy
| | - Cinzia Giorato
- Department of Surgery Oncology and Gastroenterology, Padova, Italy
| | - Ilaria Rocco
- National Research Council, Neuroscience Institute, Padova, Italy
- * E-mail:
| | - Peter Lloyd-Sherlock
- School of International Development, University of East Anglia, Norwich, United Kingdom
| | - Giampiero Avruscio
- Department of Cardiac, Angiology Unit, Thoracic and Vascular Sciences, University Hospital of Padua, Padua, Italy
| | - Fabrizio Cardin
- Department of Surgery Oncology and Gastroenterology, Padova, Italy
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Abstract
Physicians play a critical role in preventing and treating firearm injury, although the scope of that role remains contentious and lacks systematic definition. This piece aims to utilize the fundamental principles of medical ethics to present a framework for physician involvement in firearm violence. Physicians' agency relationship with their patients creates ethical obligations grounded on three principles of medical ethics - patient autonomy, beneficence, and nonmaleficence. Taken together, they suggest that physicians ought to engage in clinical screening and treatment related to firearm violence. The principle of beneficence also applies more generally, but more weakly, to relations between physicians and society, creating nonobligatory moral ideals. Balanced against physicians' primary obligations to patient agency relationships, general beneficence suggests that physicians may engage in public advocacy to address gun violence, although they are not ethically obligated to do so. A fourth foundational principle - justice - requires that clinicians attempt to ensure that the benefits and burdens of healthcare are distributed fairly.
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Affiliation(s)
- Blake N Shultz
- Blake N. Shultz is a sixth-year medical student at Yale School of Medicine and a third-year law student at Yale Law School in New Haven, CT. He is also a fellow at the Solomon Center for Health Law and Policy at Yale Law School. He received his B.A. from Cornell University (2015) in Ithaca, NY. Benjamin Tolchin, M.D., M.S., is an Assistant Professor of Neurology at Yale School of Medicine and an Attending Physician at Yale New Haven Hospital and at the West Haven VA Medical Center. Katherine L. Kraschel, J.D., is the Executive Director of the Solomon Center for Health Law and Policy as well as a Lecturer in Law, Clinical Lecturer in Law, and Research Scholar in Law at Yale Law School. She received her J.D. from Harvard Law School, and her B.A. from Mount Holyoke College
| | - Benjamin Tolchin
- Blake N. Shultz is a sixth-year medical student at Yale School of Medicine and a third-year law student at Yale Law School in New Haven, CT. He is also a fellow at the Solomon Center for Health Law and Policy at Yale Law School. He received his B.A. from Cornell University (2015) in Ithaca, NY. Benjamin Tolchin, M.D., M.S., is an Assistant Professor of Neurology at Yale School of Medicine and an Attending Physician at Yale New Haven Hospital and at the West Haven VA Medical Center. Katherine L. Kraschel, J.D., is the Executive Director of the Solomon Center for Health Law and Policy as well as a Lecturer in Law, Clinical Lecturer in Law, and Research Scholar in Law at Yale Law School. She received her J.D. from Harvard Law School, and her B.A. from Mount Holyoke College
| | - Katherine L Kraschel
- Blake N. Shultz is a sixth-year medical student at Yale School of Medicine and a third-year law student at Yale Law School in New Haven, CT. He is also a fellow at the Solomon Center for Health Law and Policy at Yale Law School. He received his B.A. from Cornell University (2015) in Ithaca, NY. Benjamin Tolchin, M.D., M.S., is an Assistant Professor of Neurology at Yale School of Medicine and an Attending Physician at Yale New Haven Hospital and at the West Haven VA Medical Center. Katherine L. Kraschel, J.D., is the Executive Director of the Solomon Center for Health Law and Policy as well as a Lecturer in Law, Clinical Lecturer in Law, and Research Scholar in Law at Yale Law School. She received her J.D. from Harvard Law School, and her B.A. from Mount Holyoke College
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31
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Abstract
The pediatrician has a privileged relationship with a child with infantile spinal muscular atrophy (SMA). At all times, he/she must be the child's mentor, promoting a comprehensive approach and support in order to ensure the best possible solution for the patient's autonomy. In all circumstances, an ethical stance is essential. After a reminder on the notions of ethics of care, we will address various ethical questions encountered through three critical situations during the care of a child with infantile spinal muscular atrophy: the announcement of the diagnosis, the transmission of information on innovative therapies, and palliative care and end-of-life support. © 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.
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Affiliation(s)
- B Chabrol
- Centre de référence des maladies neuromusculaires de l'Enfant, Neuromuscular Commission of French Society of Pediatric Neurology, Filière FINELMUS, Hôpital d'Enfants, CHU Timone, 13385 Marseille cedex 5.
| | - I Desguerre
- Centre de référence des maladies neuromusculaires de l'Enfant, Neuromuscular Commission of French Society of Pediatric Neurology, Filière FINELMUS, Hôpital Necker, rue de Sèvres, 75015 Paris
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32
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Takeshita J, Wang S, Loren AW, Mitra N, Shults J, Shin DB, Sawinski DL. Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Netw Open 2020; 3:e2024583. [PMID: 33165609 PMCID: PMC7653497 DOI: 10.1001/jamanetworkopen.2020.24583] [Citation(s) in RCA: 299] [Impact Index Per Article: 74.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE The Press Ganey Outpatient Medical Practice Survey is used to measure the patient experience. An understanding of the patient- and physician-related determinants of the patient experience may help identify opportunities to improve health care delivery and physician ratings. OBJECTIVE To evaluate the associations between the patient experience as measured by scores on the Press Ganey survey and patient-physician racial/ethnic and gender concordance. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional analysis of Press Ganey surveys returned for outpatient visits within the University of Pennsylvania Health System between 2014 and 2017 was performed. Participants included adult patient and physician dyads for whom surveys were returned. Data analysis was performed from January to June 2019. EXPOSURES Patient-physician racial/ethnic and gender concordance. MAIN OUTCOMES AND MEASURES The primary outcome was receipt of the maximum score for the "likelihood of your recommending this care provider to others" question in the Care Provider domain of the Press Ganey survey. Secondary outcomes included each of the remaining 9 questions in the Care Provider domain. Generalized estimating equations clustering on physicians with exchangeable intracluster correlations and cluster-robust standard errors were used to investigate associations between the outcomes and patient-physician racial/ethnic and gender concordance. RESULTS In total, 117 589 surveys were evaluated, corresponding to 92 238 unique patients (mean [SD] age, 57.7 [15.6] years; 37 002 men [40.1%]; 75 307 White patients [81.6%]) and 747 unique physicians (mean [SD] age 45.5 [10.6] years; 472 men [63.2%]; 533 White physicians [71.4%]). Compared with racially/ethnically concordant patient-physician dyads, discordance was associated with a lower likelihood of physicians receiving the maximum score (adjusted odds ratio [OR], 0.88; 95% CI, 0.82-0.94; P < .001). Black (adjusted OR, 0.73; 95% CI, 0.68-0.78; P < .001) and Asian (adjusted OR, 0.55; 95% CI, 0.50-0.60; P < .001) patient race were both associated with lower patient experience ratings. Patient-physician gender concordance was not associated with Press Ganey scores (adjusted OR, 1.00; 95% CI, 0.96-1.04; P = .90). CONCLUSIONS AND RELEVANCE In this study, higher Press Ganey survey scores were associated with racial/ethnic concordance between patients and their physicians. Efforts to improve physician workforce diversity are imperative. Delivery of health care in a culturally mindful manner between racially/ethnically discordant patient-physician dyads is also essential. Furthermore, Press Ganey scores may differ by a physician's patient demographic mix; thus, care must be taken when publicly reporting or using Press Ganey scores to evaluate physicians on an individual level.
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Affiliation(s)
- Junko Takeshita
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Shiyu Wang
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Alison W. Loren
- Hematology/Oncology Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Justine Shults
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Daniel B. Shin
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Deirdre L. Sawinski
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Pendleton AA, McKinley SK, Pendleton VE, Ott QC, Petrusa ER, Srivastava SD, Lillemoe KD, Ferrone CR. A multi-institutional study of patient-derived gender-based discrimination experienced by resident physicians. Am J Surg 2020; 221:309-314. [PMID: 33081931 DOI: 10.1016/j.amjsurg.2020.10.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/16/2020] [Accepted: 10/11/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study characterizes prevalence, frequency, and forms of patient-derived gender-based discrimination (GBD) experienced by resident physicians, as well as their experiences witnessing and reporting patient-derived GBD. METHODS A web-based survey was sent to residents from 12 programs at three academic institutions. RESULTS Response rate was 47.9% (309/645) with 55.0% of respondents identifying as women. Women were more likely than men to experience patient-derived GBD during residency (100% vs 68.8%, p < 0.001), including inappropriate physical contact, receiving less trust from patients, and being mistaken for a nurse (p < 0.001). While 85.9% of residents personally experienced and 95.0% of residents witnessed patient-derived GBD, only 3.4% of residents formally reported patient-derived GBD. Women were more likely to report negative personal and professional consequences of patient-derived GBD. CONCLUSIONS Patient-derived GBD is pervasive and disproportionately affects women residents. Current reporting mechanisms are not adequately capturing nor addressing patient-derived GBD.
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Affiliation(s)
- Anna Alaska Pendleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA.
| | - Sophia K McKinley
- Department of General Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Qi C Ott
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Emil R Petrusa
- Department of General Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Sunita D Srivastava
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Keith D Lillemoe
- Department of General Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Cristina R Ferrone
- Department of General Surgery, Massachusetts General Hospital, Boston, MA, USA
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Affiliation(s)
- Lisa Caulley
- From the Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, and the Clinical Epidemiology Program, Ottawa Hospital Research Institute - both in Ottawa, Canada; and the Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
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Kitta A, Hagin A, Unseld M, Adamidis F, Diendorfer T, Masel EK, Kirchheiner K. The silent transition from curative to palliative treatment: a qualitative study about cancer patients' perceptions of end-of-life discussions with oncologists. Support Care Cancer 2020; 29:2405-2413. [PMID: 32918609 PMCID: PMC7981304 DOI: 10.1007/s00520-020-05750-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/04/2020] [Indexed: 11/25/2022]
Abstract
Objective The aims of the study were to examine patients’ experiences of end-of-life (EOL) discussions and to shed light on patients’ perceptions of the transition from curative to palliative care. Methods This study was based on a qualitative methodology; we conducted semi-structured interviews with advanced cancer patients admitted to the palliative care unit (PCU) of the Medical University of Vienna. Interviews were recorded digitally and transcribed verbatim. Data were analyzed based on thematic analysis, using the MAXQDA software. Results Twelve interviews were conducted with patients living with terminal cancer who were no longer under curative treatment. The findings revealed three themes: (1) that the medical EOL conversation contributed to the transition process from curative to palliative care, (2) that patients’ information preferences were ambivalent and modulated by defense mechanisms, and (3) that the realization and integration of medical EOL conversations into the individual’s personal frame of reference is a process that needs effort and information from different sources coming together. Conclusions The results of the present study offer insight into how patients experienced their transition from curative to palliative care and into how EOL discussions are only one element within the disease trajectory. Many patients struggle with their situations. Therefore, more emphasis should be put on repeated offers to have EOL conversations and on early integration of aspects of palliative care into the overall treatment. Electronic supplementary material The online version of this article (10.1007/s00520-020-05750-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A Kitta
- Clinical Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - A Hagin
- Faculty of Psychology, University of Vienna, Liebiggasse 5, 1010, Vienna, Austria
| | - M Unseld
- Clinical Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - F Adamidis
- Clinical Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - T Diendorfer
- Department of Radiation Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - E K Masel
- Clinical Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - K Kirchheiner
- Department of Radiation Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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Price S. 'This Makes Me Feel More Alive': Catching COVID-19 Helped Physician Find New Ways to Help Patients. Tex Med 2020; 116:30-33. [PMID: 33023281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Catching COVID-19 helped family physician Tim Martindale, MD, find new ways to help his patients.
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Abstract
Truth-telling is often regarded as a challenge in Chinese medical practices given the amount of clinical and ethical controversies it may raise. This study sets to collect and synthesize relevant ethical evidence of the current situation in mainland China, thereby providing corresponding guidance for medical practices. This study looks into the ethical issues on the basis of the philosophy of deontology and utilitarianism and the ethical principles of veracity, autonomy, beneficence, and nonmaleficence. Chinese philosophy, context and culture are also discussed to provide some suggestions for decision-making about disclosure in a medical setting. This study holds that, in order to respect the basic rights to which critically ill patients are entitled, decisions regarding truth-telling and their implementation should be carried out with thorough consideration, which can be achieved by critical thinking, well-developed and effective communication skills, the consideration of cultural context, an understanding of individual differences, and compliance with relevant laws and regulations.
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Affiliation(s)
- Zanhua Zhang
- Department of Emergency Intensive Care Unit, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, China
| | - Xiaoyan Min
- Department of Intensive Care Unit, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, China.
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Véliz C. Not the doctor's business: Privacy, personal responsibility and data rights in medical settings. Bioethics 2020; 34:712-718. [PMID: 32060936 PMCID: PMC7587002 DOI: 10.1111/bioe.12711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 10/28/2019] [Accepted: 12/03/2019] [Indexed: 05/27/2023]
Abstract
This paper argues that assessing personal responsibility in healthcare settings for the allocation of medical resources would be too privacy-invasive to be morally justifiable. In addition to being an inappropriate and moralizing intrusion into the private lives of patients, it would put patients' sensitive data at risk, making data subjects vulnerable to a variety of privacy-related harms. Even though we allow privacy-invasive investigations to take place in legal trials, the justice and healthcare systems are not analogous. The duty of doctors and healthcare professionals is to help patients as best they can-not to judge them. Patients should not be forced into giving up any more personal information than what is strictly necessary to receive an adequate treatment, and their medical data should only be used for appropriate purposes. Medical ethics codes should reflect these data rights. When a doctor asks personal questions that are irrelevant to diagnose or treat a patient, the appropriate response from the patient is: 'none of your business'.
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Affiliation(s)
- Carissa Véliz
- University of OxfordUehiro Centre for Practical EthicsWellcome Centre for Ethics and HumanitiesFaculty of PhilosophyUnited Kingdom of Great Britain and Northern Ireland
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AlMahmoud T, Hashim MJ, Naeem N, Almahmoud R, Branicki F, Elzubeir M. Relationships and boundaries: Learning needs and preferences in clerkship medical environments. PLoS One 2020; 15:e0236145. [PMID: 32687536 PMCID: PMC7371200 DOI: 10.1371/journal.pone.0236145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 06/26/2020] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Relationship boundaries recognition is an essential element of medical practice. The aim of the study was to assess final year medical students' perceived need for education regarding professional boundaries. MATERIALS AND METHODS This was a cross-sectional study. An anonymous paper questionnaire was distributed to 128 final year medical students. Standard descriptive statistics, unpaired t-test to evaluate differences between male and female groups and Pearson correlation to determine relationships between variables were used. RESULTS The survey was completed by 84.4% of students who identified the need for more emphasis in the curriculum for all of topics during training and practice pertaining to boundaries and relationships (mean 6.61±1.32 on a scale of 0 to 9; and 6.66±1.27 respectively). Topics with a high interest ranking requiring additional attention were mistreatment of medical students (mean 7.22±1.96), coping with mistakes in clinical care (mean 7.25±1.63), reporting of medical mistakes (mean 7.58±1.36), and gender bias in clinical care (mean 7.10±1.82). Women perceived a greater need for attention to all topics in the curriculum. Significant differences between the perceptions of female and male students were observed regarding topics such as responding to an impaired colleague (p<0.001), and a physician's social responsibilities (p = 0.001). CONCLUSION Medical students recognized the need for more education and training in the undergraduate medical ethics curriculum regarding patient-physician relationship boundaries.
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Affiliation(s)
- Tahra AlMahmoud
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
- * E-mail:
| | - M. Jawad Hashim
- Department of Family Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
| | - Naghma Naeem
- Department of Medical Education, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
| | - Rabah Almahmoud
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, UAE
| | - Frank Branicki
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
| | - Margaret Elzubeir
- Department of Medical Education, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
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Abstract
Despite their ubiquitous presence, placebos and placebo effects retain an ambiguous and unsettling presence in biomedicine. Specifically focused on chronic pain, this review examines the effect of placebo treatment under three distinct frameworks: double blind, deception, and open label honestly prescribed. These specific conditions do not necessarily differentially modify placebo outcomes. Psychological, clinical, and neurological theories of placebo effects are scrutinized. In chronic pain, conscious expectation does not reliably predict placebo effects. A supportive patient-physician relationship may enhance placebo effects. This review highlights "predictive coding" and "bayesian brain" as emerging models derived from computational neurobiology that offer a unified framework to explain the heterogeneous evidence on placebos. These models invert the dogma of the brain as a stimulus driven organ to one in which perception relies heavily on learnt, top down, cortical predictions to infer the source of incoming sensory data. In predictive coding/bayesian brain, both chronic pain (significantly modulated by central sensitization) and its alleviation with placebo treatment are explicated as centrally encoded, mostly non-conscious, bayesian biases. The review then evaluates seven ways in which placebos are used in clinical practice and research and their bioethical implications. In this way, it shows that placebo effects are evidence based, clinically relevant, and potentially ethical tools for relieving chronic pain.
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Affiliation(s)
- Ted J Kaptchuk
- Beth Israel Hospital/Harvard Medical School, Boston, MA 02139, USA
- Contributed equally
| | - Christopher C Hemond
- University of Massachusetts Medical School, Worcester, MA 01655, USA
- Contributed equally
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Gupta N, Thiele CM, Daum JI, Egbert LK, Chiang JS, Kilgore AE, Johnson CD. Building Patient-Physician Trust: A Medical Student Perspective. Acad Med 2020; 95:980-983. [PMID: 32079958 DOI: 10.1097/acm.0000000000003201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Public trust in physicians has declined over the last 50 years. Future physicians will need to mend the patient-physician trust relationship. In conjunction with the American Medical Association's Accelerating Change in Medical Education initiative, the Mayo Clinic Alix School of Medicine implemented the Science of Health Care Delivery (SHCD) curriculum-a 4-year curriculum that emphasizes interdisciplinary training across population-centered care; person-centered care; team-based care; high-value care; leadership; and health policy, economics, and technology-in 2015. In this medical student perspective, the authors highlight how the SHCD curriculum has the potential to address issues that have eroded patient-physician trust. The curriculum reaches this aim through didactic and/or experiential teachings in health equity, cultural humility and competence, shared decision making, patient advocacy, and safety and quality of care. It is the authors' hope that novel medical education programs such as the SHCD curriculum will allow the nation's future physicians to own their role in rebuilding and fostering public trust in physicians and the health care system.
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Affiliation(s)
- Nikita Gupta
- N. Gupta is a second-year medical student, Mayo Clinic Alix School of Medicine, Scottsdale, Arizona. C.M. Thiele is a second-year medical student, Mayo Clinic Alix School of Medicine, Scottsdale, Arizona. J.I. Daum is a second-year medical student, Mayo Clinic Alix School of Medicine, Scottsdale, Arizona. L.K. Egbert is a second-year medical student, Mayo Clinic Alix School of Medicine, Scottsdale, Arizona. J.S. Chiang is a second-year medical student, Mayo Clinic Alix School of Medicine, Scottsdale, Arizona. A.E. Kilgore Jr is a second-year medical student, Mayo Clinic Alix School of Medicine, Scottsdale, Arizona. C.D. Johnson is a consultant, Department of Radiology, Mayo Clinic Hospital, Scottsdale, Arizona
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Affiliation(s)
- Mary Beth Bennett
- Third-year medical student, University of Texas at Austin Dell Medical School, Austin, Texas; ; ORCID: https://orcid.org/0000-0003-0258-5893
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Kawamura A, Harris I, Thomas K, Mema B, Mylopoulos M. Exploring How Pediatric Residents Develop Adaptive Expertise in Communication: The Importance of "Shifts" in Understanding Patient and Family Perspectives. Acad Med 2020; 95:1066-1072. [PMID: 31464732 DOI: 10.1097/acm.0000000000002963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE Communication with patients and families can be complex, especially in challenging discussions. To communicate effectively, expert physicians must often use flexible approaches. This innovative use of knowledge to handle complexity is an essential capability of adaptive expertise. Despite its importance for effective communication and implications for medical education, little is known about how adaptive expertise develops in trainees. The purpose of this study was to explore how pediatric residents developed adaptive expertise in communication. METHOD A constructivist grounded theory study, using observations of physician-patient communication and semistructured interviews as data sources and purposeful sampling of 10 pediatric subspecialty residents at the University of Toronto, was conducted in 2016-2017. Data collection and analysis occurred iteratively, and themes were identified through the research team's constant comparative analysis. RESULTS Residents navigated challenging discussions with patients and families by enabling them to express their own narratives and integrating these with their medical knowledge to provide care. At times, a "shift" in the residents' understanding of the families' perspectives was needed to effectively navigate the discussion. Residents used this shift purposefully to create new communication strategies, resulting in an opportunity for learning. CONCLUSIONS "Shifts" are defined as adjustments in the resident's understanding of a family's perspective that affect clinical care. Analysis suggests that these "shifts" can be understood to support development of adaptive expertise. The workplace learning environment promoted this development by providing opportunities that prepared residents for future learning through active experimentation, offering multiple perspectives and enhancing deeper conceptual learning.
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Affiliation(s)
- Anne Kawamura
- A. Kawamura is associate professor, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada. I. Harris is professor, Department of Medical Education, University of Illinois at Chicago, Chicago, Illinois. K. Thomas is a resident, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada. B. Mema is associate professor, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada. M. Mylopoulos is associate professor, Department of Pediatrics, University of Toronto, Faculty of Medicine, and scientist, Wilson Centre for Research in Education, University of Toronto, Toronto, Ontario, Canada
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Affiliation(s)
- Colleen M Drapcho
- Fourth-year medical student, Louisiana State University Health Sciences Center, School of Medicine, New Orleans, Louisiana; ; ORCID: http://orcid.org/0000-0002-9065-191X
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Igić R. Nonadherence to doctor's instructions. J BUON 2020; 25:1670-1672. [PMID: 33099899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Rajko Igić
- University of Banjaluka, Faculty of Medicine, Department of Pharmacology, Toxicology and Clinical Pharmacology, 78000 Banja Luka, Republic of Srpska, Bosnia and Herzegovina
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da Rocha AO, Maués JL, Chies GAF, da Silva AP. Assessing the Impact of a Ceremony in Honor of the Body Donors in the Development of Ethical and Humanistic Attitudes among Medical Students. Anat Sci Educ 2020; 13:467-474. [PMID: 31515966 DOI: 10.1002/ase.1920] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 08/26/2019] [Accepted: 09/07/2019] [Indexed: 06/10/2023]
Abstract
Activities related to body donation programs, such as donor memorial ceremonies, provide the opportunity to complement student training, especially with regard to the ethical and humanistic elements involved in medical training. This study sought to assess the impact of a ceremony in honor of the body donors has on ethical and humanistic attitudes in medical students. Medical students were surveyed about their perceptions of changes in themselves, respect for donors and donor families, and their relationship with patients. The effect of the students' contact with the family of the donor was analyzed in students who had contact with the cadaver in the dissection room and had either participated or not participated in the donor memorial ceremony. A total of 370 questionnaires were answered by first-, second-, and third-year medical students at the Federal University of Health Sciences of Porto Alegre in 2017. The students who participated in the ceremony presented more positive responses in relation to commitment to their studies, reflection on death, and positive development of empathy when compared to those who did not attend the ceremony. Most of the students that attended the ceremony suggested the event led to an improvement in the doctor-patient relationship. These results suggest that cadaver dissection with accompanied memorial ceremony involving contact with donor families is an effective means of fostering ethical and humanistic attitudes among medical students from the beginning of the course.
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Affiliation(s)
- Andrea Oxley da Rocha
- Department of Basic Health Sciences, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
- Department of Human Anatomy, Feevale University, Novo Hamburgo, Brazil
| | - Joao Lins Maués
- Department of Basic Health Sciences, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Gabriel Antônio Flores Chies
- Department of Basic Health Sciences, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Ana Paula da Silva
- Department of Basic Health Sciences, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
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Metselaar S, van Schaik MV, Molewijk AC, Widdershoven GAM. [Moral case deliberation in complex euthanasia requests]. Ned Tijdschr Geneeskd 2020; 164:D4940. [PMID: 32749813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Dealing with euthanasia requests can be a complex matter for a doctor. How to determine whether the due diligence criteria of the Dutch Euthanasia Act are met in cases that are not straightforward? We argue that moral case deliberation (MCD), methodically structured reflective discussions on concrete moral dilemmas, can provide support in dealing with complex euthanasia requests. In this article, we discuss a case that was talked about during a MCD (in particular the CURA method, where CURA stands for 'concentrating, postponing, reflecting and action') by a group of GPs and nurses who met in the context of a network for ambulatory palliative care.This was about an older patient with multiple chronic conditions who lost any prospects of quality of life.Among other things, it was examined whether requests could be 'well-considered' (one of the due diligence criteria) when the patients are in doubt as to when euthanasia should be carried out.The importance of recognising one's own emotions as a doctor and the quality of communication between patient and doctor were also considered.For that reason, we try to show that MCD can assist in making careful and well-considered decisions when determining a course of action in the case of complex euthanasia requests and can encourage collaborative learning processes.
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Affiliation(s)
- S Metselaar
- Amsterdam UMC, afd. Metamedica, Amsterdam
- Contact: S. Metselaar
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McFarland DC, Blackler L, Hlubocky FJ, Saracino R, Masciale J, Chin M, Alici Y, Voigt L. Decisional Capacity Determination In Patients With Cancer. Oncology (Williston Park) 2020; 34:203-210. [PMID: 32609867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Patients with cancer face many difficult decisions and encounter many clinical situations that undermine decisional capacity. For this reason, assessing decision-making capacity should be thought of at every medical encounter. The culmination of variable disease trajectories, following patients to the end of life, use of high-risk treatments, and other weighty personal decisions require attention to patients' ability to engage in decisions. Oncologists develop meaningful relationships with their patients. This familiarity may lead to forgoing the process of diligently assessing a patient's cognitive ability and/or decisional capacity when important decisions need to be made. While the process may feel like it takes place spontaneously, many subtle and overt details are involved with the decisions around cancer care that require pointed questioning and probing. Thus, there are many ways to fall short in determining decisional capacity. Clinicians are inconsistent in their decisional capacity determinations and generally assume more decisional capacity than the patient has. Consult and referral services such as ethics and psychiatry can help with treatment decisions and with assessing underlying psychosocial and psychiatric conditions. Decisional capacity may fluctuate and requires a variable amount of decisional ability depending on the clinical situation; hence, it is time-specific and decision-specific. This review is intended to provide a summary of key components of decisional capacity while highlighting areas in need of clinical refinement.
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Nimmons D. My First Hearing-Impaired Patient. Acad Med 2020; 95:826. [PMID: 32079937 DOI: 10.1097/acm.0000000000003213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Danielle Nimmons
- Academic clinical fellow, Department of Primary Care, Royal Free Campus, University College London, London, United Kingdom;
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