A Few Physician's New Year's Resolutions

It’s that time of the year when it is customary that people make New Year’s resolutions. Doctors should be no exception regarding their professional behavior.



One significant defect that a number of doctors bear, either because of time constraints or their own disinterest, is failure to take into consideration the whole patient and family when evaluating a medical condition. Though medical schools try to stress to their students that there is more to a patient’s illness than simply the biologic disorder. There are also psychologic and social issues involved. Sometimes this teaching gets lost as a busy practice develops. To understand these non-biologic factors, a physician practicing in a multi-cultural environment, as many do, must also have some understanding of the way patients from different cultures and religions look at the illness, which has befallen them. This learning often comes piecemeal to the doctor.



Another resolution would be for the physician to feel and be less rushed. Rushing leads to mistakes and poor relationships with their patients. Though it is true these days that time constraints are placed on the doctor’s practice, nevertheless, often these constraints are due to improper organization of the practice system and by consultation with management specialists, the physician’s time can be better organized and more will become available.



Finally for this posting, how about a doctor’s resolution to be a health model for their patients? There are still some doctors who smoke and are grossly overweight. Could this be the resolution hardest to keep in the upcoming year?



Do you have any other suggestions as to a physician’s New Year resolutions? ..Maurice.

New Year's Resolutions to Stimulate Therapeutic Innovation

Now that it is the time for everyone to declare their New Year's Resolutions,

Dr. John Crellin writes about what he wonders might be the appropriate resolution by research institutions to reduce the barriers to therapeutic innovation. Perhaps, he suggests, it might be time to resolve to revisit the regulatory ethics paradigm and debate possible changes in order to stimulate therapeutic innovation. ..Maurice.

Military Medical Conflicts of Interest Including Treating One’s Military “Family”

The very recent attack on a military dining facility in Mosul and the resulting deaths followed by the prompt mobilization of medical treatment for the numbers of wounded brought to me a revisiting of my thoughts about the profession of the military physician. I have been writing throughout this blog about conflicts of interest in the profession of medicine and I find this topic certainly applies to doctors in the military. It seems obvious that their conflicts of interest would be qualitatively quite different than those affecting physicians in civilian life.



One clear conflict is that of the physician’s allegedly primary duty to the military. This aspect is well described by John C. Moskop, Ph.D. whose article can be found in the Ethics and Healthcare newsletter of The Bioethics Center, University Health Systems of Eastern Carolina

Department of Medical Humanities, The Brody School of Medicine at East Carolina University Volume 7:Number 1 Spring 2004 under the title Ethics and Military Medicine: New Developments & Perennial Questions



The following is an excerpt of the Conclusion of the article:

What, then, is the underlying moral difference between military and civilian medical practice? It is, I believe, the fact that the military demands a more nearly total commitment to its goals and practices than other employers and, as a result, military physicians have less individual freedom to make their own moral choices. Some military goals, such as the protection of citizens and their way of life, are highly desirable; other possible goals, such as aggression against other nations, are highly morally suspect. Some military practices and procedures, such as strict discipline and rigorous training, are necessary and defensible means to achieving military goals; others, such as torture, genocide, and mistreatment of one’s own soldiers, prisoners of war, or civilians, are highly morally problematic. Upon entering military service, physicians assume obligations to pursue military goals and abide by military procedures, with only limited options to resist these on medical or other grounds. Thus, the decision to enter military service is a morally weighty one which demands careful reflection on the practices and regulations of the military service to which one is pledging obedience.

I have a theory that there is another conflict of interest, not described in the article, which though perhaps subtle represents a relationship with the traumatized patient, particularly during a war, which physicians in civilian life are not encouraged to encounter. It is reasonable to say that the military physician, especially during the immediate distress of battle and most especially for those physicians near the “front line”, the patients for whom the physician is responsible is part of a closely knit team of which the physician is an important part and partner. Together, they are all working to defeat the enemy. I have a feeling that the military physician might reasonably look at the team, emotionally, as his/her “family” of service people. And, if so, the physician could be in a way treating the severely injured of his/her “family”. In civilian life, physicians are discouraged from treating their own family members, certainly a severely traumatized one, because of the psychological-emotional effects which might affect proper medical judgment. And yet, this very act of treating one’s military "family member" is what is demanded of the military physician. And it is this responsibility which could be the basis for the subtle conflict of interest and its effect on professional judgment.

I really don’t have any data or other information to confirm my concerns. I don't know if military physicians look at their team emotionally as "family". I don’t know if there are more mistakes in clinical decision-making up front in Iraq or even at the military hospital in Germany than let’s say in a civilian hospital emergency room. And, if there were more mistakes on the “front-line” would other factors such as the psychological effect of potential of injury or death of the physicians or limited resources there be the important factors. This could all be my expounding an unrealistic personal idea. Do you think that there is any merit to my theory and worthy of further investigation? Let me know. ..Maurice.

Full Statistical Disclosure Makes Good Ethics

I write about the difficulty of the public interpreting the significance of medication risks when only the relative risks are described in the news media. An example would be the information that taking the drug “doubles the chances of getting a heart attack” than not taking it. Read it on Shrinkette, a wonderful blog expressing the views of a lady psychiatrist ..Maurice.

Physicians Making Decisions for Unconscious Patients Without Family, Friends or Surrogates (5): Ethics Committees--True Consensus?

In both of the two options involving hospital ethics committees(HEC) (see last posting) the same concern can be raised. The concern is does their final conclusion really represent a true consensus of opinions or something else? How is the final conclusion that the committee reaches developed?

Anne Griswold Peirce, RN, PhD, Associate Dean for Academic Affairs, Columbia University School of Nursing, New York writing in the Online Journal of Health Ethics, The University of Mississippi Medical Center explores some of the dynamics of decision-making by hospital ethics committees in this recent article titled “Some Considerations about Decisions and Decision-Makers in Hospital Ethics Committees”

Her cautions are well taken and are summarized by her as follows:

1. Ensure that HECs are composed of diverse professions, as well as diversity of gender and ethnicity. Diversity strengthens decisions by expanding the knowledge and opinion base (Smith, Bisanz, Kempfer, Adams, Candelari, & Blackburn, 2004).

2. Include community representation so that not all members are institutionally based. Diversity of institutional information is also important. Institutional allegiance may also influence decisions in unknown ways (DeRenzo, Silverman, Hoffman, Schwartz, & Vinicky, 2001; Deville & Hassler, 2001)

3. Make sure that the professionally powerful voices, for example physicians and lawyers do not override the other committee members’ opinions. DeVille & Hassler (2001) note that when lawyer members of HECs speak, other members may not feel any further discussion is needed. HECs might consider the technique of the military where some military tribunals vote in reverse order of seniority.

4. Consider the pooled opinion technique described by Surowiecki (2004) in the Wisdom of Crowds. Within the HEC meetings opinions might first be gathered on a paper ballot allowing each voice to be heard as an individual before pooling. As Surowieki (2004) notes no one expert is consistently right and pooled opinions are on average better than the individual.

5. Require ethics training for all members (Wilson, 2002). Exposure to the techniques of ethical analysis gives a common frame of reference for all committee members.

6. All information provided to HECs should be adequate in volume and organized in such a manner as to be interpretable by the committee. Clinical evidence should follow standard guidelines and reflect the best evidence available. Decisions should occur only after all relevant information is considered. However, committees should be aware that more information may not be better; it may only increase error (Kosko, 1993).

Note: The references are listed in the full article.

If any of my visitors here are associated with hospital ethics committees, posting their comments here on this article is most encouraged. Of course, others are encouraged to write too! ..Maurice.

Physicians Making Decisions for Unconscious Patients Without Family, Friends or Surrogates (4): Options

So what are the options available when the physician is faced with such a dilemma? An obvious one might be that the physician holds him/herself as the surrogate decision-maker. After all, in a number of these patients such as those elderly with no family who have been attended by the same physician in a nursing home for many years, the physician has had a chance to observe and talk with the patient and may have the best understanding of anyone with regard to the patient’s values and wishes. The physician also more clearly understands the science and rationale for therapy than someone else and finally the physician has a professional duty for providing only beneficence or “good” to his/her patient. On the other hand, it has been argued that the treating physician as surrogate may have no oversight by others regarding the decisions he/she is making in the patient’s name. This could be important if there is any conflict of interest, often financial. For example, the value to the physician or others to continue to treat or overtreat the patient in a fee-for-service environment or to undertreat under managed care. Finally, the physician could be reflecting his/her own values and not play the usual role of providing to the patient or family an objective evaluation of their decisions. In California, as I assume elsewhere, a treating physician cannot be named as a legal surrogate by the patient in an advance directive.



Another option would be court directed. In all states in the U.S., the court can be petitioned to appoint a conservator to make healthcare decisions for patients who are incompetent. Usually, the court appoints a public guardian when patient related individuals are absent. The problem with a public guardian is that the system is usually under-funded and they often have a huge load of clients about whom they know little and certainly cannot follow their clinical courses on a frequent basis. Because of inadequate training in medical decision-making and end-of-life care, many guardians when faced with a significant decision in starting or withholding treatment will resist and delay while consulting with a judge who has never seen the patient.



Finally, options that have been considered but still have not received uniform consensus in the bioethics or legal community of the United States involves the hospital ethics committees. One suggestion would be to assign the hospital ethics committee as surrogate decision maker for these unconscious patients without family or friends. An argument in favor would be that there are a multitude of voices on the committee with a potential variety of views including, hopefully, views from the community and that the patient’s “best interest” decision would be most reliable based on a consensus of this group. However, this role for an ethics committee would be very unusual since the committee’s function is for ethical and legal education, mitigation of conflicts and dispute resolution and not for making clinical decisions for patients. Many if not most of the committees would not accept a role of clinical decision-making.



So what is left? : A vague combination of the treating physician consulting with the hospital ethics committee before starting or withdrawing treatment. The ethics committee’s responsibility would be to assure that there are no family, friends or other potential surrogates which are present but unknown to the physician. The committee would then hear the clinical story and treatment issue from the physicians and other healthcare staff. Then the committee would, along with the physician, try to come to some consensus regarding the law, ethics, conflicts of interest and “patient’s best interest”. If all were in agreement then the committee would simply approve the decision and action by the physician. In issues involving standards of medical practice, appropriate senior medical staff or consultants may be called in. If there is no agreement between committee and physician, there is always, unfortunately, the court system. By this approach, though it is the treating physician who is making the final medical decision, the ethics committee is providing the oversight to ensure that the decision is legal and ethical. Any comments? ..Maurice.

Physicians Making Decisions for Unconscious Patients Without Family, Friends or Surrogates (3): Disorders of Consciousness

In order to better understand the decision-making issue, I have, in the previous posting, described the hospital ethics committee form and function since the committee could be involved in the process. Another element of the issue to understand is a current description and definition of the various disorders of consciousness that determine the conclusion that the patient is incompetent to participate in his or her decision-making. Also the prognosis of the specific disorder may well affect the decision made by others.



The following Glossary of Disorders of Consciousness is taken from the “State Initiatives in End of Life Care” Oct. 2004, Issue 22 published by Center for Practical Bioethics

Brain Death: The permanent absence of all brain functions, including those of the brain stem (which controls basic function like reflexes and breathing).

Coma: Patients in coma lack both wakefulness and awareness. Comas are typically transient: patients recover, die or evolve in some other state of impaired consciousness.

Vegetative States: The Multi-Society Task Force on Persistent Vegetative State (PVS), which included representatives from many of America’s most prestigious neurology associations, has defined the vegetative state as a condition of complete unawareness of self and environment, accompanied by sleep-wake cycles and either total or partial preservation of areas of the brain controlling automatic functions like heart activity and reflexes. PVS patients may cry or smile but these actions are reflexive and do not reflect true awareness.

“Persistent” versus “Permanent” Vegetative States: A vegetative state is considered “persistent” after one month. Vegetative states are considered “permanent” after one year if caused by traumatic injuries such as a blow to the head; non-traumatic vegetative states caused, for example, by oxygen deprivation to the brain are considered permanent after three months. Guidelines for children differ.

Minimally Conscious States: Patients in minimally conscious states posses sleep-wake cycles and limited, inconsistent but definite awareness of self and environment (e.g., avoiding unpleasant stimuli, uttering intelligible sounds or reaching for objects in a way that adjusts for their size and location).

Dementia: A degenerative neurological disorder characterized by progressive loss of all cognitive functions with some arousal mechanisms remaining normal. Patients with advanced dementia who lose self-awareness and learned behavior often evolve into minimally conscious states and,at times,into vegetative states.

It should be emphasized that in the case of brain death, the patient is by law considered dead and there are no treatment decisions to be made.

Coma, if produced by administration of CNS depressants as well as various metabolic causes, can be fully reversible.

The “minimally conscious state” is a more recent diagnostic entity and there is still professional controversy about this diagnosis.

Now we will go on to consider possible approaches to the ethical issue of Physicians Making Decisions for Unconscious Patients Without Family, Friends or Surrogates. ..Maurice.

Physicians Making Decisions for Unconscious Patients Without Family, Friends or Surrogates (2): Hospital Ethics Committees

Before going into the alternative approaches which has been suggested regarding dealing with the issue of treatment decisions of the unconscious patient who has no family, friends or surrogates and which would involve the hospital ethics committee, I would like to describe the history, composition and functions of those committees.



Hospital ethics committees began to be formed over 20 years ago as a need to consolidate the committees which had been created earlier to select patients for hospital renal dialysis, for abortion review and federally required review of the care given to critically ill infants. Actually, in the 1960s, US Catholic hospitals first created committees for the Discussion of Morals in Medicine.

The concerns about end-of-life issues triggered by the legal decision in the Quinlan case gave further motivation to create ethics committees.

Today, hospital ethics committees or some equivalent are required by JCAHO, a hospital certifying organization, as part of the goal to assure that the ethical concerns of patients are considered.



Although the committee will vary in size and composition depending on each hospital’s policy, there are usually about 20 or so members. The disciplines represented on the committee usually consist of physicians, nurses, spiritual care, social service, representative of staff departments such a respiratory care, members of the administration and, strongly encouraged is the presence of representatives of the community, not affiliated with hospital affairs. There also may be a professional ethicist present as well as a hospital lawyer. It may be true that many ethics committees do not really have multi-racial or multi-cultural members or members who are themselves or represent the disabled..



The function of the ethics committee is to educate its own members, the medical and nursing staff and the community about the ethics and law of various issues that arise in patient care. The committee also is involved in the offering and writing of policies and procedures dealing with activities involving clinical ethics. A very important role of the ethics committee is to provide for patients, families, physicians, nurses and any other hospital staff a resource for help in resolution of conflicts involving ethical issues. The ethics committee serves as an educator and mediator to help facilitate the resolutions of those conflicts. The hospital ethics committee cannot and will not make clinical decisions, which bear on standards of medical care. The committee is interested and considers aspects of care in which established standards of ethics are related. But hospital ethics committees do not act as “ethics police”. Most ethics committees only attend to cases in which some stakeholder has invited the committee.



With this brief description, we will shortly return to discussing the unconscious patient. ..Maurice.

Physicians Making Decisions for Unconscious Patients Without Family, Friends or Surrogates (1): The Issue

What is in the patient’s best interest is a major and frequently encountered issue in medical ethics. A conscious patient can very likely be able to tell the physician what are their values, goals and wishes with respect to their lives. An unconscious patient obviously can’t. However, if there are family and friends or legal surrogate of an unconscious patient available to communicate with the physician, they may be able to relate what they knew about the patient in this regard. But what if there are no family or friends or legal surrogate and there is no record by the patient that tells about his/her desires, how does the doctor really know what treatment or termination of what treatment would be accepted by the patient if he/she was conscious? Examples of such patients could include “street people” or often nursing home patients whom haven’t been visited by a relative in many years and/or whose location is unknown.. Without the ability to obtain informed consent, the physician has a problem that even or particularly in these days of “high-powered” medicine where so much more is known about disease and treatment, there is very little help. As I have been mentioning in the previous postings, “patient’s best interest” has a number of connotations. One definition that is used in cases of an unconscious patient without a surrogate or an advance directive, either of which can shed some light on patient desires, is “what an average or ordinary person might decide is in his/her best interest.” And how do we know what an average or ordinary person might decide? Well, it ends up being the opinion of those making the decision for the patient!



And here is the ethical dilemma that faces virtually all hospitals and their medical staffs, what is the fairest and most ethical and legal way for a physician to start treatment or terminate treatment in such an unconscious patient? It should be noted that in an emergency where a person’s life might be at stake and the patient is not able to communicate, physicians have the right and duty to do what is necessary to preserve life even without informed consent. But what if the situation is not emergent? What if the situation is a patient in whom the physicians on the case find that further treatment will not accomplish the medical benefit or that it wouldn’t provide the quality of life that an average person might expect? What should the physician do? This is the area of ethics in medicine in which most hospitals are still contemplating and trying to figure out guidelines to help their physicians. What are your views on how to solve this problem? ..Maurice.

Physician Wearing Two Hats and Patient's Best Interest (2)

Another important example of the kind of potential conflict of interest which can occur is written by Steven H. Berger, M.D. in the Psychiatric Times June 1998 Vol. XV Issue 6. It deals with the issue of ethics in forensic psychiatry. This excerpt describes the situations in which the conflict can occur.

"Dual agency also occurs when: 1) A company psychiatrist owes a treatment duty to his patient-an employee of the same company-and a simultaneous obligation to the company to return the patient to work immediately; 2) a military psychiatrist owes a treatment duty to his enlisted patient and a simultaneous duty to the military to maintain security; 3) a jail psychiatrist owes a treatment duty to his inmate patient (who is awaiting his trial) and a simultaneous duty to the state to get a confession from the inmate; 4) a state-employed psychiatrist owes a duty to the best interest of his death row patient and a simultaneous job assignment to get the execution done. Clearly, the two roles of the psychiatrist in these examples conflict with each other."

To read more about this example of a physician wearing "two hats" go to this link to read the entire article

..Maurice.

Physician Wearing Two Hats and Patient’s Best Interest

The doctor’s duty, by law, to report to authorities evidence which may be related to criminality in the patient history such as gunshot or stab wounds or other trauma or alcohol or drug blood levels is an example of a physician’s potential conflict of interest. This conflict can deny their professional goal of providing care that is in their patient’s best interest. The physician is faced with a decision of protecting his/her own self-interest by abiding by the law or following the professional ethical standards of patient confidentiality and attempting to ensure the patient’s best interest. But would the physician’s ignoring the longer-term psychosocial implications of the gunshot wound or drug level by treating the immediate problem be really in the patient’s best interest? (This again sets the question of the definition of “patient’s best interest”. Is it the goals, values and decisions of the patient or the perhaps paternalistic definition by the physician?)



One view of the work of physicians is that as part of the privileges that society has given to them is to be responsible not only to the patient but also to protect the health and safety of the greater community. The requirement of physicians to report to health officials communicable diseases is an example. Most physicians would probably not disagree with that duty. Reporting suspected child or elder abuse may pose difficulties at times since the physician may be unsure whether true abuse has really occurred and may worry about the consequences to innocents of his/her reporting.



There is, on the other hand, another view that the role of the physician as desired by society is one of healing the patient and not the simultaneous role of a policeman—“wearing of two hats”. Physicians are instructed by professional societies to avoid entering into situations where they may compromise their responsibility to the patient by the other role such as participating in the medical evaluation of prisoners scheduled for execution or in the execution process itself.



This posting provides an example of another conflict of interest that plagues physicians. I have noted others in previous postings and will likely describe others later. ..Maurice.

More on Patient's Best Interest or Is It the Physician's Interest?

As I implied in the previous posting, the physician does experience a conflict of interest when deciding what to do with his/her patient's request. Issues regarding denial of the request deal with concern about an "angry" or difficult or non-complient patient to manage in the future, loss of a patient to another physician, and finally malpractice suit by the patient or family for failure to diagnose or treat. Thus some physicians may feel it is really in their own best interest to agree to the patient or family's request. This has led, for example, in terminally ill patients,within intensive care units, apparent physician denial of the fact that the patient is dying and that any of the multitude of treatments and life-support being provided is futile with regard to any recovery. Full cardio-pulmonary resusitation in case of a cardiac arrest is continued despite the fact that this traumatic procedure usually does nothing than break ribs or may occasionally prolong the dying process. Often the physician may speak to his/her colleagues about a "no hope" prognosis but refuse to write this opinion in the chart or write orders appropriate for that prognosis. Interestingly, it is often the nursing staff who recognize the irrational decision-making by the physicians and bring the matter to hospital ethics committees for resolution. Extreme examples of the influence of family's requests to physicians and hospitals include those requests which have led to patients who are dead taken home by the family with ventilation machines working. In all these examples, whose interest is being served: family, physician, hospital?-- certainly not that of the patient. ..Maurice.

In the Patient’s Best Interest: But Within What Limits?

It is said that the physician has a fiduciary responsibility to the patient. This means that the doctor must keep the trust of the patient. In that regard, the patient retains a trust that the doctor will always be making decisions and caring for the patient in the “patient’s best interest”. This would meet the ethical requirement that the physician’s acts be consistent with beneficence to the patient. But what does “patient’s best interest” really include and should, indeed, there be limits to the extent of those professional actions?



One question might be: under what conditions, if any, should a physician consider a responsibility to the patient’s family, to other parties including society in general? Should the physician’s concern at the bedside be only for that ill person lying in the bed? How does the “patient’s best interest” actions conflict with professional standards of medical treatment, established laws, responsibilities of shepherding common resources especially if they are scarce in order to enable the ethical principle of justice in the distribution of those resources?



Is “patient’s best interest” to placate the patient to prevent unpleasant or even unhealthy emotional turmoil? Or is it an expression to emphasize the exclusion of actions of self-interest by the physician for his or her actions? Many questions—but, in practice, these issues abound. Take these common examples and decide for yourself how the physician should respond or act. The patient wants an antibiotic for a viral respiratory illness that has been shown not to be improved by antibiotic treatment. The patient wants a medical excuse from jury duty or wants the physician to authorize a disabled parking permit when none is medically indicated. The patient, surrogate or family request a test, treatment or life-support, perhaps to produce a miracle response, when any of these requests would be a medically futile action for the patient’s condition based on known scientific knowledge and standards of practice Would it be right to deny all these requests? Would “best interest” be satisfied by educating the patient about scientific facts, the law, about ethical behavior, about social demands and requirements?



How do physicians know what is in the patient’s “best interest” if they never did or were unable to ask the patient what were the patient’s own view about needs and goals? Or is “best interest” only something the physicians know? And if the physician knows and acts, should there be limits to that action? ..Maurice.

What Should Medical Students be Called--Revisited

This posting is a revisiting as an ethical issue of a situation in medical education which was first considered here on August 7, 2004 (scroll down this page if you want to read it.) The view today is written by a medical student herself for a class discussing ethical issues. Jennifer Piel is a second year medical student at the University of Southern California Keck School of Medicine. Jennifer will have any comments on her essay by visitors to this blog accessible to her. Thanks Jennifer for allowing me to post your words here. ..Maurice.

A problem that I have seen repeatedly at the hospital and in situations in community practice is the scenario in which a practicing physician introduces a medical student as a “doctor.” Addressed here are some of the ethical issues presented by the scenario.



Students Placed in Awkward Position



When a supervising physician introduces a medical student as a “doctor,” it places the student in an awkward position. Most likely, a physician makes these introductions to encourage trust between the student and patient. Nevertheless, it places the student in an uncomfortable position to correct the physician and inform the patient of the mistake.



Although the student should take responsibility to correct the statement of mistaken identity, it may be difficult for the student to confront his/her supervisor, particularly when the physician would feel that the student is undermining his/her authority or intentionally being confrontational. The student may be correct in recognizing an ethical conflict, but feel prevented from addressing the issue out of fear of reprisals from the physician.



Similarly, the student is placed in the difficult position of addressing the issue with the patient. Some students may fear that correcting the issue of mistaken identity will result with the patient refusing care by the student. However, even if some subset does refuse student care, many patients will likely be quite willing to allow appropriate student involvement in their care, In my opinion, the fact that some patients decline student care is no justification for deliberately misleading them.



Moreover, clarifying the mistake with the patient will likely preserve trust between patient and student, if the patient realizes that the student is trying to be honest and straight-forward.



Effect on Patient Decisions



When a medical student is introduced as a doctor, particularly when the student is going to be involved in the patient’s care, it prevents the patient from making informed health care decisions. Not only does this scenario present ethical concerns, but legal concerns as well.



The first issue here involves the student holding himself/herself out as a physician. To respect patient decision-making autonomy, there should be a free exchange of material information between the patient and student. Autonomy is a key ethical consideration, focusing on the right of self-determination. It is grounded in the idea that patients should have control over their personal decisions. Accordingly, it is appropriate to disclose to the patient that the physician-in-training is, in fact, a student.



It may be argued that the principle of beneficence should be the key ethical consideration in situations involving medical care. The principle of beneficence commands that benefits to individuals and society be maximized and that harms be minimized. Under this principle, one could argue that it is in the patient’s best interest to identify the student as a physician because, then, the patient is not burdened with potentially troubling information. Some patients are likely to consent to student care, but subsequently feel uncomfortable with the student’s level of knowledge or skill. This argument begs the conclusion that, because the patient would have consented to the student care, the patient is subject to less harm when the student’s true identity is withheld.



A number of flaws exist with this latter line of reasoning. To begin with, it is naïve to suggest that we could benefit a patient by withholding relevant information. Patients would likely prefer that their health care professionals are honest with them. As mentioned above, the patient may justifiably feel disrespected. This could cause the patient to mistrust other members of the hospital’s staff. Additionally, to even minimally respect a patient’s autonomy, health care providers should give the patient the option to refuse care. Even patients that would consent to student care should be asked.



In situations where a student is held out as a doctor, a second issue concerning the patient’s decision-making is brought into question. In this situation, the patient will not know to ask, nor be informed, whether the procedure or care in question is ordinarily provided by a student. Like the failure to disclose the student’s true identity, failure to adequately provide the patient with this information inhibits the patient from making a fully-reasoned decision. It could be that the patient would have agreed to the student performing the procedure, subject to certain conditions, such as an experienced physician being present or that the procedure be conducted in a particular manner. Alternatively, the patient might have agreed to student participation, but, upon hearing that a particular procedure is not a routine responsibility of medical students, decide that he rather have a physician perform the procedure after all. This illustrates the situation where the patient is unaware that the student’s competency is even a question to consider.



In terms of the law surrounding informed consent, physicians have a duty to disclose and ensure that patients understand all information material to the patient’s decision to undergo or deny particular medical attention. A physician who fails to fulfill these requirements may face liability under a simple negligence theory. Further, medical personnel who perform medical procedures without gaining proper consent may be liable for civil battery. Although courts disagree as to whether informed consent cases should be evaluated from a patient-oriented or physician-oriented approach, it is risky in either case to mislead a patient about the identity and skill-level of an individual treating the patient. This information is likely material.



Facilitating the Unauthorized Practice of Medicine



As a society, we have established regulations to prohibit non-physicians from practicing as doctors. We do this to protect the public from incompetent or unethical performance of medical services. It further serves to protect the integrity of the medical profession. Because patients often cannot distinguish between their doctors, medical students, and other health care personnel, it seems imperative that providers make specific efforts to minimize any confusion.



Although students practicing under the supervision of a licensed physician are generally protected from claims of unauthorized practice of medicine, this may not hold true where a student holds himself/herself out as a physician and/or the student is not adequately supervised. A physician may not delegate ultimate responsibility for providing medical care to an assistant. Such delegation is appropriate only when it is consistent with the assistant’s training and education.



The legal case of Oliver v. Sadler (Jury Verdicts Weekly, Oct. 7, 1994) involves a similar situation to the illustration presented here. In that case, a patient was seen by a physician assistant. When the treatment proved harmful, the patient sued Dr. Sadler, in part, because he misrepresented his physician assistant as a physician. It was argued that the patient assumed the physician assistant was a doctor because he wore a white coat and had a stethoscope. This presents the very picture of medical student and underscores the need to accurately identify for the patient the individuals who are involved in the patient’s care. Isn’t it unethical to foster patient confusion?



This essay highlights some of the ethical issues faced when a student is introduced to a patient as a “doctor.” It is unrealistic to expect that this situation will never again occur. Accordingly, it is advised that students and their supervising physicians speak openly about the student’s status, role, and responsibilities before being introduced to a patient.

"Medical Miracle" and the Other Side of the Coin

To present a different view regarding the question "what is a medical miracle?", I have extracted a small portion of a paper written by Boguslaw Lipinski, Ph.D., D.Sc. and to be found at the Faith and Culture website. Go there to read the entire paper titled "Christian Roots of Western Medicine" Also it would be most interesting to read what my visitors to this blog have to say about medical miracles. So.. comment! ..Maurice.

What is a medical miracle? There is a religious meaning, a lay meaning,

and what we shall call a scientific meaning. We define a scientific miracle an

event that has an extremely low probability of occurring. Such miracles are well

known in medicine, but generally physicians call them spontaneous remissions.

Scientific, or medical, miracles do not need any explanation: their occurrence is

explained by statistical probabilities. In other words, miracles - in our scientific

sense of the word - are definitely part of scientific thinking. (Berry RJ: “What to

believe about miracles.” Nature, 1986;322:321-322.)

In 1984 fourteen signatories, all of them professors of science in British

universities, submitted a letter to the Times about miracles (The Times, 13 July

1984). They asserted that:" It is not logically valid to use science as an argument

against miracles. To believe that miracles cannot happen is as much an act of

faith as to believe that they can happen. We gladly accept the virgin birth, the

Gospel miracles, and the resurrection of Christ as historical events. Whatever

the current fashions in philosophy or the revelations of opinion polls may

suggest, it is important to affirm that science can have nothing to say on the

subject. Its 'laws' are only generalizations of our experience." The authors have

exposed the fallacy of Hume's attack on miracles based on an assumption that

events have only a single cause and can be explained if the cause is known. "

This is logically wrong. For example, an oil painting can be 'explained' in terms

either of the distribution of pigments or the intention and design of the artist. In

the same way, a miracle may be the work of (say) a divine up -holder of the

physical world rather than a false observation or unknown cause. The authors

quote Medawar (Medawar P. The Limits of Science. [Harper&Row, New York,

1984]) who said: " There is then a prima facie case for the existence of a limit to

scientific understanding." Most of our anxieties, problems and unhappiness

today stem from a lack of purpose which were rare a century ago and which can

fairly be blamed on the consequences of scientific inquiry.

A Miracle Drug for an Advertising Generated Condition?

Could this be an example of a drug company advertising a miracle drug to be used for a condition which the advertising itself generates by its advertising to normal adults? Maybe. If you didn't watch CBS 60 Minutes tonight, here is the link to the full text and an introductory excerpt is copied below. ..Maurice.

(CBS) The use of drugs to treat children who are disruptive or inattentive in school -- children with attention deficit disorder (ADD) -- has been highly controversial for decades.



The assumption was that with treatment, kids with ADD outgrew the condition. But as Correspondent Morley Safer reports, the disorder isn't just for kids any more.



Adult ADD has created a whole new market for the drug industry, which claims that 8 million American adults now have this mental illness.



And at least one drug maker claims that a simple six-question quiz can give a strong indication whether an adult has ADD or not. Are you impulsive, restless, indecisive? Adult ADD is quickly becoming the disease du jour.

Medical Miracles or Misguided Media?

Continuing with the topic of blurring the line between medicine and "miracles", here is a link to a great analysis by Los Angeles Times Staff Writer David Shaw on how the media is, to the detriment of the public, blurring the line. ..Maurice.

Medical Miracles or Misguided Media?: "Science is both a methodical and a somewhat messy process, a gradual exploration of the unknown. It moves slowly, with each study building on the one before it--brick by brick by brick. Most discoveries are partial improvements, steps forward (or backward), subtle gradations and even contradictions. There's seldom a true end point in science. Almost invariably, the breakthrough that's published today is the final stage in a series of studies that began years, perhaps decades ago, and it, too, may still be subject to revision by future studies. Genuine breakthroughs, giant leaps forward--penicillin, for example, or the Salk polio vaccine--are rare."

Ad Tagline:"Blurring the Line Between Medicine and Miracles"

I know of a current advertising campaign to the public for a multi-specialty professional medical group to emphasize the uniqueness of the group from other groups. The tagline for the advertisements is: “Blurring the line between medicine and miracles”



Here is my opinion about the use of such a tagline. Though this may be thought as a "goodheaded" slogan from an advertising point of view, I find this tagline as misleading and ethically wrong. It simply adds irrational support to the confused idea that there really may be a relationship between medical practice and what many

define as "miracles". It sets up a concept about medical care which could in the

end lead to degrading attempts at patient beneficence, non-malificence and

justice for patients in general. Many of the conflicts brought to the ethics

committee have to do with confusion in the mind of patients and family about the

limits of medicine. Often, families want more diagnostic tests, treatment

and continued life-support in search of the "miracle".



Miracles to me are very rare medically unexpected and scientifically unclear

good-fortune. Doctors are not "miracle-workers". Hope is important as

presented to the patient and family but at some point physicians must be realistic

in their presentation as to what they can accomplish. Though it is likely that the physicians of the multi-specialty clinic deserve recognition of excellence, nevertheless the line between medicine

and miracles should be kept bright and clear and blurring should be avoided.



Do you think that miracles should not be looked upon as a medical result but due to something else, perhaps of spiritual origin? ..Maurice.

The Blogs of Two Beginning Physicians

I have found two blog sites which seem to complement what I have been writing about in the past few months. One is Chronicles of a Medical Mad House which is written by a medical resident in a city hospital and deals with his experiences there. The other is The Examining Room of Dr. Charles who is apparently a general physician who has just finished his residency and is starting up his new office practice. This blog also deals with the physician's trials and tribulations. They both appear to be worthy to link into. ..Maurice.

Breaking the Doctor-Patient Relationship: The Suing Patient

I would like to bring up an issue for discussion that has to do with a breakdown in the doctor-patient relationship. What should happen to the relationship if the patient initiates a malpractice suit against the doctor or the medical clinic and yet apparently has not terminated the professional relationship? This event has happened in the past. What could be the consequences if the relationship was to continue? Would each party have sufficient trust in the other to make the doctor-patient interaction therapeutically effective?



In a San Diego, CA case Scripps Clinic v. Superior Court (Thompson) (2003), Cal.App.4th [No.D040569. Fourth Dist., Div. One. April. 17, 2003], a physician-group practice rationalized the decision to transfer the patient to another clinic by arguing that a physician having received an intent to sue letter "irreparably compromises the physician-patient relationship, thereby potentially compromising the care rendered to the patient. Patient litigants might not be as forthcoming for fear that evidence or information would be used in their lawsuit. Further, patients may also believe that their physicians will not give them balancedcare...for example, they might believe that a physician who does not timely return a telephone call is punishing the patient." (Thanks to Lance K Stell, PhD, FACFE, Charles A. Dana Professor of Philosophy, Director, Medical Humanities Program, Davidson College, PO Box 7135,Davidson, NC 28036 for the reference.) Does the physician or clinic at this point have the right to decide not to continue treating the patient and transfer the patient to another physician or clinic, if the patient’s medical condition allows the patient to be safely transferred? What if the patient lives in a geographic area where transportation to another caregiver would be lengthy and inconvenient?



It is my understanding that as the patient has the legal right to sue and the physician or clinic has the legal right not to accept a patient except in an emergency and a right to terminate care, not to abandon the patient but transfer the patient safely to another equivalent healthcare provider. But in this particular situation what is your opinion? ..Maurice.

Possible Conflict of Interest:Doctors Selling Products and Owning Stock

As a segue from complementary and alternative medicine, consider the physician selling to the patient, out of the office, potions and lotions of alternative medicine which may have equivocal efficacy. Consider, the physician selling pharmaceuticals which have proven benefit or other products which may also be found in drug stores. What do these action do to the doctor-patient relationship? If a doctor prescribes but also sells to the patient a medication, can the patient be sure that the doctor's prescription was not based on the doctor's self-interest rather than the interest of the patient? Would a cheaper medication that the doctor was not dispensing be equally as effective? Some have equated this action as equivalent to a physician referring the patient to a lab or X-ray facility of which the physician had financial interest. Are these behaviors on the part of the physician ethical?

One can also extend the ethical concerns to physicians who own stock in certain pharmaceutical companies or have been treated to some benefit by a pharmaceutical company. Should patients consider that the physician might be prescribing a particular brand of medicine because of this influence? Should each patient be made aware at the outset of all potential conflicts of interest that their physician bears? Or should the patient always assume that a physician's interest is always in the patient? Please write me your comments on this issue.



As a resource to learn more about the issue of the physician selling products from his or her office, read the position paper representing the Ethics and Human Rights Committee of the American College of Physicians titled "Selling Products Out of the Office" by

Gail J. Povar, MD and Lois Snyder, JD, for the Ethics and Human Rights Committee, Annals of Internal Medicine, 7 December 1999 | Volume 131 Issue 11 | Pages 863-864. Here is an abstract of that paper. ..Maurice.

The sale of products from the physician’s office raises several ethical issues and may affect the trust necessary to sustain the patient-physician relationship. When deciding whether to sell products out of the office and, if so, which ones, physicians should carefully consider such criteria as the urgency of the patient’s need, the clinical relevance to the patient’s condition, the adequacy of evidence to support use of the product, and geographic and time constraints for the patient in otherwise obtaining the product. Physicians should make full disclosure about their financial interests in selling the product and inform patients about alternatives for purchasing the product. Charges for products sold through the office should be limited to the reasonable costs

incurred in making them available.

Medical Ethics of Complementary and Alternative Medicine (6)

I am going to leave the issue of the ethics of CAM now.. but I do want to refer those who want to continue this thread to another blog, Complementary and Alternative Medicine Law Blog. This blog is devoted to CAM and presents news items and discussions of the legal implications as well as the ethical and many other aspects of CAM practice. You should find the site rewarding as another resource. ..Maurice.

Medical Ethics of Complementary and Alternative Medicine (5)

In order to best understand the benefits found in the use of the various modalities of alternative medicine, evidence-based conclusions need to be presented. These conclusions are based on careful review of as many research projects available in the literature done to look for benefits of a particular modality for a particular disease or disorder. The reviewer must be able to establish that the research trial was devised to meet scientific criteria and attempt to find statistically significant data. These projects are then compared and together, a conclusion about benefits as well as harms can be established. This review then becomes the basis for rational use of the alternative medicine modality in the specific disease.



There is a developing web-site that has begun such a review of CAM studies. It is called "Complementary and Alternate Medicine" and is an evidence-based resource from New Zealand about complementary and alternative medicine. Recently completed reviews include Arnica creams, gels and sprays for the treatment of soft tissue injury; Cranberry for the prevention of urinary tract infection; Acupuncture for smoking cessation; Horse chestnut seed extract for the treatment of chronic venous insufficiency; and Garlic for the treatment of calf pain when walking. The results are summarized and a conclusion is given. A description of the modality and a description of the medical condition is also given for visitor education.

The URL for this important resource is http://www.cam.org.nz

..Maurice.

Medical Ethics of Complementary and Alternative Medicine (4)

My view of complementary and alternative medicine is that the practice should be more complementary than alternative. What I mean is that I think that the very best treatment for the patient, if alternative treatment is considered, should be a carefully orchestrated combination of both alternative and conventional standard medicine with practitioners of both disciplines working together. There is no doubt that alternative medicine has something to offer patients. For one example is the attention that the alternative practitioner provides to the patient. There is something important provided to the patient with the “listening to the patient” by the chiropractor and others in alternative medicine or the “laying on of hands” by the chiropractor or those practicing “therapeutic touch.” Medical doctors are often criticized for such deficiencies in terms of their brief history taking and their perfunctory physical examinations.



With regard to the therapeutic benefits of the techniques or substances administered, there is certainly the possibility that they provide a benefit through the so-called “placebo” effect. This effect would not involve a direct physical or pharmacologic action but produce benefit indirectly through unknown or psychologic or behavioral mechanisms. Direct benefits must be proven by research studies.



What are the ethical implications of alternative medicine as integrated into conventional medicine? I agree with much of the concerns and conclusions written in the articles of the previous two postings. With regard to establishing a benefit beyond a placebo effect, many of the techniques or substances could be subjected to controlled studies with care taken to provide the same informed consent and protection to the subjects as research studies done in conventional medicine. When alternative medicine is used with conventional medical treatment, the orchestration mentioned above should include care that the patient is not harmed or burdened by either method, that the interference of the methods be minimized and that the patient should be informed about the all the risks and known benefits. There will be cases where conventional medicine has reached a dead end in terms of specific therapy for the illness. This is where conventional medicine must reach out with comfort care to the patient and not simply abandon the patient to alternative medicine. The medical doctor should not extinguish the little flame of “hope” which the patient holds but still be realistic in talking to the patient and support the patient if the patient wishes to try alternative medicine as long as this is part of a program of comfort care for which the medical doctor is managing.



As you see,in this posting,I am supporting the view of the patient always engaging in complementary medicine rather than going out and obtaining alternative medicine on their own. My rationale is that diseases are based on anatomical,physiologic,psychologic,biologic,pharmacologic,biochemical and physical principles and the practitioners who have the best education for treating diseases are the medical doctors (or modern osteopaths)and therefore they should never remain outside the care of the patient.You may hold a different view and I certainly would like to hear from you. Please write your comments on this subject. ..Maurice.

Medical Ethics of Complementary and Alternative Medicine (3)

JAMA -- Abstract: Ethical Issues Concerning Research in Complementary and Alternative Medicine, Franklin G. Miller, PhD; Ezekiel J. Emanuel, MD; Donald L. Rosenstein, MD; Stephen E. Straus, MD



JAMA. 2004;291:599-604.



The use of complementary and alternative medicine (CAM) has grown dramatically in recent years, as has research on the safety and efficacy of CAM treatments. Minimal attention, however, has been devoted to the ethical issues relating to research on CAM. We argue that public health and safety demand rigorous research evaluating CAM therapies, research on CAM should adhere to the same ethical requirements for all clinical research, and randomized, placebo-controlled clinical trials should be used for assessing the efficacy of CAM treatments whenever feasible and ethically justifiable. In addition, we explore the legitimacy of providing CAM and conventional therapies that have been demonstrated to be effective only by virtue of the placebo effect.

Medical Ethics of Complementary and Alternative Medicine (2)

An issue which can be raised regarding complementary and alternative medicine is whether the physician’s advice to patients encouraging use of the modalities involved and their use is indeed ethical. Adams, Cohen, Eisenberg and Jonsen writing in the Annals of Internal Medicine present some criteria which if considered may pave the way to ethical use in appropriate patients. The following is the abstract from the Annals article. ..Maurice.

From the Annals of Internal Medicine, 15 October 2002 | Volume 137 Issue 8 | Pages 660-664



Ethical Considerations of Complementary and Alternative Medical Therapies in Conventional Medical Settings



Karen E. Adams, MD; Michael H. Cohen, JD, MBA, MFA; David Eisenberg, MD; and Albert R. Jonsen, PhD





Increasing use of complementary and alternative medical (CAM) therapies by patients, health care providers, and institutions has made it imperative that physicians consider their ethical obligations when recommending, tolerating, or proscribing these therapies. The authors present a risk–benefit framework that can be applied to determine the appropriateness of using CAM therapies in various clinical scenarios. The major relevant issues are the severity and acuteness of illness; the curability of the illness by conventional forms of treatment; the degree of invasiveness, associated toxicities, and side effects of the conventional treatment; the availability and quality of evidence of utility and safety of the desired CAM treatment; the level of understanding of risks and benefits of the CAM treatment combined with the patient’s knowing and voluntary acceptance of those risks; and the patient’s persistence of intention to use CAM therapies. Even in the absence of scientific evidence for CAM therapies, by considering these relevant issues, providers can formulate a plan that is clinically sound, ethically appropriate, and targeted to the unique circumstances of individual patients. Physicians are encouraged to remain engaged in problem-solving with their patients and to attempt to elucidate and clarify the patient’s core values and beliefs when counseling about CAM therapies.

Medical Ethics of Complementary and Alternative Medicine (1)

To begin this topic, first we should understand what is complementary and alternative medicine (CAM) and how it has been applied to treat patients including its use along with conventional medicine. To help explain CAM, the following is an informational fact sheet publication by the U.S. National Institutes of Health. (Please note that in this post, the URL resources listed have not been linked.) I will be presenting the ethical issues of CAM in later postings. ..Maurice.

What Is Complementary and Alternative Medicine (CAM)?



On this page:



* What is complementary and alternative medicine?

* Are complementary medicine and alternative medicine different from each other?

* What is integrative medicine?

* What are the major types of complementary and alternative medicine?

* What is NCCAM's role in the field of CAM?

* Definitions





There are many terms used to describe approaches to health care that are outside the realm of conventional medicine as practiced in the United States. This fact sheet explains how the National Center for Complementary and Alternative Medicine (NCCAM), a component of the National Institutes of Health, defines some of the key terms used in the field of complementary and alternative medicine (CAM).[These definitions are found at the bottom of this fact sheet.]



What is complementary and alternative medicine?



Complementary and alternative medicine, as defined by NCCAM, is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.1,2 While some scientific evidence exists regarding some CAM therapies, for most there are key questions that are yet to be answered through well-designed scientific studies--questions such as whether these therapies are safe and whether they work for the diseases or medical conditions for which they are used.



The list of what is considered to be CAM changes continually, as those therapies that are proven to be safe and effective become adopted into conventional health care and as new approaches to health care emerge.





Are complementary medicine and alternative medicine different from each other?



Yes, they are different.



* Complementary medicine is used together with conventional medicine. An example of a complementary therapy is using aromatherapy to help lessen a patient's discomfort following surgery.



* Alternative medicine is used in place of conventional medicine. An example of an alternative therapy is using a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional doctor.





What is integrative medicine?

Integrative medicine, as defined by NCCAM, combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness.





What are the major types of complementary and alternative medicine?



NCCAM classifies CAM therapies into five categories, or domains:



1. Alternative Medical Systems



Alternative medical systems are built upon complete systems of theory and practice. Often, these systems have evolved apart from and earlier than the conventional medical approach used in the United States. Examples of alternative medical systems that have developed in Western cultures include homeopathic medicine and naturopathic medicine. Examples of systems that have developed in non-Western cultures include traditional Chinese medicine and Ayurveda.



2. Mind-Body Interventions



Mind-body medicine uses a variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms. Some techniques that were considered CAM in the past have become mainstream (for example, patient support groups and cognitive-behavioral therapy). Other mind-body techniques are still considered CAM, including meditation, prayer, mental healing, and therapies that use creative outlets such as art, music, or dance.



3. Biologically Based Therapies



Biologically based therapies in CAM use substances found in nature, such as herbs, foods, and vitamins. Some examples include dietary supplements,3 herbal products, and the use of other so-called natural but as yet scientifically unproven therapies (for example, using shark cartilage to treat cancer).



4. Manipulative and Body-Based Methods



Manipulative and body-based methods in CAM are based on manipulation and/or movement of one or more parts of the body. Some examples include chiropractic or osteopathic manipulation, and massage.



5. Energy Therapies



Energy therapies involve the use of energy fields. They are of two types:



* Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. The existence of such fields has not yet been scientifically proven. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Examples include qi gong, Reiki, and Therapeutic Touch.



* Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields.





What is NCCAM's role in the field of CAM?



NCCAM is the Federal Government's lead agency for scientific research on CAM. NCCAM is dedicated to exploring complementary and alternative healing practices in the context of rigorous science, training CAM researchers, and disseminating authoritative information to the public and professionals.







Notes



1 Conventional medicine is medicine as practiced by holders of M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees and by their allied health professionals, such as physical therapists, psychologists, and registered nurses. Other terms for conventional medicine include allopathy; Western, mainstream, orthodox, and regular medicine; and biomedicine. Some conventional medical practitioners are also practitioners of CAM.



2 Other terms for complementary and alternative medicine include unconventional, non-conventional, unproven, and irregular medicine or health care.



3 Some uses of dietary supplements have been incorporated into conventional medicine. For example, scientists have found that folic acid prevents certain birth defects and that a regimen of vitamins and zinc can slow the progression of an eye disease called age-related macular degeneration (AMD).



Definitions



Acupuncture ("AK-yoo-pungk-cher") is a method of healing developed in China at least 2,000 years ago. Today, acupuncture describes a family of procedures involving stimulation of anatomical points on the body by a variety of techniques. American practices of acupuncture incorporate medical traditions from China, Japan, Korea, and other countries. The acupuncture technique that has been most studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation.



Aromatherapy ("ah-roam-uh-THER-ah-py"): involves the use of essential oils (extracts or essences) from flowers, herbs, and trees to promote health and well-being.



Ayurveda ("ah-yur-VAY-dah") is a CAM alternative medical system that has been practiced primarily in the Indian subcontinent for 5,000 years. Ayurveda includes diet and herbal remedies and emphasizes the use of body, mind, and spirit in disease prevention and treatment.



Chiropractic ("kie-roh-PRAC-tic") is a CAM alternative medical system. It focuses on the relationship between bodily structure (primarily that of the spine) and function, and how that relationship affects the preservation and restoration of health. Chiropractors use manipulative therapy as an integral treatment tool.



Dietary supplements. Congress defined the term "dietary supplement" in the Dietary Supplement Health and Education Act (DSHEA) of 1994. A dietary supplement is a product (other than tobacco) taken by mouth that contains a "dietary ingredient" intended to supplement the diet. Dietary ingredients may include vitamins, minerals, herbs or other botanicals, amino acids, and substances such as enzymes, organ tissues, and metabolites. Dietary supplements come in many forms, including extracts, concentrates, tablets, capsules, gel caps, liquids, and powders. They have special requirements for labeling. Under DSHEA, dietary supplements are considered foods, not drugs.



Electromagnetic fields (EMFs, also called electric and magnetic fields) are invisible lines of force that surround all electrical devices. The Earth also produces EMFs; electric fields are produced when there is thunderstorm activity, and magnetic fields are believed to be produced by electric currents flowing at the Earth's core.



Homeopathic ("home-ee-oh-PATH-ic") medicine is a CAM alternative medical system. In homeopathic medicine, there is a belief that "like cures like," meaning that small, highly diluted quantities of medicinal substances are given to cure symptoms, when the same substances given at higher or more concentrated doses would actually cause those symptoms.



Massage ("muh-SAHJ") therapists manipulate muscle and connective tissue to enhance function of those tissues and promote relaxation and well-being.



Naturopathic ("nay-chur-o-PATH-ic") medicine, or naturopathy, is a CAM alternative medical system. Naturopathic medicine proposes that there is a healing power in the body that establishes, maintains, and restores health. Practitioners work with the patient with a goal of supporting this power, through treatments such as nutrition and lifestyle counseling, dietary supplements, medicinal plants, exercise, homeopathy, and treatments from traditional Chinese medicine.



Osteopathic ("ahs-tee-oh-PATH-ic") medicine is a form of conventional medicine that, in part, emphasizes diseases arising in the musculoskeletal system. There is an underlying belief that all of the body's systems work together, and disturbances in one system may affect function elsewhere in the body. Some osteopathic physicians practice osteopathic manipulation, a full-body system of hands-on techniques to alleviate pain, restore function, and promote health and well-being.



Qi gong ("chee-GUNG") is a component of traditional Chinese medicine that combines movement, meditation, and regulation of breathing to enhance the flow of qi (an ancient term given to what is believed to be vital energy) in the body, improve blood circulation, and enhance immune function.



Reiki ("RAY-kee") is a Japanese word representing Universal Life Energy. Reiki is based on the belief that when spiritual energy is channeled through a Reiki practitioner, the patient's spirit is healed, which in turn heals the physical body.



Therapeutic Touch is derived from an ancient technique called laying-on of hands. It is based on the premise that it is the healing force of the therapist that affects the patient's recovery; healing is promoted when the body's energies are in balance; and, by passing their hands over the patient, healers can identify energy imbalances.



Traditional Chinese medicine (TCM) is the current name for an ancient system of health care from China. TCM is based on a concept of balanced qi (pronounced "chee"), or vital energy, that is believed to flow throughout the body. Qi is proposed to regulate a person's spiritual, emotional, mental, and physical balance and to be influenced by the opposing forces of yin (negative energy) and yang (positive energy). Disease is proposed to result from the flow of qi being disrupted and yin and yang becoming imbalanced. Among the components of TCM are herbal and nutritional therapy, restorative physical exercises, meditation, acupuncture, and remedial massage.





For More Information



Sources of NCCAM Information



NCCAM Clearinghouse



Toll-free in the U.S.: 1-888-644-6226

International: 301-519-3153

TTY (for deaf and hard-of-hearing callers): 1-866-464-3615



E-mail: info@nccam.nih.gov

Web site: nccam.nih.gov

Address: NCCAM Clearinghouse, P.O. Box 7923, Gaithersburg, MD 20898-7923



Fax: 1-866-464-3616

Fax-on-Demand service: 1-888-644-6226



The NCCAM Clearinghouse provides information on CAM and on NCCAM. Servics include fact sheets, other publications, and searches of Federal databases of scientific and medical literature. The Clearinghouse does not provide medical advice, treatment recommendations, or referrals to practitioners.



Sources of Information on Dietary Supplements



Office of Dietary Supplements, NIH

Web site: ods.od.nih.gov

E-mail: ods@nih.gov



ODS supports research and disseminates research results on dietary supplements. It produces the International Bibliographic Information on Dietary Supplements (IBIDS) database on the Web, which contains abstracts of peer-reviewed scientific literature on dietary supplements.



U.S. Food and Drug Administration (FDA)

Center for Food Safety and Applied Nutrition

Web site: www.cfsan.fda.gov

Toll-free in the U.S.: 1-888-723-3366



Information includes "Tips for the Savvy Supplement User: Making Informed Decisions and Evaluating Information" (www.cfsan.fda.gov/~dms/ds-savvy.html) and updated safety information on supplements (www.cfsan.fda.gov/~dms/ds-warn.html). If you have experienced an adverse effect from a supplement, you can report it to the FDA's MedWatch program, which collects and monitors such information (1-800-FDA-1088 or www.fda.gov/medwatch).



This publication is not copyrighted and is in the public domain. Duplication is encouraged.



NCCAM has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your primary health care provider. We encourage you to discuss any decisions about treatment or care with your health care provider. The mention of any product, service, or therapy in this information is not an endorsement by NCCAM.



NCCAM Publication No. D156

May 2002

READ THIS:The Course of The Topics Here

I want to take a moment to explain to my new visitors what has been the direction of the topics here since I started the blog in July 2004. What I have written,provided excerpts and links to resources, is all about the various ethical issues that arrive from the doctor-patient relationship and the some of the issues in the general topic of medical professionalism. Starting with the first posting about the office visit (at the bottom of the Main Page), I have tried to develop each posting in some form of continuity. Soon, I will migrate to other bioethical issues. Please write me e-mail or as a comment to this posting about what issues in bioethics that you have concern and would like me to cover. Thank you.. Maurice.

E-Mail in Medical Practice: My View

There is not enough time spent in face to face communication between patient and physician in the doctor-patient relationship. So many of the conflicts, errors and misunderstandings in medical practice are clearly related to deficiencies in communication. Even telephone communication may be inadequate in certain clinical situations. With the introduction of e-mail communication in medical practice, these obstructions to good medical care of the patient can only worsen unless attention is taken by both sides to avoid the wrong kind of e-mail communication.



My view is that the use of e-mail in medical practice should be very limited to simply the transmission of data between patient and physician where no discussion, explanation or detailing is necessary. In this context, the data the physician would send to the patient might include appointment dates or changes, laboratory values or results about which the patient would already be aware of the clinical significance, non-personal general health information and so forth. The data the patient would send to the physician might include appointment date requests or changes, specific self-monitoring information (such as blood sugars or weights)or non-urgent followup symptom reporting.



Issues of privacy of information also must be considered. It may be necessary to transmit this data only on secure server websites. Since consultations via e-mail should not be an e-mail activity, professional compensation specifically for appropriate use of e-mail would not be of significance.



Though, to some, my view of e-mail in medical practice might seem unduly constrained and conservative, I believe anything beyond the functions that I have written would be harmful to the profession. ..Maurice.

Electronic Communication Between Physician and Patient

Lets go back to the topic of ethical issues in doctor-patient relationships and think about the increasing role of the use of e-mail in medical practice. The National Center for Ethics in Healthcare of the Veterans Health Administration in July 2004 issued a report by their ethics panel, which speaks to this role. The benefits and cautions are presented after consideration of the ethical issues involved and recommendations (pasted below) are made. The VA is developing a website called My HealtheVet to help support this new kind of communication.

For the full report go to National Center for Ethics Veterans Health Administration

and click on “Online Patient-Clinician Messaging”. Let me know how you feel about the use of e-mail and web posting as a means of communication between patient and doctor. ..Maurice.

Excerpts from VAH Report



Surveys repeatedly show that patients want to be able to communicate with their clinicians online. And online patient-clinician communication is widely held to have significant potential to enhance patient-clinician relationships, promote greater involvement by patients in their own care (including self-monitoring), and ultimately improve the outcomes of care. Concerns have been raised, however, about patient privacy, the effects of online communication on patient-clinician relationships, and the potential impact on clinicians’ workload and reimbursement.

This report by VHA’s National Ethics Committee (NEC) examines the nature of online communication and explores the ethical challenges of online communication between patients and clinicians. It offers the following recommendations to assure the ethical practice of online patient-clinician messaging within VHA:



(1) Clinicians and health care organizations should ensure that online communication takes place only when the confidentiality and security of personal health information can be reasonably assured. Once implemented nationally, My HealtheVet will provide the foundation for a secure environment required for responsible online communication between patients and clinicians.



(2) Clinicians should ensure that patients who do not interact electronically receive the same quality of care as their online peers. Online communication should not be allowed to exacerbate existing inequalities in health care by discriminating against those who have no or limited access to online communication.



(3) Clinicians should be aware of the potential effects of online messaging on the patient-clinician relationship and take steps to avoid “depersonalization.” Just how online interaction affects patient-clinician relationships is an empirical question that is still unsettled.



(4) Participation in online messaging should be voluntary for both patients and clinicians. As VHA gains more experience with this medium, requiring clinician participation may some day be justified. However, patient participation should remain voluntary.





(5) Clinicians should assure that patient participation in online communication is well informed. Clinicians should enter into an explicit agreement with patients, either orally or in writing, regarding the terms and conditions that will govern their online communication. However, there is no need to require patients to sign an informed consent form.



(6) Clinicians should limit their online communication with patients to appropriate uses. Online communication should not be used to initiate a patient-clinician relationship, to handle situations of an urgent nature, or to convey information that is highly sensitive. Messages should be carefully worded and organized to ensure effective communication, and should conform to organizational standards with regard to message handling.



(7) Health care organizations should recognize online interactions with patients as part of clinicians’ professional activities in institutionally appropriate ways.This may be accomplished, for example, by formally scheduling time for messaging, or by adopting the recently proposed AMA CPT code for online evaluation and management of patients to capture data regarding online patient communication, evaluation, and management as a professional clinical activity.

Physician As Patient (2)

What is the VIP syndrome? The Very Important Person (VIP) syndrome is a pattern of behavior by both the ill physician and his/her healthcare providers that may be deleterious to the established standards of medical care. From the ill physician’s point of view, his or her illness as a physician requires special attention by the caregivers not given to the other patients. The physician is to be treated as a professional and is to be kept fully informed about all the clinical details and is to be consulted as a colleague by the treating physician. The ill physician may request that appointments or lab tests take priority over others for personal convenience. When hospitalized, the physician may be demanding about which nurses are assigned and how they respond to requests. Also, the family of the sick doctor may be similarly demanding.



I suspect that the VIP behavior by the ill physician is not as common as the potential for altered behavior by the treating physician. Unless the treating physician has had lengthy experience caring for medical colleagues, the experience of being a doctor’s doctor can be emotionally traumatic with anxiety, uncertainty, anger and guilt. From the outset, history taking of the doctor may be more incomplete than the average patient since there may be a tendency to avoid asking important but personally embarrassing questions such as involving mental illness, family problems, sex or drug and alcohol use. Physical exams of the ill physician may be more casual and pelvic, breast or rectal exams may be omitted. Testing may be inadequate especially if the appropriate test is uncomfortable. Telling the ill physician the diagnosis and treatment options may be difficult if the treating physician is personally uncomfortable with the conclusion and identifies with a patient with whom he or she has professionally interacted. All of these VIP elements do nothing but worsen or delay proper diagnosis and treatment



Proper communication with the ill physician is essential and probably the most important thing that a treating physician can do is at the outset to make it clear that the sick doctor is going to be treated as a patient and not as a doctor.



For more reading on this topic: "’Doctoring’ Doctors and Their Families” by Stuart A. Schneck, MD

JAMA. 1998; vol.280, pages 2039-2042.

Physician As Patient (1)

Being a physician or a nurse and being sick is a unique experience that is not experienced by other people who do other jobs in their life. For this posting, I am writing my views as a physician. Nurses should be encouraged to comment here also since I would most appreciate to read their views.



Except for the most minor of clinical illnesses, physician self-diagnosis and treatment is strongly argued against by the medical profession. And that restraint on physician behavior is well taken. Physicians are humans as everyone else and have the similar personal concerns and feelings about their life and health. Well, almost similar since some physicians, perhaps early in their career, who haven’t experienced major illness may have some feelings of invincibility over disease. The difference between physicians and others is that physicians have detailed knowledge of a whole host of symptoms and diseases. This knowledge, however, may not be the most beneficial to the doctor if the doctor is attempting to evaluate the condition not of their patient but of themselves. Instead of looking for the most likely diagnoses to account for their symptoms, out of anxiety, the rare or more serious disease may be paramount in the doctors’ mind. On the other hand, the physicians, perhaps out of feelings of invincibility or fear, may simply demonstrate denial, failing to properly evaluate the significance of the symptoms. Another impediment to make a correct diagnosis is the inability to perform, in many cases, a proper self-physical examination. All of these defects in the established standards of proper medical evaluation can lead to delay in necessary treatment and perhaps worsen the outcome.



Therefore, there is a need for another physician to take over the responsibility of diagnosing and treating the ill doctor. However, functioning as such a physician is not a simple or uncomplicated exercise. Can you think of some problems that this physician might face? I will write more about this later.



But first, to get an additional view of the impact of illness on the emotions of physicians, I would like you to read an excerpt from

When Doctors Get Sick

by Howard M. Spiro, MD and Harvey N. Mandell, MD in

Annals of Internal Medicine

15 January 1998, Volume 128 Issue 2



When a doctor is sick, especially in a hospital, he or she undergoes a role reversal. Strangely, the doctor is the patient, and the familiar aspects of the hospital are unrecognizable from a stretcher. Loss of control is hardest of all for sick doctors, so used are they to the obedience of others: Sick radiologists try to read their own films, and the bed-bound physician strains to scan the bedside monitor. Sick doctors are lonely patients, isolated but on watch, vigilant against error. Caught in the double bind of wanting to be a good patient yet worrying about what can go wrong, most sick doctors watch their colleagues as closely as they fear their colleagues are watching them. It is not easy to be a doctor and a patient all at once.

..Maurice.

Another Personal Note

As you may have gathered from my last posting, I am a victim of the West Nile Virus infection but fortunately I am gradually recovering at home. For this illness, I was hospitalized in the hospital where I worked as a physician and I plan to write about that later.



I just wanted to explain why until now I haven't been continuing with my postings here. I hope to resume to develop this blog soon. ..Maurice.

On a Personal Note

UNINVITED GUEST





Oh, Culex, you uninvited guest

Who kissed me, spreading your exotic gift

And leaving me weak, feverish, seeing double

And becoming suddenly a modern statistic.



Oh, Culex, where are you now?

What life are you going to challenge next?

Stay away. I'll be back.

And, you know, Culex, I have never been to Uganda.

Satisfactory and Effective Communication in Medical Care and Treatment

The medical humor in the last post virtually all point to the importance of and necessity for satisfactory and effective communication in medical care and treatment. As a member of a hospital ethics committee, I can attest to the fact that often what comes to the committee for resolution as an ethical conflict is not so much an ethical issue but a problem in communication between a physician and a patient or family or between physicians themselves or with their hospital nursing staffs.



In an outpatient setting, the study by Keating, Nancy L. MD, MPH; Green, Diane C. PhD, MPH; Kao, Audiey C. MD, PhD; Gazmararian, Julie A. PhD, MPH; Wu, Vivian Y. OTR, MS; Cleary, Paul D. PhD "How Are Patients' Specific Ambulatory Care Experiences Related to Trust, Satisfaction, and Considering Changing Physicians?" in the Journal of General Internal Medicine V.17, Nr. 1 pages 29-39, Jan 2002 statistically confirms the need for better doctor-patient communication.



The objective of the study was "To assess the relationships between outpatient problem experiences and patients' trust in their physicians, ratings of their physicians, and consideration of changing physicians. We classified as problem experiences patients' reports that their physician does not always 1) give them enough time to explain the reason for the visit, 2) give answers to questions that are understandable, 3) take enough time to answer questions, 4) ask about how their family or living situation affects their health, 5) give as much medical information as they want, or 6) involve them in decisions as much as they want." 2052 patients were contacted in a 1999 telephone survey. "Most patients (78%) reported at least 1 problem experience. Each problem experience was independently associated with lower trust and 5 of 6 with lower overall ratings. Three problem experiences were independently related to considering changing physicians: physicians not always giving answers to questions that are understandable,not always taking enough time to answer questions, and not always giving enough medical information."



In conclusion the authors state "Although most patients' experiences with their physicians are good, those that are not may have important consequences, including lower trust, lower ratings of physicians, and greater likelihood of changing physicians. More physician training in communication skills, particularly focused on answering questions in ways that patients can understand, taking enough time to answer questions, providing adequate amounts of information, and discussing differences in opinion about whether tests, procedures, or referrals are needed, may strengthen patient-physician relationships. This type of training is effective and should be a priority of residency training programs, medical schools, medical groups, and health care organizations."



Interestingly, though the importance of good communication is stressed in the business world and efforts are taken to improve communication skills with specific courses and consultations and there is some effort in medical school education to teach proper communication skills, virtually none is taught when the physician is in practice. There is a need for the medical community to show as much interest in improving medical communication as it does for improving diagnosis, medical drugs and treatments. ..Maurice.

Doctor Jokes: Reflections of Issues of Professionalism

For a change of pace, I am posting today examples of medical humor: "doctor jokes" from The Doctors Lounge where more humorous presentations are available. Notice how some of these examples of patient/doctor interaction seem to arise from professional issues which I have posted in the past month. If you know of some jokes that fit this point, click on comment and post them. ..Maurice.

· A man goes to his doctor and says, "I don't think my wife's hearing isn't as good as it used to be. What should I do?" The doctor replies, "Try this test to find out for sure.

When your wife is in the kitchen doing dishes, stand fifteen feet behind her and ask her a question, if she doesn't respond keep moving closer asking the question until she hears you."

The man goes home and sees his wife preparing dinner. He stands fifteen feet behind her and says, "What's for dinner, honey?" He gets no response, so he moves to ten feet behind her and asks again. Still no response, so he moves to five feet. still no answer. Finally he stands directly behind her and says, "Honey, what's for dinner?" She replies, "For the fourth time, I SAID CHICKEN!"



· "Doctors at a hospital in Brooklyn, New York have gone on strike. Hospital officials say they will find out what the Doctors' demands are as soon as they can get a pharmacist over there to read the picket signs!"



· The difference between a neurotic and a psychotic is that, while a psychotic thinks that 2 + 2 = 5, a neurotic knows the answer is 4, but it worries him.



· Doctor: I have some bad news and some very bad news.

Patient: Well, might as well give me the bad news first.

Doctor: The lab called with your test results. They said you have 24 hours to live.

Patient: 24 HOURS! That's terrible!! WHAT could be WORSE? What's the very bad news?

Doctor: I've been trying to reach you since yesterday.



· A man speaks frantically into the phone, "My wife is pregnant, and her contractions are only two minutes apart!"

"Is this her first child?" the doctor queries.

"No, you idiot!" the man shouts. "This is her husband!"



· A List of Things You Don't Want to Hear During Surgery:



Oops!

Has anyone seen my watch?

Come back with that! Bad Dog!

Wait a minute, if this is his spleen, then what's that?

Hand me that...uh...that uh.....thingy

What do you mean he wasn't in for a sex change!

Damn, there go the lights again...

Everybody stand back! I lost my contact lens!

Well folks, this will be an experiment for all of us.

What do you mean, he's not insured?

Let's hurry, I don't want to miss "Bay Watch"

What do you mean "You want a divorce"!

FIRE! FIRE! Everyone get out!



· A man goes to his doctor for a complete checkup. He hasn't been feeling well and wants to find out if he's ill. After the checkup the doctor comes out with the results of the examination.



"I'm afraid I have some bad news. You're dying and you don't have much time," the doctor says.



"Oh no, that's terrible. How long have I got?" the man asks.



"10..." says the doctor.



"10? 10 what? Months? Weeks? What?!" he asks desperately.



"10...9...8...7..."



· The seven-year old girl told her mom, "A boy in my class asked me to play doctor."

"Oh, dear," the mother nervously sighed. "What happened, honey?"

"Nothing, he made me wait 45 minutes and then double-billed the insurance company."