RICHARD L. ELLIOTT, MD, PHDPROFESSOR AND DIRECTOR

PROFESSIONALISM AND MEDICAL ETHICSMERCER UNIVERSITY SCHOOL OF

MEDICINEADJUNCT PROFESSOR

MERCER UNIVERSITY SCHOOL OF LAW

Professionalism and Ethics for Clinical Clerkships

Goals

Overview of professionalism and ethics in clerkships

Senior cases

Your case due March 1 Senior yearCase analysis format recommended, not

requiredOutstanding papers

http://medicine.mercer.edu/Academics/Degree%20Programs/Doctor%20of%20Medicine/ethicsoutstandingpapers

JMAG publication?

Click icon to add pictureInternal medicine

End-of-life decisions

Futility of care

Euthanasia

Physician assisted suicide

Your cases in professionalism and ethics

OB-GYNReproductive technologiesGenetic testing Fetal MaternalYour cases

PediatricsBaby Doe laws and futility of care in the infant

Rights of minors

Your cases

Click icon to add pictureSurgeryCase focused

Click icon to add pictureFamily Medicine

Care of the elderly

Domestic violence

Medical errors

Your cases

Psychiatry

Competence and informed consent

Commitment

Involuntary treatment

Tarasoff

How can you tell if someone is a professional?

DressTimeliness

No Houdinis need applyPreparationHonesty

Didn’t do something, don’t know something, say so

CompetenceEthical behaviorsCourtesy and respect

Towards patients, staff, colleagues, professionWillingness to take on duties cheerfully

Confidentiality

Where do you discuss cases?With whom do you discuss cases?A friend’s 16-year old daughter visits the office where you are

working and requests birth control pills. Her family is Irish Catholic and is against birth control in any form as well as premarital sex. She requests that you do not discuss this with her parents. After concluding the visit, you return to your work area where you find a message to call the patient’s mother. In the past you have always discussed the daughter’s health issues and other concerns openly with the parents. What will you do? Do you have an obligation to the patient to maintain confidentiality? Do you have an obligation to the parents to divulge the nature of their minor

child’s medical problem? Would it be different if she had presented with a URI or athlete’s foot?

Honesty

A 68-year-old man is hospitalized with fatigue and anemia. You and another student are on call for the evening and sharing responsibilities. You conduct the admission history while your colleague performs the physical examination. You have worked with this student previously and have found him to cut corners in his work and to disappear when work assignments are distributed. During his physical examination he ‘forgets’ to perform a rectal examination or perform a stool guaiac study. During the night, the patient has a myocardial infarction as a result of an undetected gastrointestinal bleed. During rounds the next morning, the attending physician asks you whether the patient’s stool was guaiac negative.

How would you respond? If the other student falsely reports a negative guaiac what

would you do?

Scut monkey

During a night while on call, a resident asks you to go out and get sandwiches.

What do you do? Why?

Competence

A resident post call makes several errors, not washing his hands following a dirty procedure and before seeing the next patient, and prescribing amitriptyline to a patient with an arrhythmia likely to be exacerbated by the medication.

What do you do? Why?

Impairment

Another student with a history of binge drinking reports for duty smelling of alcohol. You ask about this and he says it was just an eye opener and that he has seen the attending, a well-known surgeon, do exactly the same thing.

What do you do? Why?

Duty Hours

You are told you have to do only two admissions per “shift.” The team is swamped, the intern harried, another student is out,, and a new admission comes in. The intern asks if you would see the patient.

You are at the end of the maximum time allowed for your shift. A patient you admitted is going to the OR and you would like to observe.

Issues Students Raised

Fighting with other staff in the chartsCopy and paste in EMRToo little time with patientsDiscussing patients in publicMultiple appointments to maximize billing

Rule #1

We are doctors

What does it mean to be professional?

Principles Principle of primacy of patient welfare Principle of patient autonomy Principle of social justice

Responsibilities (Commitments to __) Professional competence Honesty with patients Patient confidentiality Commitment to maintaining appropriate relations with patients Improving the quality of care Improving access to care A just distribution of finite resources Scientific knowledge Maintaining trust by managing conflicts of interest Professional responsibilities

• ANN INT MED 2002;136:243-246

What is professionalism?

PROFESSIONALISM - Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: demonstrate respect, compassion, and integrity; a responsiveness to

the needs of patients and society that supercedes self -interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development.

demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices

demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities

• (ACGME, 1999)