.

[Beargryllz]

For everyone applying this coming cycle I want to try out a little activity; let's get some mock ethics questions going that can prep us for our interviews. Some medically related, some not.

First one: An elderly gentlemen has a heart attack and dies behind the wheel of his car. He hits your car causing some substantial damage. Do you file a claim with his insurance knowing that it will possibly end up being an issue his family has to deal with?

Second: You're an EMT responding to a call of a motorcycle vs. car crash. The motorcycle operator was pretty severe when you picked him up and you start CPR on the way in. After a few chest compressions he shoots blood out of his mouth, splattering you and the other EMTs. He ends up passing away. Do you go to the family and question them regarding his disease risk after they arrive? (Let's assume he is high-risk; prison tattoos and "thug" appearing.)

Third (For anyone with an interest in finance or ecology): How do you feel about the disconnect between the increasing ability to keep people alive, especially those who can not function independently in society, and the worsening state of our planet. Do you feel that as an industry, healthcare is playing a role, however substantial, in accelerating our destruction of the planet due to the increased resource burden due to these types of patients? How do you feel about this issue in terms of economic stress on the United States? Given these arguments, how does this affect your stance on euthanasia and assisted suicide?

1- Absolutely. In my opinion, failure to make a claim would be unethical. This isn't even debatable with me. Not making a claim undermines the entire purpose of insuring a vehicle.

2- I'm not sure if the hypothetical you is the one that gets involved here. More realistically, you are seen in the ED for exposure and through those channels the risk is ascertained. Just going up to the family on your own and eliciting this information seems very unprofessional. So no, you do not go the family to question them regarding his disease risk. You go to the ED for treatment. You are not Sherlock Holmes. You do not have a home laboratory for rapid HIV/whatevermegavirus detection.

3- I don't see the planet being destroyed. I don't see the planet in a worsening state, but I can see how those averse to change or uneducated in natural history could perceive this. I do see an inevitable exodus at some point, though this is likely not something we will experience for generations. Every person has the right to die. This is not debatable and it has nothing to do with the state of our planet, economic stress, or the United States.

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[senzen]

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[itsogre]

Point taken. I wouldn't personally play the role of a neutral doctor during an interview, but I was just trying to put an ethics question inside of an ethics question. Ethiception if you will.

I liked your tram analogy better. You're a pretty big poster for this forum.


To stay on topic, is there a chance an interview would ask about antinatalism? I read David Benatar's book about why it's better to never have been born, and he made a "well" reasoned argument for why “being brought into existence is not a benefit but always a harm.”

to add, a practical example of anti-natalism is the Voluntary Human Extinction Project:
http://en.wikipedia.org/wiki/Voluntary_Human_Extinction_Movement

 

[NickNaylor]

You're a psych resident that has been asked to come see a patient in the ED who has recurrent suicidal ideation (i.e., thinking of committing suicide) over the last few years. He has no history of suicide attempts. The ED attending tells you that he endorsed SI while in the ED today. When you see him ~30 minutes later he denies feeling suicidal, but you find out that he lives at home and has access to a firearm at home. He denies having a plan to kill himself using the weapon.

What do you do? What will you tell the ED attending?

 

[Bacchus]

Here's another question to think about:

You are an RN providing post-surgical care for a 53-year-old former football coach with diabetes. The patient recently had several toes amputated as a result of poor foot care. While you initially had a good relationship with this patient, he has become increasingly demanding, unappreciative, and sometimes verbally abusive. One day, as you enter his room, you find him eating from what appears to be a large-sized bag of M and M's. He pushes the bag under the bed clothes, responding defensively that he’s had “just a few.” You are concerned as the patient’s last A1C was 7.3. When you ask him how he’s doing, he snaps, “Leave me alone; there’s nothing you can do.” He refuses to allow you to change his foot dressings. He aggressively demands that you “Get out.”

You’re tired, having worked overtime the day before. You’ve had it with the coach’s ill-temper and lack of gratitude. Like most of the healthcare team, you’re fed up with the verbal abuse. You are also concerned that this patient really is not doing well. You think maybe someone else would have more success with this patient.

Should you ask to be taken off the case? * What are your other options? * What role might other members of the team play? * What ultimately should be done?

If an A1C of 7.3% is fueling your reaction, you're a health professional in for a rude awakening. A diabetic, with an A1C of 7.3% and has had toes amputated? That 7.3% is a great A1C.... but 10, 11 or 12% is more of what I'd expect.

 

[Bacchus]

I want to work at the hospital where I can asked to be assigned to a different patient..

It's funny isn't it? But if the patient complains, then the nurse is reassigned rather quickly.

 

[Bacchus]

Better ethical questions 1. Demented patient with periods of Lucency executed a durable power of attorney indicating they wanted to pull the plug and a spouse, who stands to inherit a lot wants to comply. Rest of family opposes this. They turn to you for guidance.
2. Pre-Teen having high risk sex or pregnant and on drugs doesn't want you to breach confidentiality and talk to parents. What do you do?
3. Psych patient confides in you that he has dreams of killing his spouse but insists they are only dreams and he'd never do anything. Do you tell spouse? Take action somehow?
4. Patient in chronic pain wants you to administer dangerous but non lethal level of narcotics. Do you do it?
5. Potential Kidney donor funds out in screening that she has cancer and can't donate. Wants you to lie for her as to why she won't give her sister a kidney.
6. A dad finds out he has Huntingtons. Doesn't want to tell ex wife to have the kids tested.
Etc

1. When was it written? Before the patient was diagnosed with neurocognitive dysfunction? (Thanks, DSMV for the new name -_-)
2. This is a big debate. If she was just pregnant? I wouldn't have the discussion as that's protected information and emancipates her. However, the other two, I would strongly encourage her to talk with her parents. Dangerous behavior is reportable, is it not?
3. I'd tell the spouse. The "dreams" may just be a "protective" word the patient is using. But, rather safe than sorry.
4. What's the patient's other medical comorbidities? If the patient was in the hospital, monitored appropriately, and I had approval from my supervising physician I would. Out in the real world? No, I would try to get some pain control and refer to pain management.
5. This is a conversation for her and the sister. I'd be vague. Would not use the C word or lie.
6. I don't like this question. I'm gonna skip it .

 

[Bacchus]

You're a psych resident that has been asked to come see a patient in the ED who has recurrent suicidal ideation (i.e., thinking of committing suicide) over the last few years. He has no history of suicide attempts. The ED attending tells you that he endorsed SI while in the ED today. When you see him ~30 minutes later he denies feeling suicidal, but you find out that he lives at home and has access to a firearm at home. He denies having a plan to kill himself using the weapon.

What do you do? What will you tell the ED attending?

It's documented, I'm assuming. I'd strongly try to persuade the patient to be admitted for treatment. I don't feel safe sending him home. Luckily, an attending should be supervising you and you shouldn't be directly discharging the patient as a resident.

 

[Godspeedyou]

You're a psych resident that has been asked to come see a patient in the ED who has recurrent suicidal ideation (i.e., thinking of committing suicide) over the last few years. He has no history of suicide attempts. The ED attending tells you that he endorsed SI while in the ED today. When you see him ~30 minutes later he denies feeling suicidal, but you find out that he lives at home and has access to a firearm at home. He denies having a plan to kill himself using the weapon.

What do you do? What will you tell the ED attending?

I'm a psych major (no shame in my game) and a 'no-harm contract' is often very effective when issued by a therapist, wherein if the patient performs any self-harming behaviors, their 'contract' is broken. I'm assuming this man has a therapist that knows his situation and how to deal with it, if not then I would do my best to do 'talk therapy'. If the situation is bad then the patient needs to be trapped into seeing the therapist in order to prevent them from disregarding the 'contract'.

A more Gestalt approach would probably go something like this:
"When people come to me saying they want to kill themselves, I tell them, 'What’s your rush? You can kill yourself any time you like. So calm down'... And they do calm down."

 

[medic86]

You're a psych resident that has been asked to come see a patient in the ED who has recurrent suicidal ideation (i.e., thinking of committing suicide) over the last few years. He has no history of suicide attempts. The ED attending tells you that he endorsed SI while in the ED today. When you see him ~30 minutes later he denies feeling suicidal, but you find out that he lives at home and has access to a firearm at home. He denies having a plan to kill himself using the weapon.

What do you do? What will you tell the ED attending?

Have the ED attending sign-off on a psych hold if the state has applicable laws to allow for it.

It's still a toughie, though.

 

[pageantry]

You're a psych resident that has been asked to come see a patient in the ED who has recurrent suicidal ideation (i.e., thinking of committing suicide) over the last few years. He has no history of suicide attempts. The ED attending tells you that he endorsed SI while in the ED today. When you see him ~30 minutes later he denies feeling suicidal, but you find out that he lives at home and has access to a firearm at home. He denies having a plan to kill himself using the weapon.

What do you do? What will you tell the ED attending?

Heyyyy, this is a fun thread. But I gotta disagree with everyone except the person suggesting a Gestalt approach. First I'd find out WHY he was in the ED. It doesn't sound like it was for the SI as the situation is described. Recent health issues or severe trauma may lead to ideation, and those should be addressed before depriving the patient of his liberty. Then consider other options for the patient's emotional well-being. Create a plan with the patient to respond to any more urgent suicidal thoughts. See if he has a friend or family member he's willing to have come pick him up.

Exercising the authority to hold someone in psych should be a last resort. The stigma alone considerably reduces life chances.

 

[LizzyM]

More interesting ethical questions
1. A now demented patient with multi-organ failure appointed his live-in assistant (not a relative) as his health care proxy and his heir several years ago. He also signed a living will indicating he wanted no heroic measures at end of life and the assistant , who stands to inherit a lot wants to comply. Family opposes this. They turn to you for guidance.
2. Bi-sexual having high risk sex and using recreational IV drugs doesn't want you to breach confidentiality and talk to spouse. What do you do?
3. Nineteen year old patient confides in you that he thinks of killing his parents but insists he'd never do anything. His father is a police officer and there is at least one gun in the house. Do you tell parents? Take action somehow?
4. Patient in chronic pain wants you to administer dangerous and possibly lethal level of narcotics. Do you do it?
5. Potential Kidney donor is cleared to donate but is having second thoughts about donating. Wants you to lie for her as to why she won't give her sister a kidney.
6. A dad finds out he has Huntingtons. Doesn't want to tell his children, ages 19 and 21, who are in college that they are at risk of also carrying this genetic condition.

 

[ridethecliche]

Ethical question:
1. Peanut butter and jelly or peanut butter and fluff.
2. If there's no caffeine, is there any damn point?
3. If a tree falls in the forest and no one's there to hear it, does it make a sound?
4. Is it fair that doctors have to disclose their COI's and funding whenever they take any sort of stand but politicians can hide everything?

Discuss.

 

[ridethecliche]

More interesting ethical questions
1. A now demented patient with multi-organ failure appointed his live-in assistant (not a relative) as his health care proxy and his heir several years ago. He also signed a living will indicating he wanted no heroic measures at end of life and the assistant , who stands to inherit a lot wants to comply. Family opposes this. They turn to you for guidance.
2. Bi-sexual having high risk sex and using recreational IV drugs doesn't want you to breach confidentiality and talk to spouse. What do you do?
3. Nineteen year old patient confides in you that he thinks of killing his parents but insists he'd never do anything. His father is a police officer and there is at least one gun in the house. Do you tell parents? Take action somehow?
4. Patient in chronic pain wants you to administer dangerous and possibly lethal level of narcotics. Do you do it?
5. Potential Kidney donor is cleared to donate but is having second thoughts about donating. Wants you to lie for her as to why she won't give her sister a kidney.
6. A dad finds out he has Huntingtons. Doesn't want to tell his children, ages 19 and 21, who are in college that they are at risk of also carrying this genetic condition.

1. No dilemma. Patient has a will stating their wishes. Follow them. If family wants the moolah, they should have been nicer to the patient so that he would have put them in the will.
2. Ensure patient is using adequate protection. If they qualify for PrEP put them on it asap. Discuss harm reduction strategies at every contact. Talk to patient about spousal relationship and protections there. Try your best not to slam your or the patients head against any sort of immovable object or wall due to frustration.
3. Try to connect patient to psych care asap. Ask if the gun is in a locked case and check to see if patient has access and knows code or has the key to the safe. Patient is potentially more likely to self harm than act out. Discuss why patient is that frustrated with parents. People have insane thoughts all the time, patient really sounds like he needs psychiatric care. If patient has a plan to kill parents and has thought everything through and it's not merely a passing feeling, then consider a psych intervention.
4. Negative. Ask patient to move to Oregon. See if patient has a DNR on their will. Try to connect patient to support group or such patients existing access to narcotics indicates that patient could potentially try to ingest large amounts orally at home.
5. Tell patient to sack up and either donate or own up to not donating. After talking to patient about why they're having second thoughts. Or skip that part entirely.
6. Discuss outcomes with patients and talk about things that can be done if disease is caught early. Otherwise shrug your shoulders and move on. If children are your patients, potentially consider seeing if they want to be screened for genetiecs at their next visit.

 

[pageantry]

More interesting ethical questions
1. A now demented patient with multi-organ failure appointed his live-in assistant (not a relative) as his health care proxy and his heir several years ago. He also signed a living will indicating he wanted no heroic measures at end of life and the assistant , who stands to inherit a lot wants to comply. Family opposes this. They turn to you for guidance.
2. Bi-sexual having high risk sex and using recreational IV drugs doesn't want you to breach confidentiality and talk to spouse. What do you do?
3. Nineteen year old patient confides in you that he thinks of killing his parents but insists he'd never do anything. His father is a police officer and there is at least one gun in the house. Do you tell parents? Take action somehow?
4. Patient in chronic pain wants you to administer dangerous and possibly lethal level of narcotics. Do you do it?
5. Potential Kidney donor is cleared to donate but is having second thoughts about donating. Wants you to lie for her as to why she won't give her sister a kidney.
6. A dad finds out he has Huntingtons. Doesn't want to tell his children, ages 19 and 21, who are in college that they are at risk of also carrying this genetic condition.

The thing about these questions is that they're always asked in a sort of ride-or-die vacuum. Are there not laws, lawyers, hospital guidelines, friends, other family, therapists, or other medical specialists to refer to? Would it be considered wishy washy, in an interview, to bring up these resources?

Another question I have is about the amount of harm that some obviously ethical actions can have on innocent bystanders.

For instance, I once encountered a situation where a guy was regularly smoking pot before going into his job at a walk in clinic. He had a young stay at home wife and three little kids and was a very good, popular doctor by most accounts. And this was very unethical behavior. Due to his popularity, his other various professional lapses were being ignored by the clinic owners (also MDs), but things were getting steadily worse. He had been fired from several other clinics but always found a new job due to the dearth of FP doctors. And he lived in a state where a positive drug test carried a strong risk of having his license permanently stripped--at best--and jail time at worst.

This reminds me of the cheating scenario because cheating doesn't occur in a vacuum either. And sometimes is implicitly supported by faculty. AND can harm innocent people in its proximity.

Let's say one day you actually see and smell this guy lighting up a joint before work. You work at this clinic and need the job. What would YOU do?

 

[LizzyM]

1. No dilemma. Patient has a will stating their wishes. Follow them. If family wants the moolah, they should have been nicer to the patient so that he would have put them in the will.
2. Ensure patient is using adequate protection. If they qualify for PrEP put them on it asap. Discuss harm reduction strategies at every contact. Talk to patient about spousal relationship and protections there. Try your best not to slam your or the patients head against any sort of immovable object or wall due to frustration.
3. Try to connect patient to psych care asap. Ask if the gun is in a locked case and check to see if patient has access and knows code or has the key to the safe. Patient is potentially more likely to self harm than act out. Discuss why patient is that frustrated with parents. People have insane thoughts all the time, patient really sounds like he needs psychiatric care. If patient has a plan to kill parents and has thought everything through and it's not merely a passing feeling, then consider a psych intervention.
4. Negative. Ask patient to move to Oregon. See if patient has a DNR on their will. Try to connect patient to support group or such patients existing access to narcotics indicates that patient could potentially try to ingest large amounts orally at home.
5. Tell patient to sack up and either donate or own up to not donating. After talking to patient about why they're having second thoughts. Or skip that part entirely.
6. Discuss outcomes with patients and talk about things that can be done if disease is caught early. Otherwise shrug your shoulders and move on. If children are your patients, potentially consider seeing if they want to be screened for genetiecs at their next visit.

@ridethecliche
1. Was the patient capable of making this decision at the time the decision was made. Did the live-in assistant coerce the man to sign over his life and his estate? Might the family be advised to consult a lawyer about challenging the legal documents?
2. Would your answer be different in a state where a physician is permitted, but not required, by law to inform a spouse that the patient is HIV +? (I realize that there is nothing in the question that states that the patient is or isn't seropositive.)
3. The gun in the house belongs to the dad and he keeps it in his home as a police officer. Should dad be informed of his son's homicidal ideation?
4. The patient is in chronic pain. What is the patient's goal here? Asking the patient to move to Oregon seems to suggest that you assume that the patient is asking for assistance in committing suicide. How does a DNR order fit in to the treatment of chronic pain?
5. If willingness to donate is a requirement for a living kidney donor, and this person no longer wishes to donate, then the person is not meet the requirements for donation. Does that change how you would handle this situation?
6. "Isn't 'screened for genetics' rather broad? It will be costly? Shouldn't people be aware of pre-test probability before choosing to have a test? Counseling should be provided prior to genetic testing and the genetic tests being performed need to be explained. Is it really possible to counsel someone about genetic risk without knowing what is being tested for?

 

[LizzyM]

The thing about these questions is that they're always asked in a sort of ride-or-die vacuum. Are there not laws, lawyers, hospital guidelines, friends, other family, therapists, or other medical specialists to refer to? Would it be considered wishy washy, in an interview, to bring up these resources?

Another question I have is about the amount of harm that some obviously ethical actions can have on innocent bystanders.

For instance, I once encountered a situation where a guy was regularly smoking pot before going into his job at a walk in clinic. He had a young stay at home wife and three little kids and was a very good, popular doctor by most accounts. And this was very unethical behavior. Due to his popularity, his other various professional lapses were being ignored by the clinic owners (also MDs), but things were getting steadily worse. He had been fired from several other clinics but always found a new job due to the dearth of FP doctors. And he lived in a state where a positive drug test carried a strong risk of having his license permanently stripped--at best--and jail time at worst.

This reminds me of the cheating scenario because cheating doesn't occur in a vacuum either. And sometimes is implicitly supported by faculty. AND can harm innocent people in its proximity.

Let's say one day you actually see and smell this guy lighting up a joint before work. You work at this clinic and need the job. What would YOU do?

That's a good "cheating" type question. Personally, I don't ask ethics questions but if I did, I would make them about experiences that students have or can picture themselves having rather than medical/legal questions that are covered in med school and in residency/fellowship training.

 

[pageantry]

That's a good "cheating" type question. Personally, I don't ask ethics questions but if I did, I would make them about experiences that students have or can picture themselves having rather than medical/legal questions that are covered in med school and in residency/fellowship training.

Omg I was longing for you to tell me the right answer to that question.

 

[WingedOx]

You're a psych resident that has been asked to come see a patient in the ED who has recurrent suicidal ideation (i.e., thinking of committing suicide) over the last few years. He has no history of suicide attempts. The ED attending tells you that he endorsed SI while in the ED today. When you see him ~30 minutes later he denies feeling suicidal, but you find out that he lives at home and has access to a firearm at home. He denies having a plan to kill himself using the weapon.

What do you do? What will you tell the ED attending?

Not sure this is ethnics so much as it's bread and butter psych case in the ED... and honestly this level of ambiguity is the rule rather than the exception. (the firearms come into play if you're working at the VA way too often). In the end you need more info, collateral, and ultimately confidence in your decision to make that call.

Consider this though... you determine your patient is best served by being discharged and coming to an intake appointment in the morning. The ED attending insists the patient be admitted. You obviously disagree. How hard to you push if you think an admission is the wrong choice?

 

[Law2Doc]

Here's a few others:
(1) A patient you find extremely attractive invites you to dinner. What do you do? Does it matter if the course of treatment has ended or your rotation on that service has ended?
(2) an ailing wealthy geriatric patient decides you are the only one he trusts, and wants to add you to his will.
(3) you run into your diabetic heart patient at McDonalds, super sizing it in a big way. Do you say anything or just nod "wassup" and keep moving.
(4) your fragile psych patient who doesn't handle rejection well tries to friend you on Facebook.
(5) while a med student on rotation, your attending is adamant about a course of treatment for patient that conflicts with something you just learned in class.

 

[hoihaie]

Here's a few others:
(1) A patient you find extremely attractive invites you to dinner. What do you do? Does it matter if the course of treatment has ended or your rotation on that service has ended?
(2) an ailing wealthy geriatric patient decides you are the only one he trusts, and wants to add you to his will.
(3) you run into your diabetic heart patient at McDonalds, super sizing it in a big way. Do you say anything or just nod "wassup" and keep moving.
(4) your fragile psych patient who doesn't handle rejection well tries to friend you on Facebook.
(5) while a med student on rotation, your attending is adamant about a course of treatment for patient that conflicts with something you just learned in class.

1) should still turn it down. despite her not being my patient any more, it could still be viewed negatively, especially if the disease relapses or someone complains about me as a physician and cites this as an example of inappropriate workplace conduct and thus in turn my judgement and/or ability as a physician.

2) politely decline; perhaps see why the patient thinks i'm the only one he trusts and perhaps help him get started in the reconciliation process with his own family/friends. if that fails, perhaps suggest charity of a cause he finds worthy, unrelated to me or the hospital. accepting it could raise questions in the future from either family members fighting the will (they might say I coerced the patient to have this will since i'm the doctor, or that I gave inadequate treatment to speed up his death for money ...etc). IT would also raise questions similar to #1

3) Approach them like you would a friend, say hello and see where the conversation goes. Might not be a good idea to talk about his medical problems in public. Can bring up diet in next meeting with them at the office, without directly referencing the mcdonalds meet up (potentially less awkward for the patient)

4) (not sure about this one...) Try to say you don't use facebook anymore (my settings are super private anyways, people cant see my activity if they arent my friends). if they insist, I can friend them and put them on special privacy settings that block them from seeing the majority of my contents

5) Ask the attending questions about why he chose that treatment option. Treat it as a learning experience. In the course of my questions and discussion with him, if he's wrong, he might be able to figure it out himself.

 

[Vain Brother]

Better ethical questions 1. Demented patient with periods of Lucency executed a durable power of attorney indicating they wanted to pull the plug and a spouse, who stands to inherit a lot wants to comply. Rest of family opposes this. They turn to you for guidance.
2. Pre-Teen having high risk sex or pregnant and on drugs doesn't want you to breach confidentiality and talk to parents. What do you do?
3. Psych patient confides in you that he has dreams of killing his spouse but insists they are only dreams and he'd never do anything. Do you tell spouse? Take action somehow?
4. Patient in chronic pain wants you to administer dangerous but non lethal level of narcotics. Do you do it?
5. Potential Kidney donor funds out in screening that she has cancer and can't donate. Wants you to lie for her as to why she won't give her sister a kidney.
6. A dad finds out he has Huntingtons. Doesn't want to tell ex wife to have the kids tested.
Etc

1. if wife has POA, rest of family's input doesn't mean much, regardless of perceived incentives. do as the husband would have wished
2. tough one, might even be compelled to inform in some states. i'd argue the autonomy of someone 11 or 12 could be overridden here
3. would have to know more details ("psych patient" is vague) but probably not. i'd probably ask him to talk to the wife about it tho
4. easy, depends on what dose of narcotics he's had before. no max dose on narcs
5. duh, no
6. almost certainly have to have kids tested. ex will have to find out one way or another if they have the mutation

 

[Vain Brother]

Here's a few others:
(1) A patient you find extremely attractive invites you to dinner. What do you do? Does it matter if the course of treatment has ended or your rotation on that service has ended?
(2) an ailing wealthy geriatric patient decides you are the only one he trusts, and wants to add you to his will.
(3) you run into your diabetic heart patient at McDonalds, super sizing it in a big way. Do you say anything or just nod "wassup" and keep moving.
(4) your fragile psych patient who doesn't handle rejection well tries to friend you on Facebook.
(5) while a med student on rotation, your attending is adamant about a course of treatment for patient that conflicts with something you just learned in class.

1. no, it's not ethical to pursue a romantic relationship with a patient. if it's years down the road maybe a different story. too much of a power imbalance
2. have to respectfully refuse I think
3. probably bring it up next visit, what are you gonna do, scold him in front of everyone? confiscate the big mac?
4. accept then try to explain, either via message or at the next visit, why your policy is not to friend patients on social media
5. make your case and ultimately go with what the attending wants

 

[Vain Brother]

oh I misread #5 about the kidney donation, I thought the patient wanted me to lie to the transplant board or something. the patient can tell the sister herself why she's not giving her her kidney, don't see why I have to be involved in the specifics of that.

 

[Vain Brother]

Other popular ethics question --seventh day Adventists who won't accept transfusions, requiring a significant risk surgery. Any change in you decision if it's one parent refusing transfusion for their two year old?

laws vary based on where you are practicing, but my feeling is that it is not ethical to let the child die. a doctor should do his best to explain why he is going to give the transfusion, and there are other issues a physician should understand (ie guilt on the part of the family or child as he gets older, ostracization from their community), but ultimately if the transfusion will save the child's life I think you have to order it

 

[tea guzzling traveler]

Here's a few others:
(1) A patient you find extremely attractive invites you to dinner. What do you do? Does it matter if the course of treatment has ended or your rotation on that service has ended?
(2) an ailing wealthy geriatric patient decides you are the only one he trusts, and wants to add you to his will.
(3) you run into your diabetic heart patient at McDonalds, super sizing it in a big way. Do you say anything or just nod "wassup" and keep moving.
(4) your fragile psych patient who doesn't handle rejection well tries to friend you on Facebook.
(5) while a med student on rotation, your attending is adamant about a course of treatment for patient that conflicts with something you just learned in class.

More interesting ethical questions
1. A now demented patient with multi-organ failure appointed his live-in assistant (not a relative) as his health care proxy and his heir several years ago. He also signed a living will indicating he wanted no heroic measures at end of life and the assistant , who stands to inherit a lot wants to comply. Family opposes this. They turn to you for guidance.
2. Bi-sexual having high risk sex and using recreational IV drugs doesn't want you to breach confidentiality and talk to spouse. What do you do?
3. Nineteen year old patient confides in you that he thinks of killing his parents but insists he'd never do anything. His father is a police officer and there is at least one gun in the house. Do you tell parents? Take action somehow?
4. Patient in chronic pain wants you to administer dangerous and possibly lethal level of narcotics. Do you do it?
5. Potential Kidney donor is cleared to donate but is having second thoughts about donating. Wants you to lie for her as to why she won't give her sister a kidney.
6. A dad finds out he has Huntingtons. Doesn't want to tell his children, ages 19 and 21, who are in college that they are at risk of also carrying this genetic condition.

I'll try my hand at these (feel free to critique my responses as I am soon to be in the interview stage of things). Of course, if the law is a certain way, you should comply with the law. Depending on the state, the following answers might change.

First, @Law2Doc (the 1-5):
1) I would politely decline as well. I don't want to have my practice implicated by claims of lack of professionalism. However, I don't think I would judge a colleague as harshly if several years after they had a patient, they started dating as compared to if they started dating while still in the doctor patient relationship, which I think could be taking advantage of a power imbalance. I wouldn't do it myself either way.
2) Again politely decline, as I wouldn't want to take advantage of my relationship with him. I would talk with him about his different options, whether he would want to give the money to his relatives or to charity. If it made him feel better, he could donate to charity in my name.
3) I wouldn't make any judgments about the patient, who knows they could be suffering from depression or an addictive personality, and it is not my place to judge him in public either. I might bring up diet in the next consultation in the context of proper management of diabetes and heart conditions.
4) This one's tough... I might wait on the friend request until I saw the patient in clinic, and then explain that to keep a professional relationship, I didn't have patients on Facebook as friends, but that we could certainly be friends in real life, and then say that is more important anyways.
5) Talk to the attending privately, and make your case as to why you think you are right. If you buy the attending's explanation, then go with that, if not, involve more doctors and ask for more opinions, because ultimately the patient's welfare is the most important thing. You could explain the patient's situation to the professor who had just taught you without mentioning names of course, and see what they thought.


On to @LizzyM 's questions:
1) I think the lawyers would have to settle this one and would advise the family to go to a lawyer, and they would need to try to find out the mental status of the patient at time of signing that will. I feel like if he did do it while competent, then I would comply as for me, the patient's preferences come first when they do not directly negatively affect others.
2) First, I would counsel the patient to tell the spouse of these high risk behaviors, emphasizing that he is not the only one who could be suffering. If after this and I am legally able to tell the spouse, I would. I would do so because if she engages in high risk behavior she could be spreading the disease, and this develops into a public health issue, where I need to prioritize the public. I personally feel like she has a right to know as well.
3) I think you probe how much of a desire it is, and whether there is a plan associated with it. If so, you try to get a psych hold on this individual. If not, set up a network of people willing to help, perhaps getting therapy to help talk through these issues.
4) If I felt it was a dangerous level of narcotics, I wouldn't prescribe it. There are the issues of addiction and dependance that come into this one, and I wouldn't want to enable a dangerous habit. At the same time, I would want to alleviate the pain that is present, so I would give as much as I could that would not exacerbate the problem.
5) Nope, that is her responsibility. I am not going to lie for her. I might talk to her about why she has second thoughts though.
6) Assuming he is of competent mind, that seems like a tough choice for him, and while I might counsel him to tell his children, ultimately I would respect his decision. The difference between this and the risky behavior situation is that there is nothing he or his children can do to alleviate that risk of developing Huntington's. I will admit however, that I don't know if there are early interventions that can reduce the risk of developing Huntington's. If so, I would strongly counsel him to tell his children. If not, it's kind of like the question, if you could know when you were going to die, would you want to know.

 

[Law2Doc]

... I will admit however, that I don't know if there are early interventions that can reduce the risk of developing Huntington's. If so, I would strongly counsel him to tell his children. If not, it's kind of like the question, if you could know when you were going to die, would you want to know.

Well there are always trials you can get on but nothing that's a cure per se. Certainly might dramatically change how you live your life if you know the window of being able to do certain things is short. Might (should) impact having children vs adoption.


The point of all these ethical questions is just to get you talking intelligently, see how you handle complicated issues with no single indisputable right answer. Sure there are laws, hospital regulations, etc covering some if these topics in some jurisdictions, but they were derived after years of debate on the issues, could be changed by the time you become a doctor, and there's always something similar to discuss/debate in medicine. The goal isn't to show you know the right answer. It usually better if you don't know it's already been settled. The wrong answer would always be to just shut the interviewer down and saw, "I would follow the law" and leave it at that. You need to take a position and defend it. You can acknowledge what the law says, if you know, but that's not really the point. And expect the interviewer to tweak the question as you go.(eg "what if the kidney donor in my above scenario was actually your BFFs sister", or a minor child, etc).

 

[pageantry]

Well there are always trials you can get on but nothing that's a cure per se. Certainly might dramatically change how you live your life if you know the window of being able to do certain things is short. Might (should) impact having children vs adoption.


The point of all these ethical questions is just to get you talking intelligently, see how you handle complicated issues with no single indisputable right answer. Sure there are laws, hospital regulations, etc covering some if these topics in some jurisdictions, but they were derived after years of debate on the issues, could be changed by the time you become a doctor, and there's always something similar to discuss/debate in medicine. The goal isn't to show you know the right answer. It usually better if you don't know it's already been settled. The wrong answer would always be to just shut the interviewer down and saw, "I would follow the law" and leave it at that. You need to take a position and defend it. You can acknowledge what the law says, if you know, but that's not really the point. And expect the interviewer to tweak the question as you go.(eg "what if the kidney donor in my above scenario was actually your BFFs sister", or a minor child, etc).

I still wish someone would give my real life one a shot.

 

[tea guzzling traveler]

I still wish someone would give my real life one a shot.

Sure, I'll give it a shot. I was kind of lumping it into how I would deal with cheating in general, although this is more serious in my view as they are actively consuming substances that could impair decision making processes. Your best interest should always be the patient, and so I would report the person, as patients could be in danger as a result of his actions.

 

[prettyNURSEtoMD]

I've witnessed very similar issues as to these:

You are a primary care physician and a mother comes into your office with her child who is complaining of flu-like symptoms. Upon entering the room, you ask the boy to remove his shirt and you notice a pattern of very distinct bruises on the boy's torso. You ask the mother where the bruises came from, and she tells you that they are from a procedure she performed on him known as "cao gio," which is also known as "coining." The procedure involves rubbing warm oils or gels on a person's skin with a coin or other flat metal object. The mother explains that cao gio is used to raise out bad blood, and improve circulation and healing. When you touch the boy's back with your stethoscope, he winces in pain from the bruises. You debate whether or not you should call Child Protective Services and report the mother. What do you do?

A woman comes into the ER with severe abdominal pain. A CT was conducted and the patient is diagnosed with an abdominal aortic aneurysm. Doctors tell her it is imperative she has surgery and that time is of the essence. It is a 50/50 chance of survival but if she does not go to the OR now, the aneurysm could rupture and she would be dead shortly. She is an erotic dancer and is fearful that if she has surgery she will have a scar, and adamantly refuses the surgery. You as a physician believes be patient is not of sound judgement, and is not thinking clearly, what do you do?

You are a medical student on rounds with an attending. He/she introduces you to the patient as "Dr. Johnson". What should you do?

You are working with an intern, and a patient has just passed away. He asks you to perform a procedure on the patient to help strengthen some of your skills, such as an intubation. What do you do?

 

[pageantry]

Sure, I'll give it a shot. I was kind of lumping it into how I would deal with cheating in general, although this is more serious in my view as they are actively consuming substances that could impair decision making processes. Your best interest should always be the patient, and so I would report the person, as patients could be in danger as a result of his actions.

Sorry throng of underserved patients who love him?
Sorry three tiny children and wife?

 

[pageantry]

I've witnessed very similar issues as to these:

You are a primary care physician and a mother comes into your office with her child who is complaining of flu-like symptoms. Upon entering the room, you ask the boy to remove his shirt and you notice a pattern of very distinct bruises on the boy's torso. You ask the mother where the bruises came from, and she tells you that they are from a procedure she performed on him known as "cao gio," which is also known as "coining." The procedure involves rubbing warm oils or gels on a person's skin with a coin or other flat metal object. The mother explains that cao gio is used to raise out bad blood, and improve circulation and healing. When you touch the boy's back with your stethoscope, he winces in pain from the bruises. You debate whether or not you should call Child Protective Services and report the mother. What do you do?

A woman comes into the ER with severe abdominal pain. A CT was conducted and the patient is diagnosed with an abdominal aortic aneurysm. Doctors tell her it is imperative she has surgery and that time is of the essence. It is a 50/50 chance of survival but if she does not go to the OR now, the aneurysm could rupture and she would be dead shortly. She is an erotic dancer and is fearful that if she has surgery she will have a scar, and adamantly refuses the surgery. You as a physician believes be patient is not of sound judgement, and is not thinking clearly, what do you do?

You are a medical student on rounds with an attending. He/she introduces you to the patient as "Dr. Johnson". What should you do?

You are working with an intern, and a patient has just passed away. He asks you to perform a procedure on the patient to help strengthen some of your skills, such as an intubation. What do you do?

1) I know that technique. It usually doesn't hurt more than a strong massage while it's being done, and many people do find it helpful (for whatever reason). In absence of any other warning signs, I accept the woman's statements at face value. In my opinion, alternative healing techniques should be treated like a religion, including religion's potential for abuse.

2) I would try to get her to contact a friend or family member about it. Even a social worker might help. It seems like any reasonable person would want to talk her into it where you, as a doctor with all you symbolize, might not be able to. If she still doesn't want surgery, I might try to get her to stay under observation to give her a chance to change her mind.

3) I'd supply the correct information to the patient without actively contradicting the attending, by way of interjecting "I'm a medical student," with a friendly smile. My first goal here is to avoid undermining the doctor-patient relationship, while remaining truthful.

4) I'd operate from a genuine place of uncertainty and ask for clarification re: the patient's wishes. Let the intern dig his own grave if that's really what he wants. But I have a sudden horrifying suspicion that this happens all the time.

 

[Law2Doc]

...
You are working with an intern, and a patient has just passed away. He asks you to perform a procedure on the patient to help strengthen some of your skills, such as an intubation. What do you do?

I wish this was allowed to happen -- I've practiced a lot of these skills in cadaver labs but it's very different once rigor mortis sets in. At any rate if there's to be an open casket, families won't appreciate broken teeth from aggressive intubation efforts.

But let's take this example a step further (and the following really happens at a lot of teaching hospitals). A patient is put under general anesthesia for a uterine procedure. Once the patient is out, the attending has the med student (or maybe multiple med students) practice a speculum exam on them. Does your analysis change if the patient is there for her gallbladder to be removed?

 

[Law2Doc]

...
You are a medical student on rounds with an attending. He/she introduces you to the patient as "Dr. Johnson". What should you do?

It's an even funnier example if your name isn't even Johnson...

This is actually a pretty significant and not uncommon problem. Patients don't always get the distinction of whose a doctor, resident, med student. I've seen an instance where a family refused to follow an attendings advice because they got different advice from the other "doctor" -- the one in the short white coat -- earlier in the day during his pre-rounds. Makes for a very awkward situation. A resident may sometimes try to clear the hierarchy up for the patient by introducing the attending to them as "our boss."

 

[prettyNURSEtoMD]

I wish this was allowed to happen -- I've practiced a lot of these skills in cadaver labs but it's very different once rigor mortis sets in. At any rate if there's to be an open casket, families won't appreciate broken teeth from aggressive intubation efforts.

But let's take this example a step further (and the following really happens at a lot of teaching hospitals). A patient is put under general anesthesia for a uterine procedure. Once the patient is out, the attending has the med student (or maybe multiple med students) practice a speculum exam on them. Does your analysis change if the patient is there for her gallbladder to be removed?

In regards to this, one must think of the patients rights, especially those deemed being unable to voice humiliation or embarrassment because they are unaware of the compromising position. Insert consent. Now, if consent was given prior to the examination and an explanation was given as to what would be conducted once she is sedated, then that would change the scenario a bit. Informed consent is a necessity and it must be documented whether the pelvic exam under anesthesia is a medical necessity or for the sole purposes of teaching. Most pelvic exams that are done under anesthesia are deemed necessary if and when the patient could not be adequately examined without causing physical or psychological harm.

And also maybe I'm not reading the second part clearly, she was anesthetized for a uterine procedure but was only there for her gallbladder being taken out?

 

[prettyNURSEtoMD]

It's an even funnier example if your name isn't even Johnson...

This is actually a pretty significant and not uncommon problem. Patients don't always get the distinction of whose a doctor, resident, med student. I've seen an instance where a family refused to follow an attendings advice because they got different advice from the other "doctor" -- the one in the short white coat -- earlier in the day during his pre-rounds. Makes for a very awkward situation. A resident may sometimes try to clear the hierarchy up for the patient by introducing the attending to them as "our boss."

Yes, I hear residents all the time say "my boss" all the time.

 

[Law2Doc]

...
And also maybe I'm not reading the second part clearly, she was anesthetized for a uterine procedure but was only there for her gallbladder being taken out?

No. Anesthetized for a gallbladder procedure, or some other procedure you might not expect a pelvic exam to be performed for.

And let's say the consent form is very broad in terms of being permitted to perform "a full and complete physical exam" at any point during the procedure.

 

[Vain Brother]

the jehova's witness toddler question is an easy one for me because i don't see how a doctor could just allow a child be a martyr for his parents' beliefs

more interesting is a case like this, where the child is right on the precipice of legal adulthood http://www.nytimes.com/2015/01/10/n...-court-fight-to-refuse-chemotherapy.html?_r=0

 

[WingedOx]

You are a primary care physician and a mother comes into your office with her child who is complaining of flu-like symptoms. Upon entering the room, you ask the boy to remove his shirt and you notice a pattern of very distinct bruises on the boy's torso. You ask the mother where the bruises came from, and she tells you that they are from a procedure she performed on him known as "cao gio," which is also known as "coining." The procedure involves rubbing warm oils or gels on a person's skin with a coin or other flat metal object. The mother explains that cao gio is used to raise out bad blood, and improve circulation and healing. When you touch the boy's back with your stethoscope, he winces in pain from the bruises. You debate whether or not you should call Child Protective Services and report the mother. What do you do?

CPS in my state are burdened enough without having to give a crap about some cupping or coining. Ironically enough, if the patient is a white kid from suburbia, I take a closer look at the kid's situation to make sure their hippie parents aren't neglecting other medical treatments, vaccinations, etc. You need to make sure he's not being fed a diet entirely of Kale.

A woman comes into the ER with severe abdominal pain. A CT was conducted and the patient is diagnosed with an abdominal aortic aneurysm. Doctors tell her it is imperative she has surgery and that time is of the essence. It is a 50/50 chance of survival but if she does not go to the OR now, the aneurysm could rupture and she would be dead shortly. She is an erotic dancer and is fearful that if she has surgery she will have a scar, and adamantly refuses the surgery. You as a physician believes be patient is not of sound judgement, and is not thinking clearly, what do you do?

Standard capacity assessment. Sadly too many people leave residency without the ability to do one.

You are a medical student on rounds with an attending. He/she introduces you to the patient as "Dr. Johnson". What should you do?

Honestly, even the term "student doctor" for a medical student is rather unethical. Your average layperson doesn't understand the distinctions involved in medical training. Students should be introduced as what they are: students, who have neither the practical knowledge nor the responsibilities of someone who has completed training. As for what you do? probably nothing given your passive role that is likely to be present on rounds.

You are working with an intern, and a patient has just passed away. He asks you to perform a procedure on the patient to help strengthen some of your skills, such as an intubation. What do you do?

No, just no. Here's the problem though. If the intern is expecting you to do this now, it's pretty likely this is accepted practice in his program. If you complain about it, you're suddenly the medical student who makes waves. Clerkship directors don't like students who make waves. Honestly, your deans probably don't care for them either.