Ethical scenario discussion

[MDProspect]

ER visits are free in that you don't have to pay out of pocket. And if you don't have the money to pay your bill after your visit is over, no one is going to prosecute you for failure to pay. Obviously there are opportunity costs to spending time at the hospital, but I think it's best to let patients make well-informed decisions about their own medical care instead of hiding information for the sake of peace of mind.

Why not tell cigarette smokers to get screened for lung cancer? Because they already know that what they're doing is unhealthy and could lead to lung cancer. That's entirely unrelated to someone who has a potentially cancerous lesion on their posterior shoulder that they very well may be unaware of.

In what world do you live in? You are without a doubt going to be prosecuted for not paying your debt. Failure to pay the hospital results in being put on collection. If you fail to pay them. You will get sued and your wages will garnished whether you like it or not (unless you work for cash, then they will come after anything you own of value). Secondly, stop calling this woman your patient. She didn't come to you for help nor was she admitted to a hospital where you work at. She is just a commuter on a bus, whose minding her own business. Lastly, your whole argument is that it's on her back as if she has no lateral head movement or as if mirrors don't exist. She probably knows about the lesion on her own back.

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[Ismet]

Generally, increased detection without a corresponding decrease in mortality indicates that increased screening and detection do little. See the mammogram.

ETA: If increased diagnosis doesn't change mortality, then a lot more people are potentially worrying and getting unnecessary procedures for no reason.

Where did you read that the increased incidence is due to increased detection? It could as well be due to a higher prevalence from an aging population, more time spent outdoors, higher amounts of UV radiation etc.

Your claim is certainly a possibility, but you can't just look at the data and assume that.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538462/

This study shows that disease-specific mortality is actually decreasing, as is advanced-stage disease at first presentation. Basically the incidence is increasing due to a variety of factors, but the lesions are being picked up at earlier stages. Mortality correlates with the stage of the lesion at first presentation.

 

[aalamruad]

You are living in lala land. ER visits are not free. The Emergency Department does charge and the doctors that work there charge, too, and they will send the bill to collections if you don't pay. Collections agents will hound you until you do pay, or you set up a payment plan, and being "in collections" can damage your credit rating.

I've worked extensively with impoverished families, many of whom have been to the ER countless times for things that you or I would see our primary care doc for, and none of them have ever been prosecuted in any way or pursued by collections agencies for failure to pay their hospital bill. I've also worked in 4 different emergency departments with doctors who've explained to me the frequency with which patients don't pay their bills, and it's shocking how few patients actually pay and how few patients in the ER even have health insurance. You're the one living in lala land if you think collections agencies are going to attack people who can barely afford food or rent. I've seen how collections agencies work, and it's simply not worth their time to pursue those low-level cases very aggressively. They specifically target people with money, not people who couldn't pay for an ER visit for fear of being evicted from their apartment because they couldn't pay rent.

You may want to let "patients" make their own decisions but this lady is not a patient. She is a fellow transit rider waiting at a bus stop. You have no obligation to her to tell her that something on her skin looks funky. I think it is overstepping the bounds of decency to interrupt a stranger on the street and tell them they should go to the doctor based on your knowledge as a pre-med.

You need to reread the question prompt, because it doesn't say anything about a pre-med telling the woman about the lesion. I wouldn't tell her about the lesion, because I don't know anything about melanoma and can't identify it accurately at all. But the question prompt is referring to someone who has completed their education and is now in training, who has recently been studying melanoma with their derm atlas. Enough with the straw man arguments, I'm not claiming that pre-meds should mention the lesion in cases like this.

In what world do you live in? You are without a doubt going to be prosecuted for not paying your debt. Failure to pay the hospital results in being put on collection. If you fail to pay them. You will get sued and your wages will garnished whether you like it or not (unless you work for cash, then they will come after anything you own of value). Secondly, stop calling this woman your patient. She didn't come to you for help nor was she admitted to a hospital where you work at. She is just a commuter on a bus, whose minding her own business. Lastly, your whole argument is that it's on her back as if she has no lateral head movement or as if mirrors don't exist. She probably knows about the lesion on her own back.

My God, you're out of touch with reality. If you seriously think that collections agencies will spend any time going after someone who doesn't even have enough money for rent or basic healthcare, you're off your rocker. I've seen collections agencies in action, and that's not how they work.

Also, (and this is directed at @LizzyM too) I didn't call the woman my patient. I said that patients should be well-informed so they can make their own decisions. That's a general statement about that fact that a person doesn't have true autonomy in their medical care if they aren't even aware of their options or conditions.

 

[Gurby]

You are living in lala land. ER visits are not free. The Emergency Department does charge and the doctors that work there charge, too, and they will send the bill to collections if you don't pay.

In my region of the US, there is an urgent care on every street corner. Last time I went to one, I paid $100 for a full physical exam from an MD, x-ray and splinting of a hand I sprained. I certainly don't think this lady should go to the ED. I think stopping by a doc-in-the-box to get checked out by a FM physician would be a good place to start.

 

[MDProspect]

I've worked extensively with impoverished families, many of whom have been to the ER countless times for things that you or I would see our primary care doc for, and none of them have ever been prosecuted in any way or pursued by collections agencies for failure to pay their hospital bill. I've also worked in 4 different emergency departments with doctors who've explained to me the frequency with which patients don't pay their bills, and it's shocking how few patients actually pay and how few patients in the ER even have health insurance. You're the one living in lala land if you think collections agencies are going to attack people who can barely afford food or rent. I've seen how collections agencies work, and it's simply not worth their time to pursue those low-level cases very aggressively. They specifically target people with money, not people who couldn't pay for an ER visit for fear of being evicted from their apartment because they couldn't pay rent.


You need to reread the question prompt, because it doesn't say anything about a pre-med telling the woman about the lesion. I wouldn't tell her about the lesion, because I don't know anything about melanoma and can't identify it accurately at all. But the question prompt is referring to someone who has completed their education and is now in training, who has recently been studying melanoma with their derm atlas. Enough with the straw man arguments, I'm not claiming that pre-meds should mention the lesion in cases like this.


My God, you're out of touch with reality. If you seriously think that collections agencies will spend any time going after someone who doesn't even have enough money for rent or basic healthcare, you're off your rocker. I've seen collections agencies in action, and that's not how they work.

Also, (and this is directed at @LizzyM too) I didn't call the woman my patient. I said that patients should be well-informed so they can make their own decisions. That's a general statement about that fact that a person doesn't have true autonomy in their medical care if they aren't even aware of their options or conditions.

I want to keep it civil, but I call bull**** on what you just wrote. Collection agency do go after people. If they can't collect they sell your debt to someone else for pennies on a dollar. They won't stop harassing you. FYI, Dr. Herbert refered to first year trainee as a MS1 not a PGY1 who is doing a dermatology residency. So you are nothing more than a first year student in the prompt.

 

[aalamruad]

I want to keep it civil, but I call bull**** on what you just wrote. Collection agency do go after people. If they can't collect they sell your debt to someone else for pennies on a dollar. They won't stop harassing you. FYI, Dr. Herbert refered to first year trainee as a MS1 not a PGY1 who is doing a dermatology residency. So you are nothing more than a first year student in the prompt.

Wrong on both accounts. Collection agencies are incredibly benign when pursuing those with low income. My own family has been pursued by them, and it's literally nothing more than a phone call once or twice a month that you can just ignore. For those with even lower income, like the truly impoverished families I've worked with, collections agencies don't make any contacts at all, not even so much as a phone call. You simply don't know what you're talking about.

Also, the prompt in this thread referred to the person as a first-year trainee. That means PGY1 on this forum, ask anyone who's a regular here and they'll know that "training" does not refer to undergraduate or medical education, but the years beyond. I couldn't care less what Dr. Herbert said if it's different than the prompt in the OP of this thread.

 

[Matthew9Thirtyfive]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538462/

This study shows that disease-specific mortality is actually decreasing, as is advanced-stage disease at first presentation. Basically the incidence is increasing due to a variety of factors, but the lesions are being picked up at earlier stages. Mortality correlates with the stage of the lesion at first presentation.

Like I said in my very next post, I haven't actually looked at data. I was simply explaining LizzyM's point. For Breast CA and prostate CA, incidence is increasing while mortality is not decreasing. May not be that way for melanoma.

 

[MDProspect]

Wrong on both accounts. Collection agencies are incredibly benign when pursuing those with low income. My own family has been pursued by them, and it's literally nothing more than a phone call once or twice a month that you can just ignore. For those with even lower income, like the truly impoverished families I've worked with, collections agencies don't make any contacts at all, not even so much as a phone call. You simply don't know what you're talking about.

Also, the prompt in this thread referred to the person as a first-year trainee. That means PGY1 on this forum, ask anyone who's a regular here and they'll know that "training" does not refer to undergraduate or medical education, but the years beyond. I couldn't care less what Dr. Herbert said if it's different than the prompt in the OP of this thread.

Are you mentally inept? Dr. Herbert is the author of the book, where this prompt was taken from. Good luck with your idealistic views. I just feel bad for any patient who has to cross your path in the future.

 

[aalamruad]

Are you mentally inept? Dr. Herbert is the author of the book, where this prompt taken from. Good luck with your idealistic views. I just feel bad for any patient who has to cross your path in the future.

Reported. Disappointing that you had to resort to disgusting ad hominem attacks, when you were actually making decent, logical, and respectful arguments earlier on.

Also, SDN interprets "first year of training" as PGY1, not MS1, so if the OP didn't clarify what Dr. Herbert meant, we're all going to answer the question with the assumption that the person in question has completed their medical education.

 

[ace_inhibitor111]

Well, on second thought it does seem inappropriate/offensive to talk about this issue with a stranger. And the chances of them actually seeing a doctor because of it is slim. So I think I have to agree about not talking to her after all.

 

[Ismet]

Please keep the discussion civil. Thank you.

 

[Ismet]

Like I said in my very next post, I haven't actually looked at data. I was simply explaining LizzyM's point. For Breast CA and prostate CA, incidence is increasing while mortality is not decreasing. May not be that way for melanoma.

I know. I was just providing another piece of evidence beyond the graph that was shown in the previous link.

 

[Ismet]

My own family has been pursued by them, and it's literally nothing more than a phone call once or twice a month that you can just ignore.

Which affects your credit score if you continue to ignore.

 

[aalamruad]

Which affects your credit score if you continue to ignore.

Fair. But I personally would value healthcare over good credit in a situation like this. Others might disagree, but if I had an ominous looking lesion on my own shoulder and had to risk my credit score to get it checked out by a doc, I wouldn't even hesitate.

 

[Gurby]

Just saw this commercial and immediately thought of this thread:

 

[Matthew9Thirtyfive]

Just saw this commercial and immediately thought of this thread:

That's awesome.

 

[Goro]

To follow up my wise colleague's words, hospitals not only will go after you for unpaid bills, they go after the uninsured much harder and harsher than those with insurance.

As to the ethics question, this is an example of many questions having no right answer, but there are wrong answers. No, I'm not sharing.

You are living in lala land. ER visits are not free. The Emergency Department does charge and the doctors that work there charge, too, and they will send the bill to collections if you don't pay. Collections agents will hound you until you do pay, or you set up a payment plan, and being "in collections" can damage your credit rating.

You may want to let "patients" make their own decisions but this lady is not a patient. She is a fellow transit rider waiting at a bus stop. You have no obligation to her to tell her that something on her skin looks funky. I think it is overstepping the bounds of decency to interrupt a stranger on the street and tell them they should go to the doctor based on your knowledge as a pre-med.

 

[LizzyM]

To follow up my wise colleague's words, hospitals not only will go after you for unpaid bills, they go after the uninsured much harder and harsher than those with insurance.

As to the ethics question, this is an example of many questions having no right answer, but there are wrongs answers. No, I'm sharing.

Furthermore, sometimes it is not the answer to the question itself, but your critical thinking skills that are being judged here. Having the opinin that the ER is the appropriate setting for an uninsured person to get care for non-emergencies shows a lack of critical thinking skills and knowledge of the health care environment. I'd come down more harshly on an applicant for a response of that kind than I would the response to a question about would you tell or not and why.

 

[aalamruad]

Furthermore, sometimes it is not the answer to the question itself, but your critical thinking skills that are being judged here. Having the opinin that the ER is the appropriate setting for an uninsured person to get care for non-emergencies shows a lack of critical thinking skills and knowledge of the health care environment. I'd come down more harshly on an applicant for a response of that kind than I would the response to a question about would you tell or not and why.

Sorry for the bump, but I'd like to hear your thoughts on a variation of the ethical question in the OP to see if your answer is different:
A third-year medical student meets a stranger on a bus who shows him a picture of her 2-year-old daughter, and he notices a normal red reflex in the kid's right eye and leukocoria in her left eye (could be cataracts, retinoblastoma, retinal detachment, Coats disease, etc., but the picture is taken from a slight angle so it could be benign pseudoleukocoria even though it's unilateral). Should the medical student advise the mother to take her child to a doctor, and if so, why is your answer different from the other ethical question? If she can't afford to see a doctor, is the ER an appropriate place to take her daughter for an eye exam (to in turn get a peds ophtho referral) given that some of the possible diagnoses are emergencies? If not, where should the mother take her daughter? And if the med student shouldn't mention anything at all, why not?

 

[CaliforniaDreamer]

Furthermore, sometimes it is not the answer to the question itself, but your critical thinking skills that are being judged here. Having the opinin that the ER is the appropriate setting for an uninsured person to get care for non-emergencies shows a lack of critical thinking skills and knowledge of the health care environment. I'd come down more harshly on an applicant for a response of that kind than I would the response to a question about would you tell or not and why.

I have been told multiple times now while doing volunteer health screening that I should suggest to people with high blood glucose or BP to go to the ER. I am not talking about dangerously high levels, just for anyone who is out of the normal range and might be concerned. Also for anyone who seems concerned about other medical problems. These are often under/uninsured people. The logic being that they cannot be turned away and that they will either get treated there or be given the correct referral.

 

[LizzyM]

I have been told multiple times now while doing volunteer health screening that I should suggest to people with high blood glucose or BP to go to the ER. I am not talking about dangerously high levels, just for anyone who is out of the normal range and might be concerned. Also for anyone who seems concerned about other medical problems. These are often under/uninsured people. The logic being that they cannot be turned away and that they will either get treated there or be given the correct referral.

Frankly, your mentors are part of the problem, not part of the solution. You shouldn't be doing health screenings if the screen positive doesn't have a way to access health care that can make a difference in their overall health. Clogging up the emergency department with people who have BP 160/90 or a random blood sugar of 180 is not the way to deliver health care services. There should be a protocol for referring these folks to a primary care provider or a federally qualified health clinic. There is appropriate referral and inappropriate referral. If a BP is 200/140 or a blood sugar is 500 that's a different story but anyone who "seems concerned" doesn't belong in the ED.

Sorry for the bump, but I'd like to hear your thoughts on a variation of the ethical question in the OP to see if your answer is different:
A third-year medical student meets a stranger on a bus who shows him a picture of her 2-year-old daughter, and he notices a normal red reflex in the kid's right eye and leukocoria in her left eye (could be cataracts, retinoblastoma, retinal detachment, Coats disease, etc., but the picture is taken from a slight angle so it could be benign pseudoleukocoria even though it's unilateral). Should the medical student advise the mother to take her child to a doctor, and if so, why is your answer different from the other ethical question? If she can't afford to see a doctor, is the ER an appropriate place to take her daughter for an eye exam (to in turn get a peds ophtho referral) given that some of the possible diagnoses are emergencies? If not, where should the mother take her daughter? And if the med student shouldn't mention anything at all, why not?

As for a stranger showing a third year student a photo on the bus, I don't believe the student has an ethical responsibility to the stranger. I wouldn't believe that a M3 knows enough about pediatric ophtho to have an informed opinion. If I were the M3, I might ask if the child has a usual source of medical care (for shots and the like) and if not, to recommend that the child get hooked up with a medical home or perhaps even offer the name of a health clinic for kids in the general area.

 

[Shirafune]

Frankly, your mentors are part of the problem, not part of the solution. You shouldn't be doing health screenings if the screen positive doesn't have a way to access health care that can make a difference in their overall health. Clogging up the emergency department with people who have BP 160/90 or a random blood sugar of 180 is not the way to deliver health care services. There should be a protocol for referring these folks to a primary care provider or a federally qualified health clinic. There is appropriate referral and inappropriate referral. If a BP is 200/140 or a blood sugar is 500 that's a different story but anyone who "seems concerned" doesn't belong in the ED.

As for a stranger showing a third year student a photo on the bus, I don't believe the student has an ethical responsibility to the stranger. I wouldn't believe that a M3 knows enough about pediatric ophtho to have an informed opinion. If I were the M3, I might ask if the child has a usual source of medical care (for shots and the like) and if not, to recommend that the child get hooked up with a medical home or perhaps even offer the name of a health clinic for kids in the general area.

Thanks for bringing up some of these things about care in the ED!
Led to some interesting reading. For an on example on non-emergent ED use: http://www.jabfm.org/content/26/6/680.long

I only read the intro and skimmed the results section, but here is a quick summary:

(1) Increased load in EDs--more patients are going to the ED with non-emergent conditions rather than their usual care providers because of convenience and accessibility
(2) Research suggests that increased patient satisfaction with care from PCP decreases likelihood of seeking care from ED.
(3) Barriers to primary care access such as transportation, phone access to PCP, and appointment times increase likelihood of visiting the ED
(4) Extending primary care hours associates with lower healthcare cost, but not mortality; patients of family physicians and GPs rather than internists and subspecialists tend to spend less on healthcare

Table 1 reports that ED users are more likely to be less healthy (generally and mentally) and poorer (unemployed, less income, and covered by public insurance).

Together these points highlight the value of patient relationships with their PCP in terms of patient satisfaction/trust and accessibility. As such, overloading EDs with non-emergent patients is associated with higher healthcare costs which, as a burden on patient finances and patient volume in the healthcare system, could feasibly be alleviated by improving patient perceptions and accessibility to primary care providers. This also supports the idea that poorer/uninsured folks would benefit financially and physically from a PCP and that the ED is not the ideal place to receive care for non-emergent issues.

 

[lpp06]

Back to the OP for a second -

I don't think I'd bring the lesion to the attention of the woman for several reasons. One - although as a doctor you pledge your life to advancing the health others, your obligation is very personal. As someone mentioned earlier (sorry for not quoting), to provide true care for someone, they must be vulnerable in the doctor-patient relationship so that they can feel comfortable communicating any doubts, fears, hesitations throughout the entirety of their care. This type of relationship isn't formed on a bus within seconds. Second - by engaging in the scenario you must be prepared to assume liability for the medical opinion you've dispensed, both in conscience and legality.

Honestly, as a doctor, it is unreasonable to believe that you will be able to save every life you encounter. It's simply impossible. The response in this scenario should rather be to seek out ways to help educate the community as a whole in the dangers of melanoma, how to prevent it, and how to better the public's access to preventative screenings. This is the true power of a doctor - to impact wide scale change through knowledge, leadership and advocacy.

Interesting tangent - what if you weren't educated in a healthcare field, say a businessman - would you be more or less comfortable saying something?

 

[aalamruad]

Honestly, as a doctor, it is unreasonable to believe that you will be able to save every life you encounter. It's simply impossible. The response in this scenario should rather be to seek out ways to help educate the community as a whole in the dangers of melanoma, how to prevent it, and how to better the public's access to preventative screenings. This is the true power of a doctor - to impact wide scale change through knowledge, leadership and advocacy.

Not being able to help everyone isn't a valid argument against trying to help an individual.

 

[aalamruad]

As for a stranger showing a third year student a photo on the bus, I don't believe the student has an ethical responsibility to the stranger. I wouldn't believe that a M3 knows enough about pediatric ophtho to have an informed opinion. If I were the M3, I might ask if the child has a usual source of medical care (for shots and the like) and if not, to recommend that the child get hooked up with a medical home or perhaps even offer the name of a health clinic for kids in the general area.

Well that's disappointing, I was under the impression that leukocoria was considered a pretty obvious and well-known sign that often indicates some significant life-threatening and vision-threatening conditions.

 

[wizzed101]

The original version of the starfish story was this

A young girl was walking along a beach upon which thousands of starfish had been washed up during a terrible storm. When she came to each starfish, she would pick it up, and throw it back into the ocean. People watched her with amusement.

She had been doing this for some time when a man approached her and said, “Little girl, why are you doing this? Look at this beach! You can’t save all these starfish. You can’t begin to make a difference!”

On topic, I think not interfering is a defense mechanism: once you start caring so much, you are inclined to take failures to save lives to heart and it can only go downhill from there.

 

[Labrat07]

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