Ethical scenario discussion

[greaterwing]

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Hi all,

I would really like to get some insight on this scenario. It is from the book Doing Right.


You are in your first year of training in a healthcare profession. Recently learning about the dangers of suntanning, you have taken to cautioning your friends about melanoma, the most serious form of skin cancer. You’ve seen pictures of some pretty nasty looking lesions in your Derm atlas. One hot summer’s day, you are standing in a crowded bus going to school, you happen to notice a small but ominous-looking lesion the posterior shoulder of a fellow passenger wearing a halter top. You have never seen her before.


1. Would you say anything to her? If so, what? Under what circumstances would you not say something?

2. How do you think the public and the medical community view what should be done in these situations?


I believe it would be appropriate to approach this person (alone or when she gets off the bus) and to ask her if she has ever had this lesion checked out. I would be sensitive to providing her this information as I have never seen her before, but would explain I wanted to look out for her best interest.

I would am not sure how the public and medical community would view what should be done in this situation, but I would assume that as a medical professional and having the duty to protect others, it would not be wrong to bring up something we see as dangerous to someone.


Thoughts?

 

[RogueBanana]

I wouldn't approach her. We are going to be physicians, not the health police. If the lesion is noticeable enough that a fellow passenger on a bus can see it, then it can be safely assumed she knows about it. Our obligation is to act with beneficence, but also respect the autonomy of the patient. It is the patients responsibility to check themselves and come to us if they require assistance. By making it acceptable for us to intervene with strangers (especially in a public place) it sets a dangerous precedent. In my opinion, going to the doctor is stressful enough for the general public, it would jeapordize the sacred trust between physician and patient if all of a sudden doctors just pulled you aside on the subway to tell you "Hey you might have cancer"

Just my 2 pence

 

[LizzyM]

I am reminded of the late Richard Selzer's short story, "The Consultation" in his book, Rituals of Surgery. In it, a surgeon at a convention spends the night with a call girl. In the morning, looking at her breast, he notices something awry. He examines it with his eyes and fingers and as he gets dressed he tells her that she should get it checked out. Read the rest of the story to find out what happens next.

 

[greaterwing]

I wouldn't approach her. We are going to be physicians, not the health police. If the lesion is noticeable enough that a fellow passenger on a bus can see it, then it can be safely assumed she knows about it. Our obligation is to act with beneficence, but also respect the autonomy of the patient. It is the patients responsibility to check themselves and come to us if they require assistance. By making it acceptable for us to intervene with strangers (especially in a public place) it sets a dangerous precedent. In my opinion, going to the doctor is stressful enough for the general public, it would jeapordize the sacred trust between physician and patient if all of a sudden doctors just pulled you aside on the subway to tell you "Hey you might have cancer"

Just my 2 pence

Ah, I see. This is a very good point. Thank you for your insight.

 

[greaterwing]

I am reminded of the late Richard Selzer's short story, "The Consultation" in his book, Rituals of Surgery. In it, a surgeon at a convention spends the night with a call girl. In the morning, looking at her breast, he notices something awry. He examines it with his eyes and fingers and as he gets dressed he tells her that she should get it checked out. Read the rest of the story to find out what happens next.

Hm, interesting. I will have to read on this!

 

[theonlytycrane]

@greaterwing Nice post. How do you like Doing Right btw? Is it in a textbook type of format?

 

[greaterwing]

@greaterwing Nice post. How do you like Doing Right btw? Is it in a textbook type of format?

Hey, thank you! It's a great read, especially because there are clinical scenarios sprinkled in throughout each chapter. It helps with learning what to do in ethical situations. I would recommend it! I'm not sure what you mean by textbook format?

 

[721145]

Benign skin things can look scary, and first year of training in a healthcare profession is not a license or certification to practice. I would not say anything - unless it was the most unquestionable clinical presentation of melanoma ever. This is on the posterior shoulder - there is a chance that this person has not seen the lesion/is unaware of it, in which case I would casually ask if the passenger had 1) ever had the spot looked at by a doc, and 2) if not, I'd say something like, "hey, you know, not to freak you out, but I have a friend who had a spot that looked like that and it turned out to be something, so you might really consider having a doc check it out." I would NOT in any way present myself as an expert, a healthcare professional in training, or reference any clinical/medical knowledge.

This is a complicated issue. The passenger has not sought my (uncertified, unlicensed, untrained) medical advice or opinion, and I agree with RogueBanana - patient autonomy and privacy both need to be respected. We aren't the healthcare police. But if it was my sister, I would want someone with the knowledge to recognize/be concerned about a melanoma to say something--imagine if it was melanoma and no one said anything, and the passenger never noticed it / didn't have a loved one who looks at her back every day to notice it. She could be (avoidably) dead in a relatively short time.

 

[MDProspect]

I agree with @RogueBanana and @Chekhov's gun. I also wanted to mention that you have no affirmative duty to help this person as this person is not your patient (they did not come to you for help and no doctor-patient relationship was established).

 

[Goro]

I have asked this very question!!!!!

No, I'm not sharing answers.

Hi all,

I would really like to get some insight on this scenario. It is from the book Doing Right.


You are in your first year of training in a healthcare profession. Recently learning about the dangers of suntanning, you have taken to cautioning your friends about melanoma, the most serious form of skin cancer. You’ve seen pictures of some pretty nasty looking lesions in your Derm atlas. One hot summer’s day, you are standing in a crowded bus going to school, you happen to notice a small but ominous-looking lesion the posterior shoulder of a fellow passenger wearing a halter top. You have never seen her before.


1. Would you say anything to her? If so, what? Under what circumstances would you not say something?

2. How do you think the public and the medical community view what should be done in these situations?


I would said it would be appropriate to approach this person (alone or when she gets off the bus) and to ask her if she has ever had this lesion checked out. I would be sensitive to providing her this information as I have never seen her before, but would explain I wanted to look out for her best interest.

I would am not sure how the public and medical community would view what should be done in this situation, but I would assume that as a medical professional and having the duty to protect others, it would not be wrong to bring up something we see as dangerous to someone.


Thoughts?

 

[aalamruad]

We are going to be physicians, not the health police.

Police enforce things. I wouldn't really say you're forcing anything on the woman by offering a simple statement of advice.

If the lesion is noticeable enough that a fellow passenger on a bus can see it, then it can be safely assumed she knows about it.

But it can't be safely assumed that she knows how dangerous it could be, even if she does know of its existence. Not everyone knows that certain signs and symptoms should be worrying.

And @Chekhov's gun makes a good point that there's a good chance she has never even noticed it due to its location on her shoulder.

Our obligation is to act with beneficence, but also respect the autonomy of the patient.

This isn't an issue of autonomy (it's more a matter of privacy). You haven't violated her right to make her own decisions by offering a statement of advice. Her ability to make her own decisions will simply be better informed. I could see an argument being made for not saying anything in order to respect her privacy, but anyone in public is subject to receiving opinions from others, and if those opinions happen to benefit your health, so be it. We live in a society together, with a free flow of ideas, so let's act like it rather than receding into self-absorption and social isolation.

It is the patients responsibility to check themselves and come to us if they require assistance.

But the whole point of the dilemma is that she very well might not realize that she requires assistance. That's the point of annual wellness checks for example, people don't always recognize their own symptoms, and thus don't seek the medical care they need.

By making it acceptable for us to intervene with strangers (especially in a public place) it sets a dangerous precedent.

1) A simple statement of advice isn't much of an "intervention," it's just being a human being with educated opinions and compassion and communication skills.

2) Why does this set a dangerous precedent? I can't conceive of a reasonable way in which this type of beneficent behavior could escalate to a dangerous level.

In my opinion, going to the doctor is stressful enough for the general public, it would jeapordize the sacred trust between physician and patient if all of a sudden doctors just pulled you aside on the subway to tell you "Hey you might have cancer"

I see what you mean here, and there's definitely some value in preventing resentment towards healthcare providers for the sake of patients in general. I simply think it would do much more good than harm, and don't see how it would significantly damage the doctor-patient relationship. In fact there's an argument to be made that compassionately concerned comments like this could even make people view the whole of medicine in a better light.


If it was a loved one with the lesion, almost anyone would hope that a stranger would offer helpful advice (not through making a diagnosis, but by suggesting that they get it checked out by an expert). I really think this just boils down to being a caring person who's not afraid of communicating with others. When we become so petrified of offending people that we stop interacting with them in meaningful ways (like making a concerned comment to a stranger), we're really saying that pseudo-violations of privacy should be avoided at the cost of health and well-being. That would be very sad.

 

[MDProspect]

@greaterwing Nice post. How do you like Doing Right btw? Is it in a textbook type of format?

I have also read it while studying for CASPr. Ethical guidelines are categorized by chapters (I.e patient's autonomy will be discussed in one chapter and another topic will discussed in the next chapter). The book is an easy read and the peculiar cases were interesting. My biggest disappointment with the book was when the author left some cases/ethical discussions on a cliffhanger and I had to fill in the missing pieces, which would be nice if I read it for leisure. Also Dr. Herbert was a practicing physician in Canada; thus, he mentions the Canadian jurisprudence. The laws and guidelines for big issues, such as child/elderly abuse and patient confidentiality are the same in America and Canada, but there are nuances between the two legal systems and what might be ethical in Canada, will not necessarily be considered ethical in America. If you are going to be practicing in America and want more clearcut answers on ethical scenarios, then you should use this guideline: https://depts.washington.edu/bioethx/toc.html

 

[MDProspect]

[QUOTE="we're really saying that pseudo-violations of privacy should be avoided at the cost of health and well-being. That would be very sad.[/QUOTE] I don't think that they should be avoided, but there is a time and place for everything. Yes, you can pull this lady aside and tell her that you have noticed a spot on her back, and you are concerned about it, but how do you think she would feel? Cancer is a serious matter and you can cause more harm than good. Imagine how you would feel if you were standing at a bus stop and a stranger told you that your zipper was opened. You might feel embarrassed, zip it, the end. Now imagine a situation where there is no quick fix and this situation pertains to your health. I don't know about you, but I would be stressed and losing sleep over it. As a first year, you don't have the necessary skills and knowledge. Even licensed dermatologist take tissue samples for biopsy before making a diagnoses. Therefore, you would be causing this person a lot of unnecessary stress if the spot on her back turns out to be benign. Being a physician is about helping people as much as it is about making good judgements.

 

[aalamruad]

I don't think that they should be avoided, but there is a time and place for everything. Yes, you can pull this lady aside and tell her that you have noticed a spot on her back, and you are concerned about it, but how do you think she would feel? Cancer is a serious matter and you can cause more harm than good. Imagine how you would feel if you were standing at a bus stop and a stranger told you that your zipper was opened. You might feel embarrassed, zip it, the end. Now imagine a situation where there is no quick fix and this situation pertains to your health. I don't know about you, but I would be stressed and losing sleep over it. As a first year, you don't have the necessary skills and knowledge. Even licensed dermatologist take tissue samples for biopsy before making a diagnoses. Therefore, you would be causing this person a lot of unnecessary stress if the spot on her back turns out to be benign. Being a physician is about helping people as much as it is about making good judgements.

Are you serious? Why in the world would anyone go into medicine if they can't handle the guilt of breaking bad news to people? More importantly, why would anyone spend years studying medicine to help the sick, only to avoid helping a stranger when you have the chance to potentially make an enormously positive impact on their health? I don't mean any offense, but I'm truly beyond baffled by your reasoning. Thousands of people die from melanoma every year, but you're more focused on making sure she doesn't lose a couple nights of sleep over unnecessary anxiety.

 

[LizzyM]

Are you serious? Why in the world would anyone go into medicine if they can't handle the guilt of breaking bad news to people? More importantly, why would anyone spend years studying medicine to help the sick, only to avoid helping a stranger when you have the chance to potentially make an enormously positive impact on their health? I don't mean any offense, but I'm truly beyond baffled by your reasoning. Thousands of people die from melanoma every year, but you're more focused on making sure she doesn't lose a couple nights of sleep over unnecessary anxiety.

Telling someone they have something that needs to be checked out will create anxiety. If she is not in a circumstance where she can get into see a health care provider, the anxiety could last for months. It could end up costing the woman a significant out of pocket expense, and it could be nothing (except cost and anxiety) or it could be something which being detected early will change the outcome, or it could be something that is too far gone to be curable and you have found something that would have killed her in x months whether or not you speak up. It isn't always a plus to be told you should get something checked out, at least it wouldn't be to me.

 

[MDProspect]

Are you serious? Why in the world would anyone go into medicine if they can't handle the guilt of breaking bad news to people? More importantly, why would anyone spend years studying medicine to help the sick, only to avoid helping a stranger when you have the chance to potentially make an enormously positive impact on their health? I don't mean any offense, but I'm truly beyond baffled by your reasoning. Thousands of people die from melanoma every year, but you're more focused on making sure she doesn't lose a couple nights of sleep over unnecessary anxiety.

None taken, but it could be more than couple of nights of sleep. You don't know what the person is going through. She might have other situational factors that are affecting her mental state. Everything together might cause a snowball effect. Yes, thousands of people die from melanomas, which only proves my point that telling someone that they might have cancer shouldn't be taken lightly. Please tell me how would you disclose to your patient that they have cancer? Sit them down in the room and tell them everything from A to Z?

There is a reason for a six-step protocol (SPIKES) for disclosing bad news. It factors in the patient's emotional and mental state. You first ask how the patient is doing and then ask him/her whether s/he wants to know the results of a test. If they say no or they are not ready, you leave it at that and schedule another appointment for another time when the patient had time to gain his/her composure. You should never just tell him/her the diagnosis, treatment, and prognosis in one sitting. You are supposed guide your patient and stop along the way to address concerns and allow for the patient to express his/her emotions. By telling this person at the bus stop that she might have cancer even though your a novice, doctor in training, you are doing harm. Since a bus stop is not a private setting where she will feel comfortable to express her emotions and where you can have a discussion about how you are not a doctor yet, but you feel that she should get help.

The scenarios that I imagine that will happen:
A) The woman starts panicking and gets emotional at the bus stop.
B) You tell her that the spot on her back is suspicious and she should seek medical help, and she starts questioning why. You tell her it might be cancerous and scenario A plays out.
C) She already sought help and gets offended.
D) The scenario that you are hoping for, she thanks you and immediately goes to get medical help.

 

[ace_inhibitor111]

I think the outcome of having a possibly deadly disease treated early is worth the risk of her possibly having anxiety due to not seeing a healthcare provider. It just seems unlikely for her to BOTH 1) have long term anxiety due to something a stranger pointed out to her on the bus, (2) her not being able to see a healthcare provider at all (no insurance? right now that's 10% of the population. And what about ED?).

Also, pamphlets concerning "warning signs" to look out for diabetes, cancer, high blood pressure etc. are given broadly to the public. Surely even if the disease was incurable she should still deserve the right to know?

I also don't think the six-step protocol and "patient choice" applies in this case. You are not her doctor and she is not a patient and you definitely won't be able to diagnose her with anything at the bus stop. It's not relevant to tell her you're a medical student or even that the mark is cancerous (because you really don't know). You could even say "have you noticed xxx? It could be a rash, have a doctor check it out."

 

[Uncle_Drew]

1. Would you say anything to her? If so, what? Under what circumstances would you not say something?

I would speak to her about it. I don't see any reason not to speak to someone on the bus. We all took the bus at some point and as you know, people say hello, how are you etc. There are ways of speaking to people that are conducive to getting along, and if you approach people the right way, you shouldn't get any resistance, especailly if you explain yourself. I understand people don't want to be bothered a lot of times, and it may be considered a nuisance to strike up a random conversation with someone. However, in this instance, the pros outweigh the cons. It's a simple risk reward analysis - if you do say something, two avenues occur; either the person thanks you, or they tell you to mind your own business. In either case, you don't lose or gain. If you don't say anything, the person can either be fine, which doesn't harm anyone, or potentially sick, which is a significant loss. Because the situation has little cost to you and much to gain for the person and yourself (i.e. you help save a life potentially), you should speak to the person. Again, appraoch them politely, and say "excuse me, I don't mean to bother you, but I am studying medicine or pre-med and I was a little concerned about something I saw. I notice you have a lump on your shoulder. I don't mean to alarm you, but just to be safe, it might be good to make a quick stop at your doctor to make sure everything's ok. I would want someone to tell me, so I thought I'd treat you the same. Hopefully I didn't bother you too much. ". I highly doubt if you appraoch the person in this manner, that they will respond negatively. If they do, you've done your due diligence, and tried to help. As a potential physician, I think your responsibility to your community extends past just your office, so if you want to become a physician, you should try to help in situations outside the office as well.

Note1: This is based on a free healthcare system here in Canada. There are additional considerations regarding American healthcare later in the thread that are addressed.

Note2: to reply to an earlier poster, respecting the autonomy of the patient is not a concern here. You're not intruding on their right to choose medications, right to make decisions about their treatment, etc. you're informing them of something similar to a test result. Only this isn't a lab report, but an eye-test that says something could be wrong. In some circumstances, it may be wise to withold minor information fro a patient if you think it'll cause more psychological distress than necessary and the chances of an actual illness are extremely low, however, here you're not intruding on the person and you stand to help them greatly with a polite suggestion. This is also an "ominous lookin lesion". it's not a freckle.


2. How do you think the public and the medical community view what should be done in these situations?

I think the medical community shares my opinion, and the public at large would as well. I don't see anything wrong with politely helping someone. If you're obnoxious and try to sound like a big shot, then yes, I can see how that would be considered a nuisance, but this is not the case.

 

[aalamruad]

Telling someone they have something that needs to be checked out will create anxiety. If she is not in a circumstance where she can get into see a health care provider, the anxiety could last for months. It could end up costing the woman a significant out of pocket expense, and it could be nothing (except cost and anxiety) or it could be something which being detected early will change the outcome, or it could be something that is too far gone to be curable and you have found something that would have killed her in x months whether or not you speak up. It isn't always a plus to be told you should get something checked out, at least it wouldn't be to me.

Of course it's not always a plus to be told you should get something checked out, but nothing in medicine is always the best option so we have to weigh the relative costs of action vs. inaction. I see what you're saying, but everything related to healthcare entails some financial cost and anxiety, and we as a society have decided that medical attention is worth those costs so we've embraced modern medicine. As a first-year trainee, you'll have been in medical school for 4 years plus some time as an intern/resident, and I would hope that would give you enough knowledge to be able to use your discretion in suggesting a visit to the doc for something like melanoma. It's not like you're making a diagnosis and providing a prognosis. We don't hide conditions from patients to protect their feelings. We do what we can to thoroughly inform them, allow them to make their own decisions, and then proceed per their wishes. If people aren't well-informed about their own bodies and medical conditions, they don't truly have autonomy. For the most part, I subscribe to the belief that if I would advise my friend or sibling to get something checked out, it's probably a good idea to do the same for a stranger, because after all, that stranger is a friend or sibling/loved one of someone who would want you to offer your suggestion. Do we disagree?

 

[Uncle_Drew]

Telling someone they have something that needs to be checked out will create anxiety. If she is not in a circumstance where she can get into see a health care provider, the anxiety could last for months. It could end up costing the woman a significant out of pocket expense, and it could be nothing (except cost and anxiety) or it could be something which being detected early will change the outcome, or it could be something that is too far gone to be curable and you have found something that would have killed her in x months whether or not you speak up. It isn't always a plus to be told you should get something checked out, at least it wouldn't be to me.

This is a fair point, but I highly doubt the person, if they're insaanely anxious about the lesion would avoid a doctor for months. If they financially cannot see a doctor, (i'm Canadian so forgive me here), then aren't there free clinics in the states where they could at the least just go have it looked at quickly? Also, if the lesion is nothing, I doubt it will cost signicant amounts of money for a simple check up if they have to pay.

 

[Uncle_Drew]

Just wondering, what did Doing Right say upon analysis?

 

[MDProspect]

Just wondering, what did Doing Right say upon analysis?

This is was an end of chapter question that the book does not address. The author wants you to form a group and discuss this scenario. If I recall correctly, it's from the same chapter where Dr. Herbert writes about how a doctor does not have an affirmative duty to help someone who is not their patient. He mentions an example, where a man collapsed on the floor from a cardiac arrest in a restaurant. A frequent visitor of the restaurant happened to be a physician. The waiter called out for a doctor, but the doctor decided to finish his meal instead of helping. The man died. Because there was not a previously established relationship, the physician is not held accountable for not helping.

 

[knv2u]

I would tell her without reservation, while making it clear that you are not a physician yet but that she should see a dermatologist. The potential of her not knowing and having it escalate to something more serious outweighs the comfort/anxiety issues that I believe are de minimis. The key for me is to make sure that you do so as discreetly as possible.

 

[Uncle_Drew]

This is was an end of chapter question that the book does not address. The author wants you to form a group and discuss this scenario. If I recall correctly, it's from the same chapter where Dr. Herbert writes about how a doctor does not have an affirmative duty to help someone who is not their patient. He mentions an example, where a man collapsed on the floor from a cardiac arrest in a restaurant. A frequent visitor of the restaurant happened to be a physician. The waiter called out for a doctor, but the doctor decided to finish his meal instead of helping. The man died. Because there was not a previously established relationship, the physician is not held accountable for not helping.

Law and common sense don't always go together. Legally you may not be responsible, but you have to be a piece of you know what not to help there. Also, there are other times, when the doctor doens't have direct relationship with individuals, but are required to proactively help. For example, if a patient discloses that they have homicidal thoughts towards their wife. If the doctor doens't protect the wife, he can be charged (this was in doing right). There, there is no direct connection with the wife, as she is not his patient, but because of an extended relationship, he is responsible for her safety. It's not always so clear cut when you must/must not help simply based on legal arguments. I wouldn't risk my career thinking "well legally they can't charge me" and proceed to have a steak while some guy dies at my feet.

 

[MDProspect]

Law and common sense don't always go together. Legally you may not be responsible, but you have to be a piece of **** not to help there. Also, there are other times, when the doctor doens't have direct relationship with individuals, but are required to proactively help. For example, if a patient discloses that they have homicidal thoughts towards their wife. If the doctor doens't protect the wife, he can be charged (this was in doing right). There, there is no direct connection with the wife, as she is not his patient, but because of an extended relationship, he is responsible for her safety. It's not always so clear cut when you must/must not help simply based on legal arguments. I wouldn't risk my career thinking "well legally they can't charge me" and proceed to have a steak while some guy dies at my feet.

I agree with you there, but the physician can argue that he was incapacitated by consuming alcohol and was a threat to the person so he made a judgement call. Would I help the man? It depends on the situation. I would definitely administer CPR and call 911. But if he was choking and I needed to perform a MacGyver-styled tracheotomy to save him then I would have some reservations. I am aware that you have to protect others even those with whom you don't have a direct relationship. The Supreme Court case of Tatiana Tarasoff set the precedent. A man dying at your feet or a woman with a potential death sentence on her back are not examples of those cases.

Edit: I found the case.
http://articles.chicagotribune.com/...dical-center-christopher-sercye-trauma-center

Family won the lawsuit due to a previous policy that said when requested, a nurse would help a person on hospitals campus. Without the policy, the hospital would have probably won the case.

 

[Uncle_Drew]

I agree with you there, but the physician can argue that he was incapacitated by consuming alcohol and was a threat to the person so he made a judgement call. Would I help the man? It depends on the situation. I would definitely administer CPR and call 911. But if he was choking and I needed to perform a MacGyver-styled tracheotomy to save him then I would have some reservations. I am aware that you have to protect others even those with whom you don't have a direct relationship. The Supreme Court case of Tatiana Tarasoff set the precedent. A man dying at your feet or a woman with a potential death sentence on her back are not examples of those cases.

I really wish that I could find the link to the incident where a person was stabbed and bled out 30 feet away from a hospital, because the hospital had a policy against its personnel helping anyone who was not a patient.

Ok, well you didn't mention the doctor was potentially drunk. That's a completley different question. That's about capacity to help, not about legal responsibility to help strangers.

The point wasn't that those cases of the guy dying at your feet are examples of extended relationships. The point was that you can't rely on legal technicalities in life and death situations. Frankly, if the guy's dying, I help in whatever way I can. I don't think "technically....😉😉". You know what I mean?

Again, your point about the hospital is based on legal arguments not jiving with common sense. Those are very iffy situations that can lead to disastrous results for places like the hospitals and the doctor finishing his steak. I wouldn't bank on such technicalities in snap decision situations.

 

[MDProspect]

Ok, well you didn't mention the doctor was potentially drunk. That's a completley different question. That's about capacity to help, not about legal responsibility to help strangers.

The point wasn't that those cases of the guy dying at your feet are examples of extended relationships. The point was that you can't rely on legal technicalities in life and death situations. Frankly, if the guy's dying, I help in whatever way I can. I don't think "technically....😉😉". You know what I mean?

Again, your point about the hospital is based on legal arguments not jiving with common sense. Those are very iffy situations that can lead to disastrous results for places like the hospitals and the doctor finishing his steak. I wouldn't bank on such technicalities in snap decision situations.

I was speculating. Common sense is subjective and laws are objective (not completely true, but bare with me). My common sense may be different from yours and just going off common sense, I see myself being sued by ambulance chasers and eventually losing my license. The Good Samaritan laws were established for a reason (people suing their saviors just to make a quick buck). Helping everyone seems good on paper, but in real life, there are limited resources and not every effort will help your patient. Any how this has been very helpful for my upcoming MMI interview.

 

[Uncle_Drew]

I was speculating. Common sense is subjective and laws are objective (not completely true, but bare with me). My common sense may be different from yours and just going off common sense, I see myself being sued by ambulance chasers and eventually losing my license. The Good Samaritan laws were established for a reason (people suing their saviors just to make a quick buck). Helping everyone seems good on paper, but in real life, there are limited resources and not every effort will help your patient. Any how this has been very helpful for my upcoming MMI interview.

I understand you can't help in every situation, because it can mess you up, but the point is that basing whether you help on a legal technicality, in a moment of life/death, is not a smart idea. Those ambulance chasers are more likely to mess you up if you didnt help. Essentially, the point is to err on the side of caution. Help unless you have reasonable grounds not to (i.e. drunk).

Glad it was helpful. Thankfully no one degenerated the conversation to nonsense.

 

[MDProspect]

I understand you can't help in every situation, because it can mess you up, but the point is that basing whether you help on a legal technicality, in a moment of life/death, is not a smart idea. Those ambulance chasers are more likely to mess you up if you didnt help. Essentially, the point is to err on the side of caution. Help unless you have reasonable grounds not to (i.e. drunk).

Glad it was helpful. Thankfully no one degenerated the conversation to nonsense.

I never said that you should help based on a legal technicality. I said that I have a freedom to choose. Just as there is patient autonomy, there is also physician autonomy. Yes, I am obligated to help someone who came to me for help. I can not refuse a patient based on race, sex, religion, or any other creed. I do have a choice whether I want to reveal that I am a physician in a nonclincial setting (I.e a restaurant). I also have a choice whether I want to help the woman at a bus stop. I mentioned what Dr. Herbert wrote to explain this point. Whether my decision to help or not is right or wrong is for me to decide. The law just protects this choice.

 

[Uncle_Drew]

I never said that you should help based on a legal technicality. I said that I have a freedom to choose. Just as there is patient autonomy, there is also physician autonomy. Yes, I am obligated to help someone who came to me for help. I can not refuse a patient based on race, sex, religion, or any other creed. I do have a choice whether I want to reveal that I am a physician in a nonclincial setting (I.e a restaurant). I also have a choice whether I want to help the woman at a bus stop. I mentioned what Dr. Herbert wrote to explain this point. Whether my decision to help or not is right or wrong is for me to decide. The law just protects this choice.

Legally, you have no obligation. Ethically, you might. The entire point I was making was that LEGALLY you have none of these obligations, and again, I fully understand that, but in terms of ethical problems, you may create some if you don't help outside the workplace. With that being said, basing your entire decision making on what your legally required is dangerous, as I've said multiple times. Legally, a clever lawyer can make a fool out of you and it can cost you millions. So, while you state these multiple rights you have, you have to understand that your rights are limited by the society you live in. There is no such thing as an absolute right because your right to swing your fists ends where my nose begins.

Edit : In short, you "theoretically" have no obligation. Practically however, you could cause yourself some problems with this reliance on absolute rights and legalities. Also, ethically, you may be accountable depending on the ethical system you subscribe to (i.e utilitarianism).

 

[MDProspect]

Legally, you have no obligation. Ethically, you might. The entire point I was making was that LEGALLY you have none of these obligations, and again, I fully understand that, but in terms of ethical problems, you may create some if you don't help outside the workplace. With that being said, basing your entire decision making on what you're legally required is dangerous, as I've said multiple times. Legally, a clever lawyer can make a fool out of you and it can cost you millions. So, while you state these multiple rights you have, you have to understand that your rights are limited by the society you live in. There is no such thing as an absolute right because your right to swing your fists ends where my nose begins.

Fine, I'll budge. But I can make the same argument about using common sense. It might be common sense to administer life saving measures to a patient who is in a coma, but has a good chance of recovering. However, let's say this patient signs a DNR, a DNR that states that he\she does not want to be saved regardless of the chances. Because this patient believes his/her quality of life won't be same after he/she comes out of the coma. Common sense fails in this case.

 

[Uncle_Drew]

Fine, I'll budge. But I can make the same argument about using common sense. It might be common sense to administer life saving measures to a patient who is in a coma, but has a good chance of recovering. However, let's say this patient signs a DNR, a DNR that states that he\she does not want to be saved regardless of the chances. Because this patient believes his/her quality of life won't be same after he/she comes out of the coma. Common sense fails in this case.

A DNR and finishing your meal before you bother to help a dying person are not comparable.

Come on man. You're just messing with me at this point.

 

[Uncle_Drew]

Anyway, I gotta get some sleep. Great chat. All the best with your interviews.

 

[LizzyM]

I would tell her without reservation, while making it clear that you are not a physician yet but that she should see a dermatologist. The potential of her not knowing and having it escalate to something more serious outweighs the comfort/anxiety issues that I believe are de minimis. The key for me is to make sure that you do so as discreetly as possible.

De minimis for whom? Many Americans have "Bronze Plans" with high deductables before health insurance pays a nickle (other than for wellness visits, vaccines, and birth control). Make an appointment with a primary care provider or a dermatologist, wait weeks or months, pay $$$, learn that it is nothing to worry about but now you are $$$ short on this month's rent. What is the potential that this could be something serious or become something life threatening before her next routine doctor's visit?
http://www.cancer.gov/research/progress/snapshots/melanoma

Melanoma incidence is rising in whites but there is no change in mortality. What does that tell you?
http://www.cancer.gov/research/progress/snapshots/melanoma

 

[aalamruad]

De minimis for whom? Many Americans have "Bronze Plans" with high deductables before health insurance pays a nickle (other than for wellness visits, vaccines, and birth control). Make an appointment with a primary care provider or a dermatologist, wait weeks or months, pay $$$, learn that it is nothing to worry about but now you are $$$ short on this month's rent. What is the potential that this could be something serious or become something life threatening before her next routine doctor's visit?
http://www.cancer.gov/research/progress/snapshots/melanoma

Melanoma incidence is rising in whites but there is no change in mortality. What does that tell you?
http://www.cancer.gov/research/progress/snapshots/melanoma

Alternatively, she could go to the ER or a free clinic without spending any money, where the doc could take a closer look and call a derm consult if necessary. There are ways for people to get healthcare without forking over rent money and waiting months for an appointment.

Also, people who don't have great access to healthcare are statistically much less likely to have routine wellness visits, so I don't think it's fair of you to assume that the lesion will be caught by her primary care doc in a timely manner.

 

[wizzed101]

De minimis for whom? Many Americans have "Bronze Plans" with high deductables before health insurance pays a nickle (other than for wellness visits, vaccines, and birth control). Make an appointment with a primary care provider or a dermatologist, wait weeks or months, pay $$$, learn that it is nothing to worry about but now you are $$$ short on this month's rent. What is the potential that this could be something serious or become something life threatening before her next routine doctor's visit?
http://www.cancer.gov/research/progress/snapshots/melanoma

Melanoma incidence is rising in whites but there is no change in mortality. What does that tell you?
http://www.cancer.gov/research/progress/snapshots/melanoma

But she had the choice to roll the dice and not consulting a specialist, while if I remained silence, I have just denied her that choice. We can debate whether ignorance is bliss till blue in the face, but there is another factor here: myself. If I withheld my advice, I have just derived myself of peace. In a situation where the outcome is uncertain any factor can tip the scale. Morality implies choice. I have made my choice and that is it.

Plus, it is extremely unlikely that I will be the first person to notice the sign, sooner or later someone will tell her. If she had already been told, fine. If she had not been, she would be. For possible cancer, sooner is always better than later.

 

[ace_inhibitor111]

Melanoma incidence is rising in whites but there is no change in mortality. What does that tell you?
http://www.cancer.gov/research/progress/snapshots/melanoma

Wouldn't that mean the proportion of people dying is lower? Number of incidences are higher but number of deaths are the same. I would think that reflects positively on current treatment.

 

[Matthew9Thirtyfive]

Wouldn't that mean the proportion of people dying is lower? Number of incidences are higher but number of deaths are the same. I would think that reflects positively on current treatment.

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.

 

[LizzyM]

Alternatively, she could go to the ER or a free clinic without spending any money, where the doc could take a closer look and call a derm consult if necessary. There are ways for people to get healthcare without forking over rent money and waiting months for an appointment.

Also, people who don't have great access to healthcare are statistically much less likely to have routine wellness visits, so I don't think it's fair of you to assume that the lesion will be caught by her primary care doc in a timely manner.

Do you think that ER visits are free?? They aren't when I go (for real emergencies).
On the other hand, routine wellness visits are covered 100% under the ACA.


Free clinic, really?? In my area we have a government funded hospital. You can show up there and wait 7 hours... now you've lost a day's pay which might be as much as you would have paid out of pocket to see someone in a fee for service setting and it doesn't even count toward you deductible.

With cancer, getting worked up isn't always a good thing. The New England Journal of Medicine recently had a paper and editorial about the "epidemic" of thyroid cancer that is being over diagnosed and over treated often condemning people to a lifetime of drug treatment for something that could have been left alone. We've seen the same story with prostate cancer and breast cancer. Why not stop every cigarette smoker on the street and tell them to get screened for lung cancer?

 

[Matthew9Thirtyfive]

Do you think that ER visits are free?? They aren't when I go (for real emergencies).
On the other hand, routine wellness visits are covered 100% under the ACA.


Free clinic, really?? In my area we have a government funded hospital. You can show up there and wait 7 hours... now you've lost a day's pay which might be as much as you would have paid out of pocket to see someone in a fee for service setting and it doesn't even count toward you deductible.

With cancer, getting worked up isn't always a good thing. The New England Journal of Medicine recently had a paper and editorial about the "epidemic" of thyroid cancer that is being over diagnosed and over treated often condemning people to a lifetime of drug treatment for something that could have been left alone. We've seen the same story with prostate cancer and breast cancer. Why not stop every cigarette smoker on the street and tell them to get screened for lung cancer?

The AAFP was just in time to relieve me of having to get a prostate exam. Woo hoo!

http://www.choosingwisely.org/clini...y-family-physicians-prostate-cancer-psa-test/

 

[MDProspect]

The moment when @LizzyM agrees with you. Thank you.

 

[721145]

The first issue is the likelihood of causing unnecessary emotional stress (aka harm). Anxiety may not be a strong enough word - if premeds are this neurotic about secondaries/interviews, imagine the level of emotion involved with possibly having a serious medical condition. The scenario asks about a "first year in a health profession program," not a doctor. Even in medical school, there's not a lot of time for in-depth clinical derm. As @MDProspect pointed out, even board-certified dermatologists need path to diagnose a melanoma, and like I said, some totally benign things can look very scary. I would proceed with caution when unilaterally deciding for or against approaching the passenger (what is your experience with derm? How sure are you that the spot is concerning? etc).

The second consideration is financial - time away from work is costly, pathology is expensive (and invasive - imagine being single and having a sweaty, labor-intensive job and trying to take care of stitches/wound care on your back), plus time and trouble for return visit for suture removal/results. It may be overwhelming to this person just to find a doctor (do they have a regular PCP? Can they get an appointment? Do they have a ridiculous deductible? Do they have children/caregiving responsibilities?). If the spot turns out to be nothing, that's a lot of bother and $$ for the incorrect opinion of an untrained, unlicensed, unsolicited opinion. If it turns out to be cancer, now this person has an entirely new set of problems (I'm all for diagnosing melanoma early, just explaining why @LizzyM might say that being told to get something checked out might not be a plus).

A quick untrained, unlicensed, unsolicited opinion about this particular case...this case doesn't ask about colon cancer or prostate cancer or mammography, it asks about a skin lesion/potential MM. While the prospects for stage IV MM haven't changed, the prospects with an early stage MM diagnosis are excellent, and the likelihood of an early-stage diagnosis increases with an individual's 1) awareness of the existence of the lesion 2) awareness that it is something a doctor should check. Furthermore, the huge difference in outlook between an early (stage IA 10 year survival rate is 95%) and late (stage IV 10 year survival rate is 10-15%) stage MM is massive, and is a huge reason to consider approaching the passenger IF you are extremely concerned about the lesion and confident that the possible benefit to the passenger outweighs the risk of harm.

http://www.cancer.org/cancer/skinca.../melanoma-skin-cancer-survival-rates-by-stage

 

[MDProspect]

Do you think that ER visits are free?? They aren't when I go (for real emergencies).
On the other hand, routine wellness visits are covered 100% under the ACA.


Free clinic, really?? In my area we have a government funded hospital. You can show up there and wait 7 hours... now you've lost a day's pay which might be as much as you would have paid out of pocket to see someone in a fee for service setting and it doesn't even count toward you deductible.

With cancer, getting worked up isn't always a good thing. The New England Journal of Medicine recently had a paper and editorial about the "epidemic" of thyroid cancer that is being over diagnosed and over treated often condemning people to a lifetime of drug treatment for something that could have been left alone. We've seen the same story with prostate cancer and breast cancer. Why not stop every cigarette smoker on the street and tell them to get screened for lung cancer?

It is the same where I live. This government funded hospital is also notorious for gross medical malpractice. People who have the means to pay for care avoid it at all costs. Not too long ago a young male died, because the lab tech at the blood bank mislabeled the blood type. A grandmother died, because she was having a heart attack, but the nurses thought she was just having a panic attack. Even though the care is subpar, it still costs the same as a in a private hospital, the only difference being that a private hospital will not provide the cancer screening services to a person without insurance as this is not a life or death emergency. Putting someone through hell for nothing and then making them pay the costs does more harm than just leaving the person alone at the bus stop.

 

[ace_inhibitor111]

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.

 

[wizzed101]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1372178/

Paternalism and the doctor-patient relationship in general practice.

This paper is a brief introduction to the subject of paternalism as it occurs in general practice. A definition of paternalism is provided and the four main types of doctor-patient relationship within the paternalistic spectrum are described. These relationships are illustrated with examples from general practice. Some of the extensive literature on paternalism is reviewed. It is concluded that paternalism is rarely justified when treating patients of sound mind and then only where restoration of the patients' autonomy is the main aim.

 

[Matthew9Thirtyfive]

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.

I haven't even looked at the data. That's why I said generally. LizzyM was, I'm assuming (correct me if I'm wrong @LizzyM), pointing out the many studies that show that increased detection does not always correlate with decreased mortality. And in those situations (eg, mammograms, prostate screening, and apparently melanoma), this increased detection leads to unnecessary procedures and anxiety over things that likely would not have manifested clinically (i.e., unnecessary biopsies).

 

[aalamruad]

Do you think that ER visits are free?? They aren't when I go (for real emergencies).
On the other hand, routine wellness visits are covered 100% under the ACA.


Free clinic, really?? In my area we have a government funded hospital. You can show up there and wait 7 hours... now you've lost a day's pay which might be as much as you would have paid out of pocket to see someone in a fee for service setting and it doesn't even count toward you deductible.

With cancer, getting worked up isn't always a good thing. The New England Journal of Medicine recently had a paper and editorial about the "epidemic" of thyroid cancer that is being over diagnosed and over treated often condemning people to a lifetime of drug treatment for something that could have been left alone. We've seen the same story with prostate cancer and breast cancer. Why not stop every cigarette smoker on the street and tell them to get screened for lung cancer?

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.

 

[LizzyM]

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.

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.

 

[JJRousseau]

Some wise words from a surgeon I shadowed about reverence for the patient doctor relationship really struck me, and because of them I would definitely not approach the woman. To exercise proper medical care requires a profound intrusion into the personal space and history of the patient. I am of the opinion that exercising this invasion requires an explicit invitation in the form of either request or life-threatening emergency.

 

[JJRousseau]

Oh, and I responded imagining myself to be a fully licensed consultant. As a first year student, the idea of approaching this women feels incomprehensibly inappropriate to me. I feel squeamish thinking about the idea as I type.