Pretend you are an ADCOM member interviewing an applicant. What bizarre question would you ask the interviewee to see how they react?

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Goro said:
This is a very good way to get sued. Successfully.
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No,
I’m sorry @Goro I respect your opinion on most things but in this case I do not agree.
That’s not correct especially since the patient had not given any spoken or written directive as to what they wanted to do with their own life, which as I’ve explained ad nauseum was the scenario.
If I’m a trauma surgeon presented with this case I try to save the patient. If I get sued for it, so be it. I think I would win in court. But that really doesn’t matter to me. What matters is that I saved someone’s life who may not have wished to die at that moment. I can live with that, and with being sued if it comes to that. What would be more difficult to live with is that I let someone die who may, in fact, when faced with this ultimate decision, have decided they wanted to live and would have asked me to save them, if they were able. The fact that they did not have the ability to grant consent obligates me from a moral and ethical standpoint to uphold my oath and do whatever I can to save their life, even if their religion says otherwise. Individual freedom of choice supersedes organized religion, in my humble opinion.
 
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RJ McReady said:
No,
I’m sorry @Goro I respect your opinion on most things but in this case I do not agree.
That’s not correct especially since the patient had not given any spoken or written directive as to what they wanted to do with their own life, which as I’ve explained ad nauseum was the scenario.
If I’m a trauma surgeon presented with this case I try to save the patient. If I get sued for it, so be it. I think I would win in court. But that really doesn’t matter to me. What matters is that I saved someone’s life who may not have wished to die at that moment. I can live with that, and with being sued if it comes to that. What would be more difficult to live with is that I let someone die who may, in fact, when faced with this ultimate decision, have decided they wanted to live and would have asked me to save them, if they were able. The fact that they did not have the ability to grant consent obligates me from a moral and ethical standpoint to uphold my oath and do whatever I can to save their life, even if their religion says otherwise. Individual freedom of choice supersedes organized religion, in my humble opinion.
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@gyngyn
@LunaOri
@Med Ed
@Moko
@Tenk
@Maimonides1

I think this is one of those teaching moments!
 
clumsy.md said:
Major red flag.

Although you yourself might not be religious, you still need the understanding and empathy to care for those who are. Despite what you might think is best, many patients would rather die than diverge from their beliefs. Not your or my job to play "god" just because we think we know what's best.
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Before I go to bed, I had to address this quote. The point of my saying that was that the patient DID NOT divulge their preference as to how they were to be treated, because they were unconscious. If there had been a written, or even spoken, directive from the patient, then obviously the situation would be different. I don’t purport to be “playing God”, as you suggest, simply because I am exercising my judgement on an obtundant patient who will surely die if I don’t intervene.
 
DNAJB6 said:
If a patient is part of a cult and wanted to die and had ingested toxic Koolaid (like the Jones Town Massacre except wittingly) would you accuse a doctor that resuscitates the patient against his will of lacking empathy?
One person’s cult is another person’s religion and vice versa.
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Not a great comparison you're making between a blood transfusion for Jehovah's Witnesses and cult suicide.
 
RJ McReady said:
Before I go to bed, I had to address this quote. The point of my saying that was that the patient DID NOT divulge their preference as to how they were to be treated, because they were unconscious. If there had been a written, or even spoken, directive from the patient, then obviously the situation would be different. I don’t purport to be “playing God”, as you suggest, simply because I am exercising my judgement on an obtundant patient who will surely die if I don’t intervene.
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Good clarification. The only MMI prompt I've encountered with this scenario included the unconscious patient having a Jehovah's Witness card in their purse that explicitly mentions blood transfusions.
 
DNAJB6 said:
How so? You’re singing your own death warrant metaphorically either way.
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In regards to the difference between suicide and religious belief.

Someone who has just attempted suicide is generally going through a psychological emergency. The idea is that in such an emergency, they don't have rational decision making capacity, and therefore can't give consent or refuse it. It's not that we override their refusal, it's that they couldn't refuse treatment in the first place. The law therefore empowers relatives, physicians, and sometimes law enforcement officers, to therefore make decisions in the best interests of the patient, where life and limb are concerned. This generally falls under the doctrines of implied and involuntary consent.

However, when people have rational decision making capacity, those doctrines no longer apply. Despite the best arguments of many atheists, religion is not currently classified as a mental illness, nor does it inherently diminish rational decision making capacity. People can, and do, have well thought out reasons for why they would refuse treatment on religious grounds.

Why should we consider someone who refuses treatment because of belief in a god to be any less rational than someone who signed a DNR because they preferred dying in the comfort of their home to dying in a hospital bed? Both cases are values judgements, where life has been weighed against other important considerations, such as religious belief or comfort, and ultimately your values determine which of those arguments you see as being valid.

There are religious people who believe that comfort should not be a consideration when a life is a stake. Many people would rightly agree that for the religious to impose that view on others (ex: banning DNRs) would be an "unfair imposition of religious values". Yet many who would make that argument have absolutely no problem imposing their own values on the religious, going on to state that religion should not be a consideration when a life is at stake.
 
lumya said:
Staying in Florida right now w/ my parents and I would gladly take one for the team and just take us all out.
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No one here would mind that, on the contrary, probably embrace it as an honor. Just have to REALLY pump up the tourism industry to make up for the lack of revenue. Maybe being annexed will make it more exotic? 😎
 
lumya said:
Soup is a subcategory of salad. And smoothie a subcategory of soup.
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Dear lumya,

I have a difficult classification to make: fish roe sushi?

Thank you,
8yearslate
 
RJ McReady said:
Idk
I should preface this comment by stating I am not a religious person, and that I would do what my conscience dictates.
As a (future) physician, I can’t just let an otherwise healthy person die because their religion refuses to allow a transfusion when my oath is to protect life and do no harm. Is it not harming someone to let them die when you could have saved them?
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While you might be marginally passable in your logical assessment of both arguments in medical school MMI as long you are not outlier and dangerous..,
If I were the plaintiff family lawyer and want to take your deposition in this case and you gave me this dogmatic statement on the stand.. you are a toast!!

You can’t let your ethical or religious code dictate your actions as a physician and override your patient’s religious beliefs and their expressed wishes evident by their explicit declaration of any affiliation..

The other side of the legal argument if you to say the patient left the demographic form religious affiliation blank, or as a physician I was not aware of the religious preferences of such group (even a weaker argument) and you acted in the best interest of the patient and erred on taking cautious approach.., then you might have a legal ground to defend your actions as it’s too hard to bring a suit and proof without reasonable doubts on malice or negligence in absence of clear AD!

It comes to my memory the famous case of Miami man with DNR tattooed to his chest which got reported by NEJM in 2017, how the team struggled to honor the patient implied wishes and offered basic support even the ethical consult came back to deny the basis of their care.. till they were able to track down a valid legally executed AD document “in Florida on yellow paper!” with clear DNR order to follow by the physician.

www.acepnow.com

Do-Not-Resuscitate Tattoos: Are They Valid? - ACEP Now

ACEP Now offers real-time clinical news, news from the American College of Emergency Physicians, and news on practice trends and health care reform for the emergency medicine physician. ACEP Now is an official publication of the American College of Emergency Physicians.
www.acepnow.com www.acepnow.com

In other similar case back in 2012 the patient was given oxygen to regain consciousness only to speak his wishes to the surprise of the doctors: “ I did not care for my tattoo as I had it when I lost a bet in poker game..!”

The conversation continue with valuable input from writings of famous bioethicist Arthur Caplan at NYU.

Wise @Goro
 
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swatttt007 said:
In regards to the difference between suicide and religious belief.

Someone who has just attempted suicide is generally going through a psychological emergency. The idea is that in such an emergency, they don't have rational decision making capacity, and therefore can't give consent or refuse it. It's not that we override their refusal, it's that they couldn't refuse treatment in the first place. The law therefore empowers relatives, physicians, and sometimes law enforcement officers, to therefore make decisions in the best interests of the patient, where life and limb are concerned. This generally falls under the doctrines of implied and involuntary consent.

However, when people have rational decision making capacity, those doctrines no longer apply.
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Google “depressive realism.” Also as the U.S. Supreme Court has acknowledged (albeit in a slightly different context), “death is different.”
 
DNAJB6 said:
Google “depressive realism.” Also as the U.S. Supreme Court has acknowledged (albeit in a slightly different context), “death is different.”
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That hypothesis has so many flaws. I'm going to go out on a limb and suggest that if a theory isn't mentioned in my abnormal psychology textbook, nor my medical ethics class, nor my clinical psychology class, it's probably not relevant here. If someone happens to be a stoic, then sure, that can serve as rational decision making capacity. But someone who attempts suicide because they just broke up with their girlfriend yesterday probably isn't making a rational decision. In fact, research shows that most suicide attempts are impulsive, and that strategies that increase the time it takes to initiate a suicide attempt (keeping a gun in a hard to reach area) save lives. An impulsive decision is entirely the opposite of a well-thought out, rational decision.

To be logically consist, your position is either that people always deny care for rational reasons, such as suicides, DNR, and religion, in which case we don't overrule autonomy ever, not even in suicide attempts. On the other hand, you could be saying that even if people deny care for seemingly rational reasons, physicians shouldn't listen to it, in which case you're saying that if a doctor doesn't feel a DNR is valid, he doesn't have to honor it. So either extreme autonomy or extreme paternalism. I think the medical community is significant more moderate than either of these positions would suggest.
 
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Goro said:
@gyngyn
@LunaOri
@Med Ed
@Moko
@Tenk
@Maimonides1

I think this is one of those teaching moments!
Click to expand...
The key in the scenario described by @RJ McReady is that the Jehovah's Witness was incapacitated and has no known preference related to transfusion. In that instance RJ is correct, if time is of the essence then you proceed with lifesaving treatment. To do otherwise is to make a rather large assumption about the patient's desires.

As an aside, the idea that Jehovah's Witnesses have a uniform aversion to transfusion is false. It is actually a source of endless debate in that community, and not everyone agrees with the denomination's interpretation of scripture on the subject. Moreover, the real issue generally isn't receiving blood products, it's consenting to receive them. If the patient is unconscious then active consent is moot.
 
DNAJB6 said:
But a salad is a medley or mix of things. What if it is only one fruit? Similarly a bowl of chicken wings is not a salad. Amalgamation of homogeneous substances does not equal salad... Breadless foods are not sandwiches; ergo, not all food is a salad or a sandwich.
Click to expand...
What about honeymoon salad: "lettuce alone" ?
 
Med Ed said:
The key in the scenario described by @RJ McReady is that the Jehovah's Witness was incapacitated and has no known preference related to transfusion. In that instance RJ is correct, if time is of the essence then you proceed with lifesaving treatment. To do otherwise is to make a rather large assumption about the patient's desires.

As an aside, the idea that Jehovah's Witnesses have a uniform aversion to transfusion is false. It is actually a source of endless debate in that community, and not everyone agrees with the denomination's interpretation of scripture on the subject. Moreover, the real issue generally isn't receiving blood products, it's consenting to receive them. If the patient is unconscious then active consent is moot.
Click to expand...
Very nicely summarized, exactly what I was trying to say. For example, there are members of this community who are okay with autotransfusion during elective surgery (either donating their own blood preop or using cell-saver products during surgery,)and those that are not.
 
Maimonides1 said:
If I were the plaintiff family lawyer and want to take your deposition in this case and you gave me this dogmatic statement on the stand.. you are a toast!!

You can’t let your ethical or religious code dictate your actions as a physician and override your patient’s religious beliefs and their expressed wishes evident by their explicit declaration
Click to expand...
Why am I toast if there is no willful disregard of patients wishes as they are obtundant and unable to provide consent?
 
Med Ed said:
The key in the scenario described by @RJ McReady is that the Jehovah's Witness was incapacitated and has no known preference related to transfusion. In that instance RJ is correct, if time is of the essence then you proceed with lifesaving treatment. To do otherwise is to make a rather large assumption about the patient's desires.

As an aside, the idea that Jehovah's Witnesses have a uniform aversion to transfusion is false. It is actually a source of endless debate in that community, and not everyone agrees with the denomination's interpretation of scripture on the subject. Moreover, the real issue generally isn't receiving blood products, it's consenting to receive them. If the patient is unconscious then active consent is moot.
Click to expand...
The question stem that RJMcReady was responding actually specifies that the patient refused transfusion though. It's not specified how - maybe the patient was conscious, refused transfusion, then became unconscious; maybe the patient had one of those cards that Jehovah's witnesses might carry that specifies which blood products they are O.K. with receiving, and blood transfusions was not on that list. Would either of these scenarios change the decision to perform the transfusion?
 
blacco said:
Not ****. I would recognize that this is an extremely stressful process for many young people and would try to make them more comfortable instead of less. My goal in and interview would be to have a conversation to assess someone’s personality and bedside manner. The interview for me would be an opportunity to make sure that in addition to the impressive resume, you are not a robot. If the person is able to communicate effectively, I’d be more supportive of accepting. Not to say that a good doctor can’t be awkward or shy, but I’d want to know that you are capable of holding a conversation, that you can talk in depth about your significant experiences, and that you have some humility. Being able to think on the fly is a skill that can be developed with training.
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I don’t think this thread was intended to be taken seriously. Personally, I don’t usually need to ask challenging questions in an interview to get to know the candidate. Please don’t worry that we are torturing applicants IRL!
 
Goro said:
@gyngyn
@LunaOri
@Med Ed
@Moko
@Tenk
@Maimonides1

I think this is one of those teaching moments!
Click to expand...
I was asked the JW question when I interviewed for a general surgery residency, and I think I answered pretty much the same way. I remember asking if the patient had refused transfusions in the past, and whether they had a family member or religious leader who was authorized to speak for them. In the scenario I was given, it was even more tricky, because the patient was supposedly in the 3rd trimester of pregnancy!
 
RJ McReady said:
Very nicely summarized, exactly what I was trying to say. For example, there are members of this community who are okay with autotransfusion during elective surgery (either donating their own blood preop or using cell-saver products during surgery,)and those that are not.
Click to expand...
In our hospital we have established a bloodless / no transfusion surgery service line just for groups who overwhelmingly ask for it with 100% adherence to this protocols.., this is not the case you presented in your scenario
 
Maimonides1 said:
Read your statement explaining your actions through your beliefs..,

I gave you what is defensible and what is not and where you will be deemed “out of bound”
Click to expand...

In the absence of written or spoken directive in a patient who is crashing and you are only told the patient is a JW and their religion does not believe in blood transfusion, my best judgement on acting in the interests of the patient is all I have to go on.
 
RJ McReady said:
In the absence of written or spoken directive in a patient who is crashing and you are only told the patient is a JW and their religion does not believe in blood transfusion, my best judgement on acting in the interests of the patient is all I have to go on.
Click to expand...
The question stem stated the patient refused transfusion. So the assumption is that either written or spoken directive exists, or existed prior to the patient becoming unconscious.
 
I understand that, but the scenario I was given was there was no directive given one way or the other.
Again, I don’t think there is a right or wrong answer; it is how one explains their thought process that matters.
 
Goro said:
@gyngyn
@LunaOri
@Med Ed
@Moko
@Tenk
@Maimonides1

I think this is one of those teaching moments!
Click to expand...
The whole situation is unrealistic and wouldn’t actually happen irl. If they had previously refused a blood transfusion and had medical decision making capacity at the time (ie adult years and sound mind) then the answer is simple: no transfusion.

If they are a minor and lacks capacity the answer is also simple: transfuse. You won’t get sued for saving the life of a child and even if I did I’d stand up in the court room and give the parents the finger.

These first two are not ethical dilemmas btw, they are legal issues that are very black and white.

There’s a problem with this scenario though that makes it completely unrealistic and that is saying you wouldn’t have time to contact anyone. Blood transfusions are not instant. A regular blood transfusion will take 1+hr to get started. The only time you can do a rapid transfusion is if you crack O- blood. Then transfusing the blood takes an hour+ unless you use the rapid transfuser. The problem with THIS is that even this is not as rapid as you would think and you’d be easily able to make a phone call. In fact the only things in emergency medicine where the outcome could be disastrous in less time than a phone call would be: cardioverting arrhythmias, treating hyperkalemia with profound ekg changes, airway issues, tamponade without a pulse, and tension pneumothorax. These could easily go from a semi-stable walky-talky patient to dead in less than a minute without definitive treatment. There’s probably one or two others I didn’t think of but the idea is the same. Blood transfusion isn’t on this list because even with a rapid transfuser it takes time to set up and administer.
 
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Tenk said:
The whole situation is unrealistic and wouldn’t actually happen irl.
Click to expand...
Totally agree. Maybe someone should tell the medical school that presented this scenario...
 
I love the stark juxtaposition between the two ongoing conversations:

1) non-clinician faculty and a few pre-meds arguing with a medical student about medical ethics in which the non-clinician faculty called in clinician faculty as backup but they ended up supporting the medical student or being indifferent

2) What counts as a salad.

reading them in-line with one-another with no separation between the two conversations and neither relating to the original question posed in the title of the thread is the most SDN thing.
 
2021-2022-NonTrad said:
I love the stark juxtaposition between the two ongoing conversations:

1) non-clinician faculty and a few pre-meds arguing with a medical student about medical ethics in which the non-clinician faculty called in clinician faculty as backup but they ended up supporting the medical student or being indifferent

2) What counts as a salad.

reading them in-line with one-another with no separation between the two conversations and neither relating to the original question posed in the title of the thread is the most SDN thing.
Click to expand...
SDN is nothing if not entertaining...!
 
RJ McReady said:
In the absence of written or spoken directive in a patient who is crashing and you are only told the patient is a JW and their religion does not believe in blood transfusion, my best judgement on acting in the interests of the patient is all I have
Click to expand...
RJ McReady said:
I understand that, but the scenario I was given was there was no directive given one way or the other.
Again, I don’t think there is a right or wrong answer; it is how one explains their thought process that matters.
Click to expand...

This is not about right or wrong answer.. , it’s more about your willingness to walk the tight robe in a legal gray zone during your professional life.. and when you get challenged, on what ground will you defend your actions!
 
2021-2022-NonTrad said:
I love the stark juxtaposition between the two ongoing conversations:

1) non-clinician faculty and a few pre-meds arguing with a medical student about medical ethics in which the non-clinician faculty called in clinician faculty as backup but they ended up supporting the medical student or being indifferent

2) What counts as a salad.

reading them in-line with one-another with no separation between the two conversations and neither relating to the original question posed in the title of the thread is the most SDN thing.
Click to expand...

And most importantly.. A Chicago hotdog is “Sandwich+Salad”
 
Maimonides1 said:
This is not about right or wrong answer.. , it’s more about your willingness to walk the tight robe in a legal gray zone during your professional life.. and when you get challenged, on what ground will you defend your actions!
Click to expand...
I wouldn’t go that far...
As @Tenk said it’s a completely unrealistic scenario to begin with, and one that I’m never going to be faced with in my professional career. I was simply answering a prompt in the same way I’m sure a lot of others would have.
 
Goro said:
@gyngyn
@LunaOri
@Med Ed
@Moko
@Tenk
@Maimonides1

I think this is one of those teaching moments!
Click to expand...
I haven't followed this debate too closely, but from what I've gathered, we have an unconscious patient who is reportedly a Jehovah's Witness and is coming in with hemorrhagic shock. Strangely the trauma bay is devoid of any attendings, PAs and residents, and somehow this decision is falling upon the interviewee, who I can only presume is playing the role of Chief medical student (MS-V?).

I personally stay away from asking these ethical dilemmas because they often rely on information that is beyond most applicants' knowledge base, e.g. in this scenario, knowing the relevant laws, that not all Jehovah's Witnesses are against blood transfusions, and that patients don't just keel over the moment their hemoglobin drops below 7. These questions also unfairly favor those who have prepared for this type of question (not uncommonly those with superior resources).

Regardless, there is a general framework that I learned from consulting to successfully answer these types of questions. In my opinion, the key is to demonstrate a thoughtful and analytical approach so you get credit even if your answer is "wrong". One should always ask clarifying questions first: the How's, What's and Why's. How do we know this patient is a Jehovah's Witness? Are they carrying a card explicitly stating their preferences, or is there documentation in the EMR about their religious affiliation and preferences regarding blood products? What prior conversations have been documented on this topic? Or is this all hearsay from a family member or friend? What alternatives to blood transfusions are available, and how much time do we have to make a decision? Who is the legal decision maker? Is there concern that the legal decision maker is not acting in the patient's best interest? If so, what does local law say on this topic, and what consulting services are available for further guidance? The interviewer may paint this scenario as emergent and that there is no time to consult others, but by asking these questions, you have demonstrated your framework.

I personally never hesitate to admit my own ignorance as I probe with these questions, and my answer and rationale would include qualifiers specific to the scenario at hand. The few times I was asked these questions, my answers seemed to be adequately received with the above approach. Ethical dilemmas are rarely black-and-white and require nuance when deciding next steps. As a general rule, significant deference should be given to patient autonomy and their expressed wishes, and any attempt to circumvent it must be done with the utmost thoughtfulness and caution*.

An applicant who appears to rush in guns-blazing with transfusions while willfully ignoring others' cultural and/or religious beliefs will probably fair very poorly. The goal is to appear thoughtful, and not be seen as a walking liability for the school/hospital system. Just my thoughts.

* and documentation.. Lots and lots of documentation.
 
alm414 said:
The question stem that RJMcReady was responding actually specifies that the patient refused transfusion though. It's not specified how - maybe the patient was conscious, refused transfusion, then became unconscious; maybe the patient had one of those cards that Jehovah's witnesses might carry that specifies which blood products they are O.K. with receiving, and blood transfusions was not on that list. Would either of these scenarios change the decision to perform the transfusion?
Click to expand...
In the former case it comes down to whether or not the patient could be considered competent (or not) before becoming unconscious. Making that determination would require a lot of detail and nuance that isn't typically seen in an interview scenario.

The card would halt any decision to transfuse if it represents an advance medical directive that is completed in accordance with state law.
 
Tenk said:
In fact the only things in emergency medicine where the outcome could be disastrous in less time than a phone call would be: cardioverting arrhythmias, treating hyperkalemia with profound ekg changes, airway issues, tamponade without a pulse, and tension pneumothorax. These could easily go from a semi-stable walky-talky patient to dead in less than a minute without definitive treatment.
Click to expand...
True, but until a sizable religious denomination objects to emergent treatment for tension pneumothorax these don't make good fodder for cliché interview questions.
 
matrix pills.jpg

Asking a nervous interviewee -

You take the blue pill, this interview ends, you wake up in your bed and you believe whatever you want to believe. You take the red pill and we will continue this interview, and the conclusion will be in your hands. What do you choose?
 
An interview with two of my colleagues, and make the student answer a Bang, Marry, Kill: me, colleague #1, colleague #2
 
RJ McReady said:
I wouldn’t go that far...
As @Tenk said it’s a completely unrealistic scenario to begin with, and one that I’m never going to be faced with in my professional career. I was simply answering a prompt in the same way I’m sure a lot of others would have.
Click to expand...
It's not meant to be a realistic scenario. It's not a Specialty exam. It's an ethics question that meant to probe where your moral focus is, even without the knowledge of true medical ethics. It's also an assessment to see if you at least have some knowledge of the Big Picture about patient autonomy.

You know the moral decision question about the runaway train and who do you save by turning the track switch? In reality, there are lots of fail-safe mechanisms built into railroad operations, so the question is fantasy, just like the EM scenario of the exsanguinating JW.

But railroad engineering and track safety protocols are not the point of the question.
 
I think everyone on this thread is forgetting about the ONLY MMI question that ever mattered (and has a factual, definitive answer):

Did Yoko Ono intentionally break up The Beatles?
 
A friend of mine who applied to med school two years ago was asked an MMI question along the lines of:

"If you had to listen to only one Beatles song for the rest of your life, which would it be and why?"

My friend jokes that if a person couldn't name a Beatles song, they were automatically rejected for having bad taste in music.
 
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