scenario questions?

[eunice]

What would you answer if the interviewer asked you this:

If an AIDS patient is bleeding profusely from a laceration, what would you do? If you didn't have any gloves? if you had an open wound on your hand?

any other scenario/ethics questions that you guys find hard?
eunice

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[kito]

i wouldn't hesitate to get to work. those are risks that you pledge to take when you take that oath and wear that coat.

 

[Joe Joe on da Radio]

high-dose abacavir will basically solve that dilemma

 

[Tweetie_bird]

hmmmm, interesting.

The answer for me differs if I was "on call" or "not on call." If I was let's say ....on the road and nobody knew I was a doc, I probably would have a man take off his shirt and put tons of padding on it enough so the blood does not seep through. I want to take care of myself, so I can help the long line of patients in the future. Jeopardizing myself over ONE patient is not good justification for me (I've got my flame suit on ). But in all seriousness, if you jeopardize the potential of helping the myriad of patients you will have henceforth, for helping this ONE person, it's simply not justifiable in my eyes.

The same reasoning is used to justify why a doc should not do anything to lose his license over ONE patient. Losing his licence would not help him serve the hundreds of patient after this one, so it's simply better to let this one go for the betterment of the majority of people.

If I was AT WORK--it's a whole different issue. Not helping a person would be negligence and i could lose my career over that.

 

[Tweetie_bird]

oh ya and about that AIDS thingy--

I believe there's some antidote like thing that you can take within 24 hours if you THINK you've been exposed to the virus. I don't know what it's called nor do I know how it works. I have just heard of people who have had to use it.

 

[Street Philosopher]

sorry, can't help ya.

 

[daver]

I think it is easy for anyone to sit in a chair and say how quickly you would jump in head first regardless of whether or not you had gloves or open wounds. BUT...when faced with the real situation can you honestly say that you would not hesitate and think of the risk you are about to undertake. I agree that you have to do what you have to do as a physician but I think if I were on an adcom (which let's face it, I am not, they have this pesky rule about having been in med school first, go figure) I would want to hear the hesitation, I do not think or hope that med schools are looking for science robots but living, breathing, thinking, feeling people. If you can't stop and think of the risks YOU are taking why would you stop and think of the risks that you are putting your patients through.

 

[Diogenes]

I dunno, safety protocols exist for a reason. I have no Hollywood-inspired delusions of martyrdom -- if I had an open wound I'd get some gloves damn quick. Always know where the nearest pair of gloves are. And if you aren't in the hospital, carry some in your car (like policeman do).

 

[DW]

uhh, how many patients will a dead doctor save in the future? if there are no gloves, find some.

 

[Tweetie_bird]

Originally posted by daver
If you can't stop and think of the risks YOU are taking why would you stop and think of the risks that you are putting your patients through.

AMEN brotha! Very well put.

 

[tBw]

Originally posted by Tweetie_bird
oh ya and about that AIDS thingy--

I believe there's some antidote like thing that you can take within 24 hours if you THINK you've been exposed to the virus. I don't know what it's called nor do I know how it works. I have just heard of people who have had to use it.

There is no "antidote" as strictly defined Tweetie. What some people take is a post-exposure prophylactic protocol which consists of 30 days of AZT - the same drug infected people take. It reduces infection rates by 96% if commenced within 12 hours and taken consistently. However, AZT is a strong drug (that's why it helps people actually infected....) and many people are not tolerant of it's side effects. It can cause severe liver damage and even death in those not able to tolerate it. Many people experience fatigue and nausea when first taking the drug and it thus can severly impair your ability to carry on with daily life. Thus many people do not take it. In addition there is mounting evidence that repeated use of this lessens its effectiveness, and that in AZT-resistant strains which are already abundant its effectiveness is almost nil.

 

[Diogenes]

Okay, here's a scenario posed to me (rather complicated one):

Let's say you are a transplant surgeon -- one of the best in the world. Someone comes to you and asks you to perform a kidney transplant on an anonymous VIP. You agree, and they blindfold you and put you on an airplane and take you somewhere you don't know. When you get there, everything is set up perfectly -- there is a highly trained team to work with you, the facilities are perfect, and there is a willing live donor. But you find out the patient is Osama bin Laden. What do you do?

AND, you eventually realize where you are exactly, enough that you can identify the specific location. When you return to the US, what do you do with that knowledge?

 

[tBw]

Originally posted by Diogenes

AND, you eventually realize where you are exactly, enough that you can identify the specific location. When you return to the US, what do you do with that knowledge?

I stop smoking crack cos evidently the hallucinations have become too bizarre...

 

[BushBaby]

Originally posted by DW
uhh, how many patients will a dead doctor save in the future? if there are no gloves, find some.

For real get some gloves and always carry a box in your truck.

Tell the interviewer that you have a mother, father, sister, brother, friend, husband, wife and kids that you love dearly and who all wish to see you live to the age of 100.

No where on the job description of being a physician does it say "be prepared to sacrifice your life to save a patient".

I think most adcoms will think you are either crazy or lying if you say you would try to help the patient even if it means you run the risk of contracting the disease.

 

[Joe Joe on da Radio]

i'd personally be more concerned of exposure to hepatitis C since there is still no vaccine, effective treatment, etc.

 

[Diogenes]

Originally posted by Joe Joe on da Radio
i'd personally be more concerned of exposure to hepatitis C since there is still no vaccine, effective treatment, etc.

You mean compared to the vaccine and effective treatments for HIV?

I thought even the "effective" HIV treatments were pretty hit and miss from patient to patient.

 

[tBw]

Originally posted by Diogenes


You mean compared to the vaccine and effective treatments for HIV?

you beat me to it Diogenes....

 

[tBw]

btw, I think it's interesting the focus every single response to this has taken - that of your risk of HIV infection (whether you ignore this or account for it). If you have an open wound you can pose a significant risk of infection to the immune compromised patient. It is also your duty to avoid doing this, regardless of your lack of concern for your own safety.

As a physician it may be ones duty to provide care, but no one said you had to do it directly. Either improvise with something that is not gloves, do it with your other hand, or recruit a passerby who does not have open wounds and would risk themselves and the patient - you can supervise the treatment. Yes there are issues with any of these solutions too, but no solution will be perfect.

 

[Joe Joe on da Radio]

Originally posted by Diogenes


You mean compared to the vaccine and effective treatments for HIV?

I thought even the "effective" HIV treatments were pretty hit and miss from patient to patient.

there is prophylatic treatment for HIV exposure. there is none for HCV. the only treatment for HCV is interferon therapy, which is 16 weeks long and rife with severe side-effects (hair loss, fatigue, nausea, night sweats) and there is only a 10% chance at a response, let alone a recovery. of those who do NOT build immunity to the virus (and many do not), 40% will eventually develop hepatocelluar carcinoma (leads to liver cancer).

HIV is largely manageable with medications today if you're financially secure (which you will be as physicians). i work with HIV infected patients every week...many have been infected for 20+ years and there T cell count is just fine.

 

[Diogenes]

Aren't there pretty significant consequences (or potential consequences) to a physician's career from both HIV and HCV?

Also what is the proportion of patients that react poorly to current HIV treatments? I mean, you hear about success stories (thus far anyway) like Magic Johnson, but aren't there a lot of people who aren't so lucky?

 

[Joe Joe on da Radio]

Originally posted by Diogenes
Aren't there pretty significant consequences (or potential consequences) to a physician's career from both HIV and HCV?

Also what is the proportion of patients that react poorly to current HIV treatments? I mean, you hear about success stories (thus far anyway) like Magic Johnson, but aren't there a lot of people who aren't so lucky?

you are still entitled to practice medicine even if you are seropositive for HIV or HCV, however, you're malpractice insurance would skyrocket. it would be discriminatory otherwise. yes, i know patients would be put at risk, but universal precautions exists for a reason.

in the UK, seropositive physicians do not have to disclose this information...pretty controversial eh?

again, much to think about...

as far as response to HIV drug regimes, i'm not sure about the actual proportion of those who react poorly (though i should since i do epidemiological work, heh). that said, it is more about the degree of side-effects one experiences from a cocktail rather than reacting poorly to it (the meds are effective).

genotype/phenotype testing can identify resistance to a med.

 

[tBw]

Originally posted by Joe Joe on da Radio
the only treatment for HCV is interferon therapy, which is 16 weeks long and rife with severe side-effects (hair loss, fatigue, nausea, night sweats) and there is only a 10% chance at a response, let alone a recovery. of those who do NOT build immunity to the virus (and many do not), 40% will eventually develop hepatocelluar carcinoma (leads to liver cancer).

HIV is largely manageable with medications today if you're financially secure (which you will be as physicians). i work with HIV infected patients every week...many have been infected for 20+ years and there T cell count is just fine.

Undoubtedly concern over HCV (Hepatitus C) infection is valid as it is a serious disease, and affects almost 4 million americans (more than HIV). However, I don't agree that it is more serious an infection than HIV. To begin with you are incorrect regarding the treatment regime for HCV - interferon therapy is usually used in combination with ribavirin which has almost doubled response rates - indeed the CDC currently quotes 50% response rates, not 10%. The severe responses and side-effects that you quote for interferon therapy are infact identical to the side effects and response rates of patients undergoing standard HIV treatment (AZT, ddI, etc). Your value of 40% resulting in liver cancer also disagrees strongly with CDC values. CDC guidelines currently report 20-30% of people infected with HCV will develop cirrhosis over 10-30 years and of those with cirrhosis, an estimated 25-30% (or up to 5% of all persons initially infected with HCV) will develop end-stage liver disease or liver cancer.

Note that is 5% over 30 odd years. In contrast, while protease inhibitors have extended the period of conversion from HIV infection to full blown AIDS that period still, currently stands at a median value of 7 years. It is also true that in 1980 only 14% of those infected survived more than 1 year after their first AIDS diagnosis and now that figure is 82%. Undoubtedly the face of AIDS has changed, but that still gives 18% of people dying within 7 years of HIV infection. In that time period most people infected with HCV are not even aware of their infection unless they happen to have a liver enzyme test. In contrast even those "doing well" on anti-HIV treatment will have had an average of 4 hospitalizations and had to take drugs every day for 7 years which will have caused varying amounts of fatigue, nausea etc.

If you deal with people that are fine 20 years post HIV infection then you are talking about people that became infected in 1982. These people are exceptionally lucky to still be surviving but are amongst the few that evidently showed good resistance to HIV DESPITE not having drugs (HAART treatment was only introduced in 1996 - so it is impossible that their 20 year survival is entirely attributable to the latest drugs.

While HCV is serious, I think your comparison overly dramatizes the life-impact of this nevertheless (5%) fatal illness and trivializes the impact and death rate of HIV. I do not know where your figures are from. All the figures I have quoted are from the CDC current guidleines on HIV and HCV.

 

[unregistered]

Originally posted by eunice
What would you answer if the interviewer asked you this:

If an AIDS patient is bleeding profusely from a laceration, what would you do? If you didn't have any gloves? if you had an open wound on your hand?

any other scenario/ethics questions that you guys find hard?
eunice

I would like to say that these kinds of questions are intended to catch poor unsuspecting med school applicants off guard. The truth is, with OSHA in place there are procedural directives and safeguards for every possible scenario. You would be aware of the procedural directives if you were actually in the position to be in PROFESSIONAL contact with a "profusely bleeding aids px".

Even the average bear on the street knows (at least in your head you know it) that you should treat EVERY bleeder (child, old lady in tennis shoes, whatever) like they have aids.

In an interview DON'T answer from your initial emotional reaction-think it through-breathe-then answer.

 

[JmE]

Originally posted by Diogenes
Okay, here's a scenario posed to me (rather complicated one):

Let's say you are a transplant surgeon -- one of the best in the world. Someone comes to you and asks you to perform a kidney transplant on an anonymous VIP. You agree, and they blindfold you and put you on an airplane and take you somewhere you don't know. When you get there, everything is set up perfectly -- there is a highly trained team to work with you, the facilities are perfect, and there is a willing live donor. But you find out the patient is Osama bin Laden. What do you do?

AND, you eventually realize where you are exactly, enough that you can identify the specific location. When you return to the US, what do you do with that knowledge?

Were you looking for a serious reply? I almost replied but then I thought you might be joking.

I would, however, find reading replies to this question interesting reading.

-JmE-

My reply would be:

I would treat him and forget about it. I would be a physician first and foremost, not a soldier, politician, or even a patriot in that scenario.

 

[mvervaine]

um...first of all, if i refused to do the transplant surgery i doubt they'd let me return to the states with my head still attached to my neck. so if my answer to the first question is no there is no opportunity for the second question to arise.

my answer to the first question is no. an ex-con, reformed-murderer...maybe. but osama'd be lucky if i don't agree to do the surgery and then sew him back up without the new liver. it's the least i can do to flat out refuse.

 

[Joe Joe on da Radio]

Originally posted by the boy wonder


Undoubtedly concern over HCV (Hepatitus C) infection is valid as it is a serious disease, and affects almost 4 million americans (more than HIV). However, I don't agree that it is more serious an infection than HIV. To begin with you are incorrect regarding the treatment regime for HCV - interferon therapy is usually used in combination with ribavirin which has almost doubled response rates - indeed the CDC currently quotes 50% response rates, not 10%. The severe responses and side-effects that you quote for interferon therapy are infact identical to the side effects and response rates of patients undergoing standard HIV treatment (AZT, ddI, etc). Your value of 40% resulting in liver cancer also disagrees strongly with CDC values. CDC guidelines currently report 20-30% of people infected with HCV will develop cirrhosis over 10-30 years and of those with cirrhosis, an estimated 25-30% (or up to 5% of all persons initially infected with HCV) will develop end-stage liver disease or liver cancer.

Note that is 5% over 30 odd years. In contrast, while protease inhibitors have extended the period of conversion from HIV infection to full blown AIDS that period still, currently stands at a median value of 7 years. It is also true that in 1980 only 14% of those infected survived more than 1 year after their first AIDS diagnosis and now that figure is 82%. Undoubtedly the face of AIDS has changed, but that still gives 18% of people dying within 7 years of HIV infection. In that time period most people infected with HCV are not even aware of their infection unless they happen to have a liver enzyme test. In contrast even those "doing well" on anti-HIV treatment will have had an average of 4 hospitalizations and had to take drugs every day for 7 years which will have caused varying amounts of fatigue, nausea etc.

If you deal with people that are fine 20 years post HIV infection then you are talking about people that became infected in 1982. These people are exceptionally lucky to still be surviving but are amongst the few that evidently showed good resistance to HIV DESPITE not having drugs (HAART treatment was only introduced in 1996 - so it is impossible that their 20 year survival is entirely attributable to the latest drugs.

While HCV is serious, I think your comparison overly dramatizes the life-impact of this nevertheless (5%) fatal illness and trivializes the impact and death rate of HIV. I do not know where your figures are from. All the figures I have quoted are from the CDC current guidleines on HIV and HCV.

i'm not trying to dramatize or trivialize anything. believe me, i can relate to these issues all too well.

all i am saying is, as a health professional, I personally would be more concerned about HCV exposure than HIV simply b/c there is prophylatic treatment available for HIV exposure that is highly effective. i am in no way trying to justify what disease is worse to have.

socioeconomic status, access to and quality of healthcare, compliance to medication, etc. are all related to HIV disease progression/non-progression. those CDC statistics do not take these factors into account. rather, they look at the incidence of disease for the entire population, which skews the reality for different cohorts and sub-cohorts as epidemiological studies have proved.

i apologize if my percentages were incorrect for HCV. thanks to you, i just realized that i confused it with chronic HCV (usually occurs in maternal transmission during birth) which doesn't apply here.

-joe joe

 

[Diogenes]

Originally posted by JmE


Were you looking for a serious reply? I almost replied but then I thought you might be joking.

I would, however, find reading replies to this question interesting reading.

-JmE-

My reply would be:

I would treat him and forget about it. I would be a physician first and foremost, not a soldier, politician, or even a patriot in that scenario.

God, my sarcasm-reputation is out of control. No, this question actually happened. Seriously. My answer was that I would do the surgery because I will not withhold my medical expertise based on a moral judgment about the patient, but that I would tell the government where he was when I got back because I didn't think doctor-patient privilege would apply to his location -- just his medical condition. The interviewer said that he thought I had a good answer (but he wasn't looking for a "right" or "wrong" answer).

 

[JmE]

Originally posted by Diogenes


God, my sarcasm-reputation is out of control. No, this question actually happened. Seriously.

Yes, most of the time, I miss obvious sarcasm and it can be quite embarrasing to take things too literal.

My answer was that I would do the surgery because I will not withhold my medical expertise based on a moral judgment about the patient, but that I would tell the government where he was when I got back because I didn't think doctor-patient privilege would apply to his location -- just his medical condition. The interviewer said that he thought I had a good answer (but he wasn't looking for a "right" or "wrong" answer).

I agree that your answer is very well put. I think it is a tough question to be asked in an interview...

-JmE-

 

[Street Philosopher]

I would put some sort of time bomb in his liver so he would explode when I'm safe at home. But that's just me and my "morality" talking.

 

[Smurfette]

Early on in med school, we had a lecture on Universal Precautions (i.e. dealing with body fluids, etc.). They gave us the stats on getting bloodbourne diseases...directly from the handout, the likelihood of getting HIV from an infected person via a needlestick or other "sharps injury" is VERY small ("under 0.5%"). It may be higher via an open wound, but the odds are still pretty low. Hepatitis C, however, is ~10% and Hep B 30%. Does knowing this change anyone's mind?