Learning about Ethics and Professionalism through Vignettes

John Spandorfer MDJefferson Medical College

At Jefferson, we use written vignettes and At Jefferson, we use written vignettes and trigger videos to begin discussions of trigger videos to begin discussions of challenging topics in professionalism and challenging topics in professionalism and ethicsethics

Small group meetings – year 1-3Small group meetings – year 1-3 Large group – all day professionalism Large group – all day professionalism

session, spring year 3session, spring year 3 Project with the Annals of IM and Michael Project with the Annals of IM and Michael

LacombeLacombe

Honesty with patientsHonesty with patients

http://professionalism.jefferson.edu/http://professionalism.jefferson.edu/video1/ video1/

Professionalism in Professionalism in MedicineMedicine

A Case-based Guide for Medical StudentsA Case-based Guide for Medical StudentsCasesCases

Commentaries Commentaries

Literature-based reviews of professionalism Literature-based reviews of professionalism topicstopics

VideosVideos

http://professionalism.jefferson.edu/http://professionalism.jefferson.edu/

Ethical Considerations Surrounding First Time Procedures: A Study and Analysis of Patient Attitudes Toward Spinal Taps by

Students Kennedy J Ethics 1992;2:217

173 patients surveyed FM clinic, GM clinic, inpatient ward, heme-onc

ward 64% response rate

80% wanted to know the experience level of the person doing the LP, 6% would not, 14% neutral

Ethical Considerations Surrounding First Time Procedures: A Study and Analysis of Patient Attitudes Toward Spinal Taps by

Students Kennedy J Ethics 1992;2:217

Patients would let the trainee perform a first spinal tap on them if that person were: Medical student (52%) Intern (62%) Resident (66%)

72% said they would be “upset” if they later found they had been the unknowing subject of a student’s first LP.

Honesty with patients Informed consent – patients needs to

understand who will do the procedure Should all students perform LPs? Misrepresentation and student

identification Ranking of experience by patients “medical student”< “student doctor” (JGIM 1997:12:669

Moral distress

Patient confidentialityPatient confidentiality

http://professionalism.jefferson.edu/http://professionalism.jefferson.edu/video6/ video6/

Maintaining appropriate Maintaining appropriate relations with patientsrelations with patients

http://professionalism.jefferson.edu/video9/ http://professionalism.jefferson.edu/video9/

Students only: Was it appropriate or inappropriate for the student to have disclosed her past smoking history?

1 2 3

78%

8%14%

1. Appropriate2. Inappropriate3. Unsure

Students only: Was it appropriate or inappropriate for the student to have disclosed her relationship difficulties

related to smoking cessation?

1 2 3

34%

9%

57%1. Appropriate2. Inappropriate3. Unsure

Students only: Should the student allow the patient to “friend her” on

Facebook?

1 2 3

3% 6%

91%1. Yes2. No3. Unsure

Commitment to Professional Responsibilities

Observation of Unprofessional Behavior

http://professionalism.jefferson.edu/video15

Students only: If you were this student, in the OR, how would you

most likely respond to the surgeon’s behavior?

1 2 3 4

13%

4%

50%

34%

1. Stand by quietly2. Name a fattening

food3. Deflect or avoid

the question4. Respectfully

question the appropriateness

Students only: After the case, how would you respond to the surgeon’s behavior? You

would discuss your concern with the…

1 2 3 4 5

0%

8%

21%

51%

21%

1. surgeon.

2. clerkship director or a Jefferson Dean.

3. resident and not an attending.

4. a friend or family member

5. keep it to yourself.

Students only: In the operating room setting only, how would you characterize the

surgeon’s behavior?

1 2 3 4 5

2%5%

2%

47%45%

1. Professional2. Somewhat

professional3. Somewhat

unprofessional4. Very

unprofessional5. Unsure

Students only: How often have you seen similar behavior in physicians

other than surgeons?

1 2 3 4

5%

20%

45%

31%

1. Never2. Rarely3. Occasionally4. Frequently

ON BEING A DOCTOR

© Copyright Annals of Internal Medicine, 2011

Medical Humanities

Reflections on Playing God

Essay by Michael A. LaCombe, M.D.

Online module prepared for the Annals of Internal Medicine by:

John Spandorfer, M.D.

Sal Mangione, M.D.

Jefferson Medical College

Nielufar Variavand, M.D.

Drexel University College of Medicine

ON BEING A DOCTOR

© Copyright Annals of Internal Medicine, 2011

Playing Godhttp://annals.org/public/onbeingdoctor.aspx

ON BEING A DOCTOR

© Copyright Annals of Internal Medicine, 2011

Obligation of the Physician

Legal obligations

Physician codes (e.g. ACP, AMA)

Ethical approaches

Consequentialist, Deontological, Casuistry, Virtue Ethics

ON BEING A DOCTOR

© Copyright Annals of Internal Medicine, 2011

Obligation of the PhysicianLegal

This physician is an accomplice to the crime and has committed a felony.

Before altering the evidence, what was the physician’s obligation to report the murder?

All but 5 states (Alabama, New Mexico, South Carolina, Washington, and Wyoming) have laws requiring health providers to report injuries resulting from firearms, knives, or other weapons.

Ann Emerg Med 2002;39:56-60

ON BEING A DOCTOR

© Copyright Annals of Internal Medicine, 2011

Obligation of the PhysicianCodes

American College of Physicians Ethics Manual, 5th edition

All physicians must fulfill the profession’s collective responsibility to advocate the health and well-being of the public.

Physicians should protect public health by reporting disease, injury, domestic violence, abuse or neglect to the responsible authority as required by law.

Ann Intern Med 2005;142:560-582

ON BEING A DOCTOR

© Copyright Annals of Internal Medicine, 2011

Obligation of the Physician

Ethical approaches

Consequentialist

Deontological

Casuistry

Virtue Ethics

ON BEING A DOCTOR

© Copyright Annals of Internal Medicine, 2011

Physician Deception

Common areas of physician deception include:

Giving false information to third-party payers

allow for insurance payment for a medication, diagnostic test, or hospitalization

False information after medical errors

Minimizing bad news