Professional Behavior

Tom Heston, MD

Case Study 1
A physician over time becomes attacted to a current patient The physician and patient mutually agree to end the physician-patient relationship The physician now asks the former patient out on a date, and they go on several additional dates. What do you think?

Case Study 1
Relationship soured Complaint made to the state medical board Physician was disciplined by the state medical board and license was restricted for 2 years

Principles
Physicians are in a position of power Patients can be vulnerable to their influence Physician power should only be utilized for medical purposes, not personal gain
Romantic relationships with a current patient is not allowed Some states prohibit the treatment of family, friends, or employees

Doctor-Patient Relationship
Both parties must agree Physicians do not have a legal obligation to enter into a doctor-patient relationship with anyone, however note that:
Emergency departments must treat everyone Physicians working in such settings have agreed to provide treatment to all patients seeking care

Ending the relationship: reasonable notice, provide alternatives, maintain records

Gifts From Patients

Small gifts acceptable Large gifts should be refused Patients may be vulnerable, and as a result give a provider a large gift.

Impaired Physicians
Substance abuse Physical disability Mental illness Old age resulting in poor performance

Principles to Follow
Self Regulation
Surgeon with advanced arthritis stops operating Elderly physician retires Physicians have a duty to do their very best to self regulate their medical practice

Physician Colleague Regulation

Must ensure that the impaired physician gets help When discovered, all physicians have an ethical obligation to ensure impaired physicians get help Physicians are often in the best position to identify impairment in a colleague

Medical Malpractice
Error and mistakes occur. This alone does not equal malpractice Must prove the 4Ds: dereliction of duty results in damage directly to the patient
Dereliction: giving substandard medical care Duty: a physician-patient relationship exists Damages: actual damage to the patient occurred Directly: damages were the result of dereliction

Impact on Physicians
All physicians are at risk of getting sued
~10% per year in US historically Top specialties: surgery, ob/gyn, anesthesiology

Malpractice is a tort, i.e. a civil wrong.

Compensation typically is financial.

Physicians occasionally, but rarely, accused of a criminal malpractice violation

Result can be jail time

Types of Damage
Compensatory
Reimbursement of medical bills Reimbursement of lost wages Pain and suffering

Punitive Damages
Designed to punish the offending party Designed to set an example

Deviation From the Standard of Care

Generally determined by LOCAL practice Practice guidelines http://guideline.gov Medical society guidelines

Informed Consent
Not simply a signature on a page Fully Informed
Procedure Alternatives Benefits Risks

Informed Refusal

This is a high-risk situation Frequently occurs in emergency room settings Must fully document and ask patient to sign out AMA

Patient Obligations
Fully inform the physician Ask questions Be honest Follow medical advice

Medical Errors
Ethical duty to inform patients of an error if it will impact the patients care. Minor errors that will have no impact upon care do not need to be reported to the patient

Case Study 2
Patient with high blood pressure admitted to hospital Order for Diovan misinterpreted as for digoxin, possibly due to sloppy handwriting Patient overdosed on digoxin requiring a prolonged stay Patient successfully treated, being unaware of situation What are the principles here?

Case Study 2
Physician, pharmacist, and nurse all made a mistake
Dosage difference for digoxin vs Diovan should have been caught by pharmacist and nurse Physician should have written more legibly

Harm occurred, even though patient unaware

although no long-term harm, the patient did have a prolonged hospital stay

Case Study 3
What is the role of the Risk Management team in a hospital?
Patient advocacy? Improve clinical care? Ensure the ethical treatment of patients? Minimize legal risk to the hospital?

Case Study 3
Risk Management Teams are tasked with reducing the legal risk to the hospital. May or may not lead to improved clinical care Sometimes, but not always, also reduces the liability risk of physicians and nurses.

Case Study 4
Adult patient with leukemia informed (procedure, alternatives, benefits, risks) regarding bone marrow transplantation versus chemotherapy Patient agrees to bone marrow transplantation Patient dies and lawsuit filed What is the likely outcome?

Case Study 4
Lawsuits can be filed for any reason In states with no tort reform, outcomes are unpredictable due to high emotion and low level of medical expertise of non-professional (lay public) jurors. Theoretically, the physician should not lose this lawsuit because of documented, full informed consent, and the therapy being within the standard of care

Case Study 5
Patient with acute myocardial infarction Angioplasty offered The procedure and risks were fully explained to the patient Patient decides to go with medical therapy alone Patient dies What is the medico-legal situation here?

Case Study 5
Consent was not done properly: the alternatives and benefits were not discussed Procedure and associated risk of procedure explained, but...
Benefit of procedure not explained Alternatives (and their risks) not explained

Case Study 6
Resident disagrees with medical management by attending physician What should the resident do?

Case Study 6
The resident should first discuss the case with the attending, using evidence-based medicine If no satisfactory response, then resident should bring the issue to a higher local authority
Do not go to the patient Do not go directly to the state board Go to a local, higher authority

Case Study 7
Elderly women admitted to hospital with gastroenteritis and dehydration Does not complain of dizziness Left alone to use the toilet, gets dizzy, and falls Sues hospital for negligence What are the legal principles here?

Case Study 7
Patients are required to fully inform physician of medical condition and physical complaints Patients required to inform nurses about dizziness when it affects nursing duties Fall precaution policies in hospitals try to prevent this situation from occurring.

Case Study 8
Patient with osteomyelitis You forget to reorder antibiotics, and the patient misses 2 days out of his 6 week course of antibiotics (2 days out of 42 total) The patient does not experience any clinical deterioration Condition successfully treated by 6 weeks What should you do?

Case Study 8
This is a medical error but not malpractice (no damage occurred) You should inform the patient and reassure them that they will be okay

Case Study 9
Patient admitted with massive intracranial bleed Patient on a ventilator Brain death confirmed What do you do?

Case Study 9
Inquire about organ donation Death is determined by the physician, not the family Brain death = death Cardiopulmonary arrest resistant to rescussitation = brain death = death Remove the ventilator after speaking with the family

Case Study 10
A parent brings a 5-year old child to the ER You suspect child abuse What do you do?

Case Study 10
Report the situation to child protective services You are ethically and legally required to report even a suspicion of abuse You are legally protected even if it turns out to not be abuse

General Principles
The patient comes first Open communication Tell the patient what you know Expect reciprocity from the patient Try to remove barriers to communication such as computers, other family members

General Principles
Work on long-term relationships Negotiate rather than order. Paternalism is out. Admit errors Never pass-off care. Stay involved even after referral to subspecialist.

General Principles
Ensure you understand the patient first Patients do not get to select inappropriate treatments Best answers serve multiple goals. Consider both short-term and long-term issues.

General Principles
Never lie. Accept the health beliefts of patients
Expect to come across folk remedies Explain your care in plain language

Accept and honor religious beliefs of patients, participate if appropriate Anything that improves communication is good

General Principles
Have a good bedside manner and be respectful A good rapport increases patient satisfaction, compliance, and physician satisfaction

References
Kaplan Medical USMLE Medical Ethics (2006) Deja Review USMLE Step 1