This article was written by a medical student (who is now faculty in the Department of Medicine at UW) who describes feeling uncomfortable with a patient care task he was asked to perform. He felt silenced by the medical hierarchy and didn’t speak up at the time due to fear. He emphasizes the importance of changing the culture of medicine to one that respects open communication and respectful advocacy to promote safety in the learning environment and patient care.
This article (also available online at: https://www.newyorker.com/news/news-desk/curiosity-and-the-prisoner) explores the foundational principle of medicine that all lives are created equal and how in modern day applying these principle requires a willingness see the humanity in all people even those different from you and to try to understand what it is like to be them. It requires a curiosity and openness and level of respect and through a respect of the humanity of others you “will be given trust ot see human beings at their most vulnerable and serve them.”
This document reviews the importance of professionalism is the basis of medicine’s contract with society and that understanding the principles and responsibilities of medical professionalism is key to physicians social contract with society.
GOAL: Appreciate the idea of aftermath of medical error and idea of provider as second victim..
Context and Instructions: Read article to begin to appreciate medical errors can have on providers and get introduced to a way of thinking of how to support ourselves and colleagues who experience the aftermath of a medical error.
Goal: Explain the ethical conflicts involved in deciding if and when to provide medical care for family members.
Instructions/context for reading: Almost all medical students and physicians will receive requests for medical advice from family or friends at some point in their career. These requests can range from simple questions about routine medical care to complex inquiries about serious health issues or medications. Read this article about handling a request for medical care from a family member and consider how you might respond as a medical professional.
Goal: Explain the implications of the policy statements from the AMA Board of Ethics and explore the ramifications of providing medical care for family and friends
Instructions/context for reading: Responding to requests for medical care from family and friends in a manner that maintains professional integrity without compromising a personal relationship takes introspection and practice. Participating in class discussion will help students begin to analyze the nuances of these interactions and the ethical dilemmas involved in approaching requests from family and friends.
In this session, we will be focusing on the Ethical Framework of Rules/Obligations (see Ethics Case Analysis Tool). We will investigate one of the primary obligations of clinicians: respect for patient autonomy, and consider what this might mean in more complex clinical cases. We will also explore another primary obligation of clinicians: the obligation to build trusting relationships with patients. This second obligation is often required for fulfilling the first, and these cases help us to see why.
**Keep in mind that this session will focus on cases that are meant to draw out population level biases and ethical concerns in particular clinical interactions. We will be addressing more societal, systematic, and broader justice issues in other sessions (see Justice in Healthcare). Likewise, we will come back to system level methods of advocacy (including advocacy for clinicians with underrepresented minority identities) in other sessions. Here, our intention is to start thinking creatively about how to be in relationship with particular patients in complex contexts.**
As you read CONSIDER… Autonomy is a complicated concept. While in the US it is often understood as the capacity of an individual to make independent choices, this isn’t the reality of choice and this article helps us to see why. Our choices are always enmeshed in complicated interpersonal (e.g. family) and structural (e.g. cultural norms) social relations.
How do you think building trust and being trustworthy relates to respecting patient autonomy?
What are Doris’ goals and those of the care team? How do they align and how they conflict?
How does trustworthiness factor into this case? Might it guide clinicians in some particular way? How so?
What does it mean to respect a patient’s autonomy in this case?
CASE 1 – DORIS
Doris at hospital admission
Doris Carlson is a 72-year-old woman who was brought to the ED by medics shortly after collapsing at home with shortness of breath and leg weakness. She was in her usual state of health, able to walk a couple of blocks and care for herself, until a week prior to admission, when she noticed that she was even more short of breath than usual and her legs were swelling. She thought maybe it was the heat, but four days ago she couldn’t lay flat to sleep. Finally her legs were so weak that she fell in her hallway this morning. She was able to crawl to the phone to call the medics, who had a tough time getting her out of her apartment because the rooms were stacked with books and periodicals.
Doris lives alone and says she likes it that way. When she retired 4 years ago from her job as a librarian, she moved into a second floor apartment with an elevator. Doris has a BMI of 35 and was diagnosed with type 2 diabetes and hypertension almost 15 years ago, but hasn’t actually seen a doctor in years and takes no prescription medications. She does take Vitamin D because she read about the low levels among Seattleites. At baseline, she can walk a couple of blocks before feeling out of breath, and is able to get to the grocery store and other key places on foot. In the week before collapsing though, she hadn’t been able to get to the store, and had no one she could call on for help.
Doris at Hospital Day 19
Doris refused most recommendations and therapies, yet she loved to have long conversations with everyone on the team. The Cardiology team spent hours teaching about her cardiac disease, and trying to negotiate a mutually acceptable plan. The pharmacy team spent hours providing drug education. The team eventually resorted to only sending one person into the room during morning rounds to avoid delaying their rounds. The dietitian had prolonged conversations about better diet choices for diabetes, as well as a low sodium diet (and also tried to help out with the avocado situation). Hospital dentistry evaluated Doris given her lack of dental care, diabetes, and left lower jaw tenderness while in the hospital, but she refused to go down to the clinic for a full exam or x-rays. The team social worker spent hours first trying to identify community supports, and then skilled nursing facility placement, only to have Doris refuse all options. Doris even refused to be discharged home by cabulance insisting she would take a taxi.
While most patients on the medical floor have a primary nurse, no one would volunteer to take Doris. Eventually, a plan was developed for rotating care of Doris daily among the nursing team to diminish frustration. Doris would often complain that she didn’t like someone on her care team, often trying to engage the person currently with her to “help” with some problem. The physical therapist and occupational therapist also spent hours with Doris but had a different experience. While Doris was fairly passive receiving OT and PT therapy, she was appreciative of their attention and efforts.
Because of her unwillingness to take most oral medications, Doris remained quite hypoxic on room air, and was thus not ready for discharge. She declined home oxygen, though she wore it in the hospital. Doris’ hospitalization dragged on for weeks during a time when the hospital was full and other patients were being diverted.
The Cardiology team requested a Psychiatry consult to assess Doris’ decision-making capacity. Doris refused to talk to Psychiatry but after discussing with other team members, the psychiatrist (and cardiologists) felt Doris was indeed able to make decisions for herself.
By hospital day 19, the Cardiology team decided to discharge Doris with or without home oxygen, medications, dental follow-up, assistive equipment or any other social services. They had offered ample recommendations but she was unwilling to accept any. Other team members were uncomfortable with this plan, given that her room air oxygen saturation remained in the low 80s. Her nurse asked if she was supposed to just remove the oxygen at the curb and wish her “good luck” as she got in the cab?
One team member eventually was so uncomfortable, discharge was delayed and an ethics consultation was requested.
SHIFTING GEARS A LITTLE…We’re going to look at the intersection of the values of autonomy and trustworthiness in the more complicated context of IV drug use and addiction. This reading will be directly relevant to an in-class exercise in which students will be expected to participate in a mock family meeting.
(4) READ this publication by Dr. Kirkpatrick (Cardiologist and Ethics Consultant at UWMC):
Dr. Kirkpatrick uses a case and casuistic comparisons to critically reflect on the meaning of the term ‘futility’ in contexts where a patient’s addiction to IV drugs might be taken as a reason against pursuing a particular medical intervention.
As you read HIGHLIGHT the central ethics rules/obligations that Dr. Kirkpatrick applies in his discussion.
(5) OPTIONAL PREP FOR MOCK FAMILY MEETING: in light of what you’ve read in Dr. Kirkpatrick’s article, review the following case…
Moira is 28yrs old with two children (7 and 9yrs old). She has a history of injection opioid and meth use, and is admitted for fever and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Moira has been admitted several times over the past 6 years for S. aureus endocarditis, had a mitral valve repair for an anterior leaflet perforation 5 years ago, and then a bioprosthetic valve replacement 2 years ago. Although she has tried rehabilitation programs a number of times in the past, she relapsed 2 months ago and continues to inject heroin. Each time she’s been admitted, staff have been surprised by her ability to recover, but also frustrated by each new admission. When an echocardiogram is done during this current admission, she is found to have a large vegetation on her bioprosthetic mitral valve, with a small perivalvular abscess.1 She is currently receiving antibiotics and being considered for a valve replacement. Her surgeon believes that a mechanical valve would be the best option for long-term cardiac function, but is concerned that she won’t adhere to anticoagulation therapy and could reinfect the valve, given her ongoing injection drug use.
Moira alternates between passive acceptance of her care and anger at staff. She will sometimes knock food off her tray, throw her bedpan, or verbally lash out at medical staff (e.g. “just leave me alone!” or “don’t pretend you care!”). Because of this, staff members have warned each other to take caution when entering her room. Moira has a “behavior contract” and often behaves more passively when her father (Rick) is in the room. So, the medical team typically waits until the father is present to conference with the patient. Moira is often alone in her room as her father is very busy with his job and taking care of Moira’s two children.
The surgical team disagrees about whether or not to offer the valve surgery to Moira. While one of her nurses doesn’t understand why it has not yet been offered, another feels burnt out from caring for Moira over several admissions and is frustrated by Moira’s lack of participation in her care. Similarly, while the attending surgeon is reluctant to do another valve replacement knowing it will not fix Moira’s underlying disease (her addiction), the resident believes that she is a sufficiently good candidate medically and it will likely allow her more time (months to years) with her family.
Moira and her family have been consistently homeless or houseless. She had been staying in a shelter with her children prior to the current admission. While the children’s father is not present, Moira’s father Rick is very involved in her care and is in the process of adopting the two children.
Should Moira be offered a third heart surgery?
Family Meeting: The care team, Moira and her dad will meet in a family meeting to explore Moira’s goals, and the previous challenges in her care, in order to inform future care decisions, including the possibility of a future valve replacement.
Trust and the virtue of trustworthiness are integral to the moral life. At a very basic level, society requires trust to function (e.g. what if you couldn’t trust your bank to hold your money?, or e.g. what if you couldn’t trust that teachers were doing their best to provide accurate information?, or e.g. what if you couldn’t trust your doctors to keep their interactions with you confidential?). In order to survive and flourish with those around us, we must be able to trust each other.
It is important to note that trust also makes us vulnerable. To trust in another is to make oneself vulnerable to that person or system. This point is a key feature of patient care. Physicians depend on patient’s to trust them in their care for them to be successful. Likewise, patients depend on physicians not to abuse their trust. When physicians and patients are able to engage in trusting relationships and be trustworthy, we have a better chance of enhancing the wellbeing of the patient, the physician, and the relationship.
Relations of trust are also vulnerable to social norms and history. Norms that categorize a particular population as not trustworthy can affect patient care and pose significant challenges to clinician-patient relationships. For instance, it is common for clinicians to distrust the demands of patients with Sickle Cell Disease, particularly by doubting the validity of their requests for stronger pain medications in a crisis. This mistrust is tied up in social perception of opioids as well as the visible identity of being black (as many sickle cell patients are). So, when building trust and trustworthiness in relations with patients, we must acknowledge how social norms and history can affect those efforts.
Physicians and patients alike will agree that empathy is integral to patient care. But it is not as easy as we might think. Empathy is not unlike other clinical skills and practices. Take learning to listen to a heart. We begin with simple instructions about how to use a stethoscope and then slowly build more precise attunement to any irregularities in heartbeat. In empathy, we begin with simple questions like “how do you feel today?”, but experience, practice, and knowledge will create greater attunement to the feelings of others. This article by Dr. Shapiro is just one step in the direction of building the knowledge necessary to becoming an excellently empathically attuned physician.
The conversation in this video is an excellent example of what it means to be curious, humble and empathic in conversation with others and across sameness/difference. Sunaura Taylor is an artist and writer, she articulates the social model of disability and demonstrates its effect on her life excellently. Taylor and Butler call on us to think about how what our bodies can do in the world depends on what the world allows physically and through social norms. Most importantly, Taylor and Butler show us how important it is to know about the experiences of others by talking with them and privileging their perspective by always remaining curious and open.
If you’re feeling eager for more… explore this article on How to Teach Doctors Empathy which talks about the growing emphasis on empathy training for health care professionals and describes a few such trainings across the country.
Start by reading this JAMA Piece of My Mind “Speak Up”which describes one physician’s experience with speaking up when witnessing micro-aggressions or biased comments or behavior in the clinical workplace.
Then read this post from STAT News that describes a medical student’s experience with racist comments during her clinical training and how it felt when no one spoke out against it.
ToolsforResponding to Bias
Goal: Communicate a message of disapproval without damaging interpersonal relations
Rehearse what you would do or say in situations before they occur
You know what feels most natural for you
Remember the Bystander effect
No one else will probably say anything
Consider saying something, even if it is a small effort
Decide whether to say anything
Silence is often interpreted as passive complicity
Consider saying something simple like “that’s not cool” or “I don’t appreciate that”
You don’t have to take a dramatic stand if you’re not comfortable or not able
Consider taking more time if:
You know you respond badly in the heat of the moment
You fear retaliation or mistreatment and need more support
The situation is not appropriate (ie during a patient care emergency)
Try to speak calmly, or consider waiting until another time
Try to avoid inducing defensiveness
Clarify or Restate what was said
Make sure you are understanding what was said
Make the speaker think about what they said
“So I am hearing you say….” Or even “excuse me, what was that you just said?”
If a joke was made, ask the speaker to explain it to you
When identifying the behavior, avoid labeling, name-calling or the use of loaded terms.
Describe the behavior; don’t label the person.
Appeal to principles
“I’m surprised to hear you say that. I think of you as more… (egalitarian, open-minded, etc).”
Change the subject (more effective than it sounds)
You may not change beliefs but you may change behavior
Reflect on what happened
Journaling or meditation
Debriefing with a peer or college mentor
It’s never too late to bring it up
Defer until later: “let’s talk about this when we have more time”
Bring it up later: “I’ve been thinking about what you said last week…”
Don’t get discouraged
You won’t know the lasting impact you’ll have later on, both for the speaker and those who were present
Know your resources
College mentors and college heads
Other trusted faculty
Student Affairs office
Traps to Avoid
Avoid making light of any comments, making jokes (which often backfire!), or getting defensive