Learning about Ethics and Professionalism through Vignettes

1. Learning about Ethics and Professionalism through Vignettes John Spandorfer MD Jefferson Medical College

2. At Jefferson, we use written vignettes and trigger videos to begin discussions of challenging topics in professionalism and ethics • Small group meetings – year 1-3 • Large group – all day professionalism session, spring year 3 • Project with the Annals of IM and Michael Lacombe

3. Honesty with patients http://professionalism.jefferson.edu/video1/

4. Professionalism in MedicineA Case-based Guide for Medical Students Cases Commentaries Literature-based reviews of professionalism topics Videos http://professionalism.jefferson.edu/

5. 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

6. 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.

7. 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

8. Patient confidentiality http://professionalism.jefferson.edu/video6/

9. Maintaining appropriate relations with patients http://professionalism.jefferson.edu/video9/

10. Students only: Was it appropriate or inappropriate for the student to have disclosed her past smoking history? • Appropriate • Inappropriate • Unsure

11. Students only: Was it appropriate or inappropriate for the student to have disclosed her relationship difficulties related to smoking cessation? • Appropriate • Inappropriate • Unsure

12. Students only: Should the student allow the patient to “friend her” on Facebook? • Yes • No • Unsure

13. Commitment to Professional Responsibilities Observation of Unprofessional Behavior http://professionalism.jefferson.edu/video15

14. Students only: If you were this student, in the OR, how would you most likely respond to the surgeon’s behavior? • Stand by quietly • Name a fattening food • Deflect or avoid the question • Respectfully question the appropriateness

15. Students only: After the case, how would you respond to the surgeon’s behavior? You would discuss your concern with the… • surgeon. • clerkship director or a Jefferson Dean. • resident and not an attending. • a friend or family member • keep it to yourself.

16. Students only: In the operating room setting only, how would you characterize the surgeon’s behavior? • Professional • Somewhat professional • Somewhat unprofessional • Very unprofessional • Unsure

17. Students only: How often have you seen similar behavior in physicians other than surgeons? • Never • Rarely • Occasionally • Frequently

18. 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 NielufarVariavand, M.D. Drexel University College of Medicine

19. Playing God http://annals.org/public/onbeingdoctor.aspx

20. Obligation of the Physician • Legal obligations • Physician codes (e.g. ACP, AMA) • Ethical approaches • Consequentialist, Deontological, Casuistry, Virtue Ethics

21. 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

22. 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

23. Obligation of the Physician • Ethical approaches • Consequentialist • Deontological • Casuistry • Virtue Ethics

24. 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