Professionalism and Ethics for Clinical Clerkships

1. Professionalism and Ethics for Clinical Clerkships Richard L. Elliott, MD, PhD Professor and Director Professionalism and Medical Ethics Mercer University School of Medicine Adjunct Professor Mercer University School of Law

3. Goals • Overview of professionalism and ethics in clerkships

4. Senior cases • Your case due March 1 Senior year • Case analysis format recommended, not required • Outstanding papers • http://medicine.mercer.edu/Academics/Degree%20Programs/Doctor%20of%20Medicine/ethicsoutstandingpapers • JMAG publication?

5. Internal medicine End-of-life decisions Futility of care Euthanasia Physician assisted suicide Your cases in professionalism and ethics

6. OB-GYN Reproductive technologies Genetic testing Fetal Maternal Your cases

7. Pediatrics Baby Doe laws and futility of care in the infant Rights of minors Your cases

8. Surgery Case focused

9. Family Medicine Care of the elderly Domestic violence Medical errors Your cases

10. Psychiatry Competence and informed consent Commitment Involuntary treatment Tarasoff

12. How can you tell if someone is a professional? • Dress • Timeliness • No Houdinis need apply • Preparation • Honesty • Didn’t do something, don’t know something, say so • Competence • Ethical behaviors • Courtesy and respect • Towards patients, staff, colleagues, profession • Willingness to take on duties cheerfully

13. Confidentiality • Where do you discuss cases? • With whom do you discuss cases? • A friend’s 16-year old daughter visits the office where you are working and requests birth control pills. Her family is Irish Catholic and is against birth control in any form as well as premarital sex. She requests that you do not discuss this with her parents. After concluding the visit, you return to your work area where you find a message to call the patient’s mother. In the past you have always discussed the daughter’s health issues and other concerns openly with the parents. • What will you do? • Do you have an obligation to the patient to maintain confidentiality? • Do you have an obligation to the parents to divulge the nature of their minor child’s medical problem? • Would it be different if she had presented with a URI or athlete’s foot?

14. Honesty • A68-year-old man is hospitalized with fatigue and anemia. You and another student are on call for the evening and sharing responsibilities. You conduct the admission history while your colleague performs the physical examination. You have worked with this student previously and have found him to cut corners in his work and to disappear when work assignments are distributed. During his physical examination he ‘forgets’ to perform a rectal examination or perform a stool guaiac study. During the night, the patient has a myocardial infarction as a result of an undetected gastrointestinal bleed. During rounds the next morning, the attending physician asks you whether the patient’s stool was guaiac negative. • How would you respond? • If the other student falsely reports a negative guaiac what would you do?

15. Scut monkey • During a night while on call, a resident asks you to go out and get sandwiches. • What do you do? Why?

16. Competence • A resident post call makes several errors, not washing his hands following a dirty procedure and before seeing the next patient, and prescribing amitriptyline to a patient with an arrhythmia likely to be exacerbated by the medication. • What do you do? Why?

17. Impairment • Another student with a history of binge drinking reports for duty smelling of alcohol. You ask about this and he says it was just an eye opener and that he has seen the attending, a well-known surgeon, do exactly the same thing. • What do you do? Why?

18. Duty Hours • You are told you have to do only two admissions per “shift.” The team is swamped, the intern harried, another student is out,, and a new admission comes in. The intern asks if you would see the patient. • You are at the end of the maximum time allowed for your shift. A patient you admitted is going to the OR and you would like to observe.

19. Issues StudentsRaised • Fighting with other staff in the charts • Copy and paste in EMR • Too little time with patients • Discussing patients in public • Multiple appointments to maximize billing

20. Rule #1 • We are doctors

22. What does it mean to be professional? • Principles • Principle of primacy of patient welfare • Principle of patient autonomy • Principle of social justice • Responsibilities (Commitments to __) • Professional competence • Honesty with patients • Patient confidentiality • Commitment to maintaining appropriate relations with patients • Improving the quality of care • Improving access to care • A just distribution of finite resources • Scientific knowledge • Maintaining trust by managing conflicts of interest • Professional responsibilities • Ann Int Med 2002;136:243-246

23. What is professionalism? • PROFESSIONALISM - Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: • demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self -interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development. • demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices • demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities • (ACGME, 1999)