Cases For Professionalism and Ethics

1. Cases For Professionalism and Ethics

2. CASE 1: Interactions with pharmaceutical companies You are invited to attend an educational session about the new treatment for patients who have suffered a stroke. The session is sponsored by a company which manufactures and markets a thrombolytic agent. The session is in the evening at one of the best local restaurants. If the administrative staff in your department will arrange for the physicians in your group to attend, the company will pay all costs of dinner and pay each physician who attends $100 for his or her time.

3. CASE 1: Interactions with pharmaceutical companies • Should you agree to this arrangement? • Should the administrative staff of your department • make the arrangement?

4. CASE 2: Health Maintenance Organizations One of the HMOs in your region is known to deny payment for certain diagnoses and to be willing to pay for others. For example, they will pay for treatment of bronchitis because of the presumed need for antibiotics, but will not pay for treatment of a viral upper respiratory infection. They will only pay for the gastroenteritis if it involves dehydration and the need for parenteral fluids. Your department encourages you to find diagnoses that the HMO will cover.

5. CASE 2: Health Maintenance Organizations • What should your response be? • 2. Does it make a difference if you have to alter your treatment because of the diagnosis (e.g. give antibiotics when you think the person likely has a virus, or fluids to a patient who could likely take oral fluids)?

6. CASE 3: Impaired Health Care Providers You work in an emergency department in a small community that has only one surgeon within 50 miles. He is well respected in the community and has always been regarded as competent. On two occasions when you have been working the night shift, he has come in to evaluate patients dressed in evening clothes. Although he has seemed to care for the patients appropriately, you believe you smell alcohol on his breath.

7. CASE 3: Impaired Health Care Providers • What should you do?

8. CASE 4a: Autonomy As the base command physicians, you receive a call from your paramedics. They were called to a nursing home for a patient in respiratory distress. Upon arrival they found the patient to have agonal respirations and a pulse of 35. The daughter arrived seconds later and says the patient’s advanced directives state she did not want intubation or advanced cardiopulmonary resuscitation. The daughter asks for the paramedics to leave her mother alone and not transport the patient to the hospital. Written copies of the advanced directives cannot be found.

9. CASE 4a: Autonomy 1. What is your response? 2. What would you do if there was a written directive that seemed to reflect the patient’s wishes, but could not technically be honored by the EMTs because policy dictated that a different form had to be used?

10. CASE 4b: Autonomy A 60 year old male fell 7 feet from ladder. Injuries included multiple rib fractures, a scapular fracture, pelvic fracture and a small subarachnoid bleed. He remained alert and oriented throughout his ED stay. He had a “no blood” Jehovah’s Witness card in his pocket and was an elder in the Church, but on 2 prior occasions in the ED, he stated he would accept blood if it was necessary to save his life. About 3 hours after his arrival his hematocrit dropped and he became hypotensive. Multiple family and church members were in the waiting room and stated that they knew the patient well and he would not want blood and it should not be given.

11. CASE 4b: Autonomy • What should you do? Is there anything that would cause you to decide differently? 2. Who should make the decision?

12. CASE 4c: Autonomy A man is brought into the emergency department in police custody for a forensic examination because the man is accused of rape. He does not consent to the examination.

13. CASE 4c: Autonomy • What is your obligation to the patient? 2. What is your obligation to society? 3. Should you do the examination?

14. CASE 5: Staff Disagreement During a busy shift your attention is drawn to the nursing station where your ward clerk and the medical admitting resident of the day are involved in a loud, heated argument regarding the location of order sheets. The interaction is in full view of patients and other staff.

15. CASE 5: Staff Disagreement • What should you do?

16. CASE 5a: Staff Disagreement You observed an emergency medicine resident try without success to admit an elderly woman to a subspecialty service. The attending then talked to the subspecialty attending who not only refused the admission, but also called the emergency attending a barnyard epithet. The EM attending replied with a similarly offensive, though more creative insult.

17. CASE 5a: Staff Disagreement • You observe the interaction, and agree, in spirit, with the name used to describe the subspecialist. What do you tell the resident? Do you discuss this with your partner? 2. Can you think of another way to handle the interaction?

18. CASE 6: Providing Comfort Which May Not Be Medically Necessary It is 1 AM when a pregnant woman presents to the emergency department with complaint of painless vaginal bleeding early in her first trimester. Her pelvic exam reveals a closed cervical os and no adnexal masses. Her BHCG is 1200. The patient tells you her neighbor had an ectopic pregnancy and she is extremely concerned she could have this also. She has no risks for ectopic pregnancy. She asks you if she could get a test to be more sure that nothing is wrong. She specifically requests an ultrasound and is insistent and anxious. Your ultrasound is broken, and you would need to call the radiologist to get the technician in from home to do the ultrasound.

19. CASE 6: Providing Comfort Which May Not Be Medically Necessary 1. How do you proceed? 2. Would it make a difference if the ultrasound technician was in the ED (i.e. easily available)?

20. CASE 6b: Providing Comfort Which May Not Be Medically Necessary In a busy EMS system, a patient with a minor medical problem requests going to a hospital which is a significant distance from the scene though there are a number of closer hospitals. At the time of the call there are very few ambulances available and going the extra distance could delay arrival of an ambulance to the next patient.

21. CASE 6b: Providing Comfort Which May Not Be Medically Necessary • Should the EMS system allow patients to choose destination even if it will delay care for others? • Does it make a difference if the system is tax supported? 3. Is the paramedic’s obligation to the individual patient or to the system?

22. CASE 7: Professional Responsibility and Patient-Physician Honesty A 32-year-old man comes in with a fever of 101 F, anorexia and right lower quadrant tenderness. You believe he has appendicitis. He does not have a personal physician and does not know any doctors at this hospital. The patient asks whom you would recommend as the surgeon. Personally, you would not choose the person who is on the on-call list.

23. CASE 7: Professional Responsibility and Patient-Physician Honesty • What do you tell the patient?

24. CASE 8: Responsibility to a Patient and an Employer A 28 year old presented to the emergency department on a Monday morning and requested a note for work. The person told of missing 3 days of work during the prior week because of the flu. Now the person’s supervisor requires documentation of the illness. What do you do?

25. CASE 8: Responsibility to a Patient and an Employer 1. What do you do? 2. What personal perceptions, judgments, and biases do we apply to patients with these requests?

26. CASE 9: Confidentiality The region in which you work has just passed an ordinance requiring that all weapons related injuries (intentional, self-inflicted, and accidental) must be reported to the Department of Health. The form asks for the patient’s name, address, medical history, and demographic information such as whether the patient or a family member is on welfare. The Department of Health wishes to develop a database to better target future public health interventions. Physician non-compliance could result in a $300 fine and 90 days in jail per offense.

27. CASE 9: Confidentiality • What will you do?

28. CASE 9b: Confidentiality Your emergency department has a status board that lists, among other things, the patient’s name and chief complaint. It is in a hallway between treatment areas which receives a lot of patient and staff traffic. Rounds at change of shift are also conducted at this board.

29. CASE 9b: Confidentiality • Is this a violation of patient confidentiality? 2. Does it matter if certain “sensitive” information such as HIV status, rape or psychiatric complaints are listed on the board or some code is used? 3. Does it matter if most family members don’t notice it?

30. CASE 9c: Confidentiality A person comes into your ED with a first time seizure. Your work-up does not find a cause. The man works as a taxi driver. Your state law requires notification of the Department of Motor Vehicles.

31. CASE 9c: Confidentiality • What should you do? 2. What do you say when he says that if he does not work he will be unable to pay his rent and he and his two children will become homeless? 3. Is this a good law? Is it ethical?

32. CASE 9d: Confidentiality In the course of gathering history from a 24 year old woman, she tells you that she is HIV positive, but she has not told her current boyfriend because she does not want him to know. She admits that they are sexually active and “usually” use a condom. He is in the ED waiting room and is concerned about her illness.

33. CASE 9d: Confidentiality 1. Do you have an obligation to tell? 2. Would it make a difference if he were your patient, too? 3. What should you tell each of them? 4. What words would you choose? How would you get the message across? 5. How much time would you spend? Would you spend time to discuss primary care issues and antiretroviral therapy?

34. CASE 9d: Confidentiality-Examining Biases What race did you presume this couple to be? Would you have a slightly different interaction with the patient if the couple were inner-city African-Americans? Affluent, white college students? A homosexual couple? If the patient was a man and the accompanying partner a woman?

35. CASE 10: Special Treatment of a VIP The mother of one of the hospital administrators arrives in the emergency department with new onset angina. There is only one monitored bed left in the hospital. The patient who was assigned that bed is still in the ED. He received thrombolytics in the ED earlier for an acute MI. You are asked which patient should go to that bed. There are no other foreseeable monitored beds.

36. CASE 10: Special Treatment of a VIP 1. What would you do?

37. CASE 11: DNR in the ED A patient with COPD comes into the emergency department during a severe exacerbation. His pH is 7.08 and his pCO2 is 74. He indicates that he has been intubated previously and does not want to be intubated again.

38. CASE 11: DNR in the ED 1. What do you do?

39. CASE 12: Teaching Issues You are attending during a busy shift during August. A student had been evaluating a patient with a stab wound to the thigh when a code came into the emergency department. Upon completing the code, you note that the stab wound is sutured. The student states that the patient was presented to the upper year resident. When you question the senior resident, he states that he only had told the student to get the equipment assembled to copiously irrigate the wound and explore the area for a foreign body. The student then admits that he took it upon himself to suture the patient because he thought that is what should happen. The student is interested in obtaining a letter of recommendation from your residency program director as he is applying to emergency medicine residencies.

40. CASE 12: Teaching Issues • What should you do? 2. Should you mention this in a letter of recommendation? 3. How, if at all, should this be addressed in the clerkship evaluation?

41. CASE 13a: Racism and Sexism You happen to observe a senior resident’s interactions with several patients. His first patient was a 45 year old woman with chest pain. His history was focused, but thorough and the physical examination was accurate. The resident was polite and interacted well with the patient, calling her “Mrs.” His next patient was an elderly African- American man with a chief complaint of vertigo. Again, the history and physical were accurate and complete. However, you notice he called the patient “chief.” You also notice that he calls elderly women, “honey” and refers to young men as “buddy.” No patient has complained, although a nurse thought that his references were inappropriate. When brought to his attention, the resident states that his demeanor is always professional and that the nicknames help him establish rapport.

42. CASE 13a: Racism and Sexism • Does this resident exhibit racism? Does he exhibit sexism? 2. How should you approach the resident?

43. CASE 13b: Harassment You receive an evaluation from an off-service attending stating one of your residents was frequently late and did not complete her assignments. This surprises you since the resident has always received above average evaluations and been noted for her responsibility. You interview the resident who tells you that on the first day of the rotation this attending put his arm around her and patted her buttocks to compliment her after a procedure. She confronted him, and from then on he was hostile toward her.

44. CASE 13b: Harassment 1. What should you do? 2. What obligation do residents have to come forward and report harassment? 3. Was this harassment? 4. Does your program have a policy about sexual harassment? What educational programs do you have, if any?

45. CASE 14: Conflict of Interest A physician is performing a clinical trial of a new drug. Preliminary data shows that the drug appears to be failing to provide any benefit and has some unexpected side effects. The researcher’s retired father owns stock in the drug company. The company asks the researcher to delay reporting the results until after the company’s annual meeting in two months because of a concern about a drop in the stock price.

46. CASE 14: Conflict of Interest 1. What should the researcher do? 2. Should the researcher tell her father to sell his stock? 3. What are the ethics of doing research on a drug and owning stock in the same company? 4. When should a clinical trial be stopped?

47. CASE 14a: Authorship The chair of emergency medicine at a prominent department has an extensive bibliography. Many of the papers on which he is listed as an author were researched and written by other faculty members or residents. The chair’s contribution was minimal, consisting of methodological or statistical advice. Every time he proofreads a paper or offers advice, he insists that he be listed as an author.

48. CASE 14a: Authorship 1. Is this practice ethical? 2. Who is responsible for determining authorship? The chair? The senior author? All authors? The journal editor? 3. What is adequate participation for authorship?

49. CASE 15: Contracts and Billing An emergency medicine specialist negotiated a contract with the hospital to provide ED services. At some financial risk and legal expense, the contract was awarded. The contract holder hired you at $90/hr. You have no administrative, management, or billing responsibilities. You request billing records to see how much was billed in your name and the contract holder refuses.

50. CASE 15: Contracts and Billing 1. What issues of professionalism are involved? 2. Who has the right to control this information?