Duty to third parties: a new worry for doctors

The Hawaii Supreme Court ruled on June 10, 2002, that physicians might be liable to non-patient third parties if they fail to warn their patients regarding a medication's adverse effect on driving. Conceivably, this liability may also extend to physicians who fail to inform their patients and/or the Department of Motor Vehicles of medical conditions that affect operating a vehicle safely. Physicians must be cognizant of every medication's impact on driving ability, inform their patients of these adverse effects, and should consider asking their patients to stop driving if the risks are substantial.     

Driving and epilepsy. A review and reappraisal

Driving and epilepsy is a problem that involves physicians as both care providers to patients and consultants to regulatory authorities. Driving restrictions for people with seizure disorders are intended to ensure the public's safety, but such restrictions may unduly harm the welfare of many people with seizures. In the United States, all states now permit some people with epilepsy to drive. In general, only people whose seizures are adequately controlled are licensed to drive. Adequate control has been judged principally by the seizure-free interval, but individual state standards widely vary. There is a trend toward greater liberalization of driving standards for people with seizure disorders, but the appropriateness and application of these standards continue to raise questions, as does the role physicians should have in the licensing process. Our responsibilities to persons with disabilities and advances in our understanding of seizures and the nature of driving risks warrant a reappraisal of the current medical, legal, and social implications of driving and epilepsy.     

Physicians' evaluations of patients' decisions to refuse oncological treatment

OBJECTIVE: To gain insight into the standards of rationality that physicians use when evaluating patients' treatment refusals. DESIGN OF THE STUDY: Qualitative design with in depth interviews. PARTICIPANTS: The study sample included 30 patients with cancer and 16 physicians (oncologists and general practitioners). All patients had refused a recommended oncological treatment. RESULTS: Patients base their treatment refusals mainly on personal values and/or experience. Physicians mainly emphasise the medical perspective when evaluating patients' treatment refusals. From a medical perspective, a patient's treatment refusal based on personal values and experience is generally evaluated as irrational and difficult to accept, especially when it concerns a curative treatment. Physicians have a different attitude towards non-curative treatments and have less difficulty accepting a patient's refusal of these treatments. Thus, an important factor in the physician's evaluation of a treatment refusal is whether the treatment refused is curative or non-curative. CONCLUSION: Physicians mainly use goal oriented and patients mainly value oriented rationality, but in the case of non-curative treatment refusal, physicians give more emphasis to value oriented rationality. A consensus between the value oriented approaches of patient and physician may then emerge, leading to the patient's decision being understood and accepted by the physician. The physician's acceptance is crucial to his or her attitude towards the patient. It contributes to the patient's feeling free to decide, and being understood and respected, and thus to a better physician-patient relationship.     

Diabetes and the license to drive

People with diabetes are subject to restrictive licensing policies that bar them from driving certain types of motor vehicles. Discriminatory rules regarding the license to drive are based mainly on concerns that treatment with blood glucose-lowering agents, especially insulin--may induce episodes of altered consciousness due to hypoglycemia. The risk of hypoglycemia, however, differs greatly among insulin-requiring diabetics and it is not difficult to identify those few who present a substantial risk. Moreover, the advent of simple, portable devices for blood glucose self-monitoring allows diabetics to know when blood glucose levels are becoming low and to take prompt corrective action. Thus, it would seem that blanket rules prohibiting diabetics from driving certain types of vehicles are unfair and unwarranted. In view of these considerations, rules are being revised by some licensing agencies to eliminate blanket restrictions and to allow for case-by-case evaluations to determine medical qualifications of people with diabetes. Tight control of diabetes currently is being advocated widely as a means of preventing chronic complications, but it carries an increased risk of hypoglycemia. Physicians who institute tight control regimens must ensure that patients understand the potential risk of hypoglycemia and are capable of minimizing the risk. Physicians should report patients to the Department of Motor Vehicles (DMV) who, in their judgement, are unable to drive safely because of concerns about hypoglycemia. Wisconsin state law protects physicians who make such reports from liability.     

Satisfactions, dissatisfactions, and causes of stress in medical practice.

Careers of physicians who graduated from Case Western Reserve School of Medicine have been examined in several longitudinal career studies. Physicians have been interviewed in their own offices, have filled out short-answer questionnaires, and have taken four tests. Emphasis has been placed on factors that have made their medical careers particularly satisfying or dissatisfying. Physicians report many satisfactions that evolve around helping patients, solving problems, and developing relationships with patients and their families. A major dissatisfaction relates to time pressures. In the current interviews with graduates, several sources of stress (malpractice suits, having to give up certain aspects of medical work, threats of physical harm, and certain features of peer review) are being expressed that were infrequently mentioned in previous studies.     

Medical restrictions to driving: the awareness of patients and doctors

The study was set up to investigate the awareness of elderly patients and medical doctors of medical restrictions to driving. Separate questionnaires were completed by patients and doctors. All were interviewed face-to-face, without prior warning and their immediate answers were recorded. In total, 150 elderly patients from the acute elderly care wards, rehabilitation wards and day hospital, and 50 doctors (including all grades from consultant to junior house officer) were interviewed. The main outcome measures were numbers of patients currently driving and previously driving; patients' awareness of how their medical condition affected their ability to drive; doctors' spontaneous knowledge of medical conditions which restrict driving, current licensing policy, and restrictions for five specific medical conditions (epilepsy, myocardial infarction, stroke, 5-cm abdominal aortic aneurysm, and diabetes). Only 21 patients were current drivers, and six of these should not have been driving. While 103 perceived themselves eligible to drive, 46 had medical restrictions to driving. Seventeen of the 47 patients who perceived themselves not eligible to drive possibly did not have restrictions to driving. Doctors' knowledge of the current licensing policy and action to be taken if a patient was not eligible to drive was very poor. Knowledge of medical restrictions to driving was scanty, with few doctors giving the correct driving restrictions for the five specific conditions. We recommend that education of doctors regarding medical restrictions to driving should begin at an undergraduate level and be continued throughout their postgraduate career.     

Bioethics for clinicians: 28. Protestant bioethics

“PROTESTANT” IS A TERM APPLIED TO MANY DIFFERENT Christian denominations, with a wide range of beliefs, who trace their common origin to the Reformation of the 16th century. Protestant ideas have profoundly influenced modern bioethics, and most Protestants would see mainstream bioethics as compatible with their personal beliefs. This makes it difficult to define a uniquely Protestant approach to bioethics. In this article we provide an overview of common Protestant beliefs and highlight concepts that have emerged from Protestant denominations that are particularly relevant to bioethics. These include the sovereignty of God, the value of autonomy and the idea of medicine as a calling as well as a profession. Most Canadian physicians will find that they share certain values and beliefs with the majority of their Protestant patients. Physicians should be particularly sensitive to their Protestant patients' beliefs when dealing with end-of-life issues, concerns about consent and refusal of care, and beginning-of-life issues such as abortion, genetic testing and the use of assisted reproductive technologies. Physicians should also recognize that members of certain Protestant groups and denominations may have unique wishes concerning treatment. Understanding how to elicit these wishes and respond appropriately will allow physicians to enhance patient care and minimize conflict.     

Healers and strangers. Immigrant attitudes toward the physician in America--a relationship in historical perspective

The current wave of immigration to the United States--mostly Asians and Latin Americans--may well be the largest in the 20th century. Many newcomers practice habits of health and hygiene deficient by American standards. Some prefer the shaman to the physician and traditional herb remedies to modern medical therapies. Physicians find themselves practicing at an invisible border separating them from their foreign-born patients, where differences of language and culture can lead to misunderstanding and frustration, impeding a physician's ability to gain cooperation with prescribed therapy. Similar issues faced physicians at the turn of the century. Newly arrived Italians, East European Jews, and Chinese were often ambivalent toward physicians and their therapies. Quacks further undermined the physician's credibility among immigrants. Today, some physicians try collaborating with shamans and herbalists to accommodate patients' cultural preferences. Respect for the customs and taboos of immigrant patients pays dividends in physician effectiveness and efficiency.     

Iatrogeny: why patients come to harm

latrogeny remains a constant challenge to all members of the health team who must be made aware from the onset of their roles and responsibility to their patients with particular reference to patients' rights and well-being. Physicians, as the acknowledged leaders of the health team, have the greatest role in this respect; their training and involvement in supervising and monitoring members of their health teams must reflect an acknowledgement of this responsibility. The protection of the legacy associated with the medical profession for ethical behaviour and acting in the patient's best interest remains a challenge which must be addressed in the face of changing societal dynamics where rights and responsibilities are in a constant state of evolution. Medical schools must be at the forefront of responding to these challenges and reflect this by constant review of their training programmes.     

Autonomy, informed consent and advance directives: a study of physician attitudes

The rights of patients to make decisions concerning their care have been promoted by ethical guidelines under the banner of respect for autonomy, and by legal statutes that address informed consent requirements and advance directives. Given these trends, this study investigated the opinions of 90 physicians specializing in family practice and internal medicine at the Joan C. Edwards Marshall University School of Medicine and the West Virginia University School of Medicine in relation to physician-patient communication. Beliefs and attitudes of these physicians with respect to the participation of patients and family members in medical decisions were explored, using a survey instrument with closed questions. Although physicians surveyed showed respect for the primary elements of informed consent and supported stronger patients' rights, many respondents reported a willingness to override the explicit directives of patients, based on the requests of surrogates. These results reveal a conflict between current ethical and legal standards and the moral intuitions of many practicing physicians. More research focusing explicitly on the role and authority of surrogate decision-makers is warranted.     

Treating competent patients by force: the limits and lessons of Israel's Patient's Rights Act

Competent patients who refuse life saving medical treatment present a dilemma for healthcare professionals. On one hand, respect for autonomy and liberty demand that physicians respect a patient's decision to refuse treatment. However, it is often apparent that such patients are not fully competent. They may not adequately comprehend the benefits of medical care, be overly anxious about pain, or discount the value of their future state of health. Although most bioethicists are convinced that partial autonomy or marginal competence of this kind demands the same respect as full autonomy, Israeli legislators created a mechanism to allow ethics committees to override patients' informed refusal and treat them against their will. To do so, three conditions must be satisfied: physicians must make every effort to ensure the patient understands the risks of non-treatment, the treatment physicians propose must offer a realistic chance of significant improvement, and there are reasonable expectations that the patient will consent retroactively. Although not all of these conditions are equally cogent, they offer a way forward to assure care for certain classes of competent patients without abandoning the principle of autonomy altogether. These concerns reach past Israel and should engage healthcare professionals wary that respect for autonomy may sometimes cause avoidable harm.     

On ethics and advocacy

Organized medicine has been urged to take a firmer stand in declaring physician participation in the business aspects of medicine to be unethical. The author maintains that physicians must adjust to new realities and reassert control over medical care and compensation. Passive acceptance of the role of physician-employee may result in loss of the ability to respond to patients' needs, while involvement in business may allow physicians to use their positions for patient advocacy and to fund improved care or to increase compensation lost to discounted fees. Physicians must be active in developing new health care services and businesses to insure quality and avoid loss of control; organized medicine must have faith in professional integrity.     

The inner life of physicians and care of the seriously ill.

Seriously ill persons are emotionally vulnerable during the typically protracted course of an illness. Physicians respond to such patients' needs and emotions with emotions of their own, which may reflect a need to rescue the patient, a sense of failure and frustration when the patient's illness progresses, feelings of powerlessness against illness and its associated losses, grief, fear of becoming ill oneself, or a desire to separate from and avoid patients to escape these feelings. These emotions can affect both the quality of medical care and the physician's own sense of well-being, since unexamined emotions may also lead to physician distress, disengagement, burnout, and poor judgment. In this article, which is intended for the practicing, nonpsychiatric clinician, we describe a model for increasing physician self-awareness, which includes identifying and working with emotions that may affect patient care. Our approach is based on the standard medical model of risk factors, signs and symptoms, differential diagnosis, and intervention. Although it is normal to have feelings arising from the care of patients, physicians should take an active role in identifying and controlling those emotions.     

Associations of physician burnout with organizational electronic health record support and after-hours charting

In 2017, 43.9% of US physicians reported symptoms of burnout. Poor electronic health record (EHR) usability and time-consuming data entry contribute to burnout. However, less is known about how modifiable dimensions of EHR use relate to burnout and how these associations vary by medical specialty. Using the KLAS Arch Collaborative’s large-scale nationwide physician (MD/DO) data, we used ordinal logistic regression to analyze associations between self-reported burnout and after-hours charting and organizational EHR support. We examined how these relationships differ by medical specialty, adjusting for confounders. Physicians reporting ≤ 5 hours weekly of after-hours charting were twice as likely to report lower burnout scores compared to those charting ≥6 hours (aOR: 2.43, 95% CI: 2.30, 2.57). Physicians who agree that their organization has done a great job with EHR implementation, training, and support (aOR: 2.14, 95% CI: 2.01, 2.28) were also twice as likely to report lower scores on the burnout survey question compared to those who disagree. Efforts to reduce after-hours charting and improve organizational EHR support could help address physician burnout.     

Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists.

CONTEXT: Few data are available regarding how patients view the role of primary care physicians as "gatekeepers" in managed care systems. OBJECTIVE: To determine the extent to which patients value the role of their primary care physicians as first-contact care providers and coordinators of referrals, whether patients perceive that their primary care physicians impede access to specialists, and whether problems in gaining access to specialists are associated with a reduction in patients' trust and confidence in their primary care physicians. DESIGN, SETTING, AND PATIENTS: Cross-sectional survey mailed in the fall of 1997 to 12707 adult patients who were members of managed care plans and received care from 10 large physician groups in California. The response rate among eligible patients was 71%. A total of 7718 patients (mean age, 66.7 years; 32 % female) were eligible for analysis. MAIN OUTCOME MEASURES: Questionnaire items addressed 3 main topics: (1) patient attitudes toward the first-contact and coordinating role of their primary care physicians, (2) patients' ratings of their primary care physicians (trust and confidence in and satisfaction with), and (3) patient perceptions of barriers to specialty referrals. Referral barriers were analyzed as predictors of patients' ratings of their physicians. RESULTS: Almost all patients valued the role of a primary care physician as a source of first-contact care (94%) and coordinator of referrals (89%). Depending on the specific medical problem, 75% to 91% of patients preferred to seek care initially from their primary care physicians rather than specialists. Twenty-three percent reported that their primary care physicians or medical groups interfered with their ability to see specialists. Patients who had difficulty obtaining referrals were more likely to report low trust (adjusted odds ratio [OR], 2.7; 95% confidence interval [CI], 2.1-3.5), low confidence (OR, 2.2; 95% CI, 1.6-2.9), and low satisfaction (OR, 3.3; 95% CI, 2.6-4.2) with their primary care physicians. CONCLUSIONS: Patients value the first-contact and coordinating role of primary care physicians. However, managed care policies that emphasize primary care physicians as gatekeepers impeding access to specialists undermine patients' trust and confidence in their primary care physicians.     

Physicians and the minefield surrounding informed consent.

Most of the legal cases that follow the informed-consent standard set in recent court cases have involved surgical procedures. However, issues concerning a pregnant British Columbia mother who contracted chicken pox and whose child was subsequently born with severe medical complications demonstrate the complexity of medical decision making and the inadequacy of established legal requirements, especially when consent has dimensions beyond technical considerations usually associated with medical procedures. The problem physicians face, says lawyer Karen Capen, is to find a way to balance a range of professional responsibilities and the overriding fiduciary obligation to patients in matters associated with informed decision making and consent.     

Subtracting insult from injury: addressing cultural expectations in the disclosure of medical error

This article proposes that knowledge of cultural expectations concerning ethical responses to unintentional harm can help students and physicians better to understand patients' distress when physicians fail to disclose, apologize for, and make amends for harmful medical errors. While not universal, the Judeo-Christian traditions of confession, repentance, and forgiveness inform the cultural expectations of many individuals within secular western societies. Physicians' professional obligations concerning truth telling reflect these expectations and are inclusive of the disclosure of medical error, while physicians may express a need for self-forgiveness after making errors and should be aware that patients may also rely upon forgiveness as a means of dealing with harm. The article recommends that learning how to disclose errors, apologize to injured patients, ensure that these patients' needs are met, and confront the emotional dimensions of one's own mistakes should be part of medical education and reinforced by the conduct of senior physicians.     

医务人员对医患关系中自身法律地位的认知与评价分析

目的探讨医患关系中医务人员对自身法律地位的认知状况及其对和谐医患关系的影响。方法随机抽取458名临床医务人员，采用问卷调查的方式收集资料，再进行统计分析与比较研究。结果不同基本情况的医务人员对医患关系中自身法律地位的认知状况不同，对自身职业的评价、医患关系的诠释、法律中医患关系的界定及医疗纠纷的认识均存在不同程度的差异。结论加强医务人员对自身法律地位的认知，有助于医务人员明确行业职责与义务，保障医患合法权益，减少医疗纠纷，有助于和谐医患关系的建立。     

Study of smoking habits in hospital and attitudes of medical staff towards smoking.

Most hospital policies place little or no restriction on patients' smoking in hospital. In this study patients were surveyed to determine if they smoked and if their doctors advised or ordered them to stop smoking in hospital. As well, the smoking habits and attitudes towards smoking of the medical staff and other hospital workers were explored. Of 741 patients 37% were smokers, and those who responded fully to a questionnaire 86% continued to smoke in hospital. Patients who were advised or ordered not to smoke (59%) were no more likely to stop smoking than those who were not so advised or ordered. Physicians were less likely to smoke than other hospital staff, and those who did smoke were much more likely not to smoke while in the hospital. Physicians appear to have a reasonable appreciation of the health hazards of smoking, and almost two thirds are in favour of stricter restrictions on patients' smoking in hospital. The ineffectiveness of their efforts is primarily due to hospital policies that are not in keeping with physicians' standards of practice and with established knowledge of the deleterious effects of smoking on health.