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Topic: Doctor-Patient Relationships
July 1, 2014 | Posted By Marleen Eijkholt, PhD

Crowdsourcing seems this month’s health care buzzword. It is everywhere. I’ve seen it used in three different health care contexts over the last months: 1) as a means to raise money for treatment, 2) as a means to gain access to treatments, and 3) as a means to help medical diagnoses.  In thinking about these contexts I found myself asking: Would I use it, or would I not? I am curious to hear if you would use the tool of crowdsourcing, after I give my ideas. Please feel free to comment at the end of my post.

What is crowdsourcing?

The dictionary defines crowdsourcing as: “the practice of obtaining needed services, ideas, or content by soliciting contributions from a large group of people and especially from the online community rather than from traditional employees or suppliers”In my own terms, crowdsourcing is an appeal to the online crowd/public to assist in a specific endeavor, like the above. Crowdsourcing is about ‘power in numbers’.  It could be an appeal to the public to raise money, signatures, or to gather information/expertise. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

December 9, 2013 | Posted By Jane Jankowski, LMSW, MS

A recent article published in ACPInternist (www.acpinternist.org) estimates that 35% of adults have looked online to try to diagnose a medical condition for themselves or for someone else, based on a 2013 survey.  While many providers dread having to explain that minor ailments are indeed minor because the patient fears something more dire based on website material, it seems that other providers are learning to accommodate and embrace the possibilities the internet holds for both patients and physicians. Like it or not, it seems clear that the online medical tools have become a part of many doctor patient relationships.

Given that you are reading this on a website, it seems reasonable to presume that my audience here is internet savvy and likely to be aware of the many types of websites and services available to healthcare consumers. There and numerous informational sites, symptom Mayo Clinic symptom checker, medical detective services where (for a fee) a large group weighs in with opinions on what an elusive diagnosis might be www.CrowdMed.com . Just to see what these tools offer, I decided to play ‘patient’ with Isabel, a relatively advanced symptom checker.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

September 26, 2013 | Posted By Paul Burcher, MD, PhD

Many of my obstetrical colleagues groan when a patient presents a birth plan during prenatal care, but I do not.  I see it as an opportunity to do what Frank Chervenak and Laurence McCullough have called “preventive ethics”—avoiding conflict later by addressing issues before problems arise.  Prenatal care is unique in medicine in that we spend so much time with generally healthy patients seeking to prevent medical complications that, if they arise at all, are likely to arise much later during labor.  The same mindset that propels and justifies prenatal care should direct our response to birth plans:  this is an opportunity to prevent problems, and misunderstandings during labor, and the fact that the patient has well-formed opinions about what kind of care she wishes to receive during labor means she is engaged and seeking to educate herself.  In short, women presenting with birth plans are generally our most conscientious and informed patients.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

July 8, 2013 | Posted By Jane Jankowski, LMSW, MS

The long awaited DSM-V was finally released for clinical use in May 2013, and was welcomed with a storm of debate. The task force charged with the revising the manual note that the manual had not been updated for 20 years and required revision to reflect changes in scientific knowledge and clinical experience in an ever shifting social context. Whether or not the DSM-V will alter clinical practice may depend on how the manual is viewed by practitioners. 

One possible benefit of expanding the list of diagnoses in a psychiatric manual includes improving recognition of problematic behavior health issues by insurance companies who fund treatment for diagnosable problems. Expanding the diagnostic options may enhance access to beneficial services for many, and this could prove helpful to those who might not otherwise receive treatment. Practitioners in the US know all too well that a diagnosis is needed if the provider is going to be paid by an insurance company. It remains to be seen if the changes in the DSM-V affect payment to providers.

One point to consider in the reimbursement argument is that a diagnosis is not necessary for treatment because those in desperate need are not turned away, though ongoing therapy may be hard to find with or without a diagnosis. The downside of expanding the various diagnostic categories is that people may be less likely to be held accountable for behavior negative or even legal consequences, notably changes in the paraphilia categories. We must be vigilant that mental health does not become misused as an excuse for antisocial, illegal, or dangerous behaviors where it is inappropriate to do so. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

June 24, 2013 | Posted By Wayne Shelton, PhD

The moral basis for competent, clinical ethics consultation, I would like to argue, is largely derived from the moral premises of our normative understanding of what it means to be a “good doctor” as reflected in a self-conscious commitment of a good physician to treat patients as best as one can according to prevailing standards of professionalism and medical ethical principles. The good doctor stands in relationship to a patient, within a well-defined framework of moral rights and professional obligations. This linkage between the activity of clinical ethics consultation and our understanding of a good physician further defines the work of the ethics consultant squarely in framework of clinical, medical competencies.  

To further see this linkage, it is useful to consider how and when value conflicts arise in the physician-patient relationship. For the vast majority of physician-patient encounters, there is agreement and absence of conflict. But in the less frequent cases of moral conflict, there are competing visions of what should happen—regarding the goals of care and who has the moral authority to define those goals. In short, how are competing rights and obligations to be balanced between the patient and physician, but also the surrogate, the hospital and potentially many other interests, especially in the midst of the emotion and stress that illness and impending death can induce both to patients and their families? It is the latter contextual aspect of grounding value conflicts within a patient’s and family’s illness experience, and the necessary ability to function effectively in clinical encounters, that requires the competent ethics consultant to also possess the general qualities of a caregiver, and to understand the moral perspective of a good physician.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

May 9, 2013 | Posted By Wayne Shelton, PhD

In the fall of 1970 Philip Tumulty, a Johns Hopkins’ internist, gave a lecture to the 3rd year medical school class at Johns Hopkins. His lecture was published in the same year in the New England Journal of Medicine under the title of “What is a clinician, and what does he do?” (Tumulty PA. What is a clinician and what does he do? N Engl J Med. 1970 Jul 2;283(1):20-4.) In this classic piece, this eminent physician of his era claimed that the primary role of the clinician is to “manage a sick person with the purpose of alleviating the total effect of his illness”. 

This paper, probably better than any other paper I have ever read gets to the essence of what a patient needs from an expert clinical caregiver; it lays out eloquently and robustly the characteristics of a good clinician and what is involved in excellent clinical care of patients. As Tumulty says, it is not a diseased body organ that shows up for physical diagnosis and treatment; rather, it is an anxious, fearful, wondering person concerned about her personal life, including her family, work, friends as well as her hopes and dreams. This means the clinician must be a thoughtful and systematic fact finder, a careful listener, a keen analyst of the facts and a prudent planner regarding which tests and treatment options make the most sense for this particular patient. Moreover, Tumulty rightly assumes that these skills should be embodied in the clinician as natural traits that the clinician genuinely enjoys performing. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

February 12, 2013 | Posted By Jane Jankowski, LMSW, MS

With the explosion of health information available online and in print media it can be difficult for consumers to determine which sources to trust and which ones to toss.  As with all of the material available on the World Wide Web, consumers must exercise caution and diligence when evaluating the veracity of internet information. While we may be pretty good at knowing how to determine which sites look trustworthy enough to safely manage credit card information or other private data, it may be more difficult for consumers to assess the reliability of health information on the internet. Given the sometimes high stakes involved in making healthcare decisions perhaps such sites should be required to include links which will connect consumers to tools which will train them to better evaluate health information in the media. Though this will not guarantee any given web surfer will take advantage of these links, but it could be a start to improving health information literacy.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

January 11, 2013 | Posted By Wayne Shelton, PhD

As someone who has done clinical ethics consultations for many years I long ago reached the conclusion that many of the so-called ethical problems that we encounter during ethics consultations could be prevented if only a more constructive line of communication had been established from the beginning of the patient’s hospital stay. Let me specify just what kind of patients and families I have in mind, the kind of communication I am talking about and the type of intervention that is needed.

Let’s face it, most patients come to the hospital with an identifiable medical problem about which there is little controversy, so the physician can diagnose and treat with a predictable, usually favorable, outcome. These are not the cases for which we get called on to do ethics consultations, nor are they the cases that take excessive amounts of time and create significant emotional stress such as cases that involve conflicts. In the less common cases where serious conflicts between various parties emerge, we are usually dealing with patients who have more medical problems, which often involve the risk of dying. The patient often lacks capacity and is unable to speak his or her mind about the goals of care and how far to use aggressive medical interventions. This means that families or loved ones of the patient must speak for the patient, i.e. serve as surrogates, and communicate with physicians about care plan goals and the appropriateness of particular procedures such as CPR in the event of cardio-pulmonary arrest.  To say the least, this is a stressful role for families and loved ones.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

 

November 23, 2012 | Posted By Jane Jankowski, LMSW, MS

Giving bad news is a difficult thing to do. Receiving bad news is hard, too, but is perhaps a close second to hearing a complicated, vague version of the same set of facts. In healthcare, the failure to disclose pertinent facts in clear, uncomplicated language and verify the information is understood is harmful to the recipient of this information, but also to the provider, who must often untangle the resulting misunderstandings later on.  Families and patients who find they are asking "Why didn’t someone tell me?" may be on the receiving end of an attempt to give bad news.

I tend to think of these vague communication moments as 'dodges.' Rather than stating "I believe your Aunt Lila’s condition will not improve and we need to talk about what kind of care she would want" is instead a listing of diagnoses, medications, lab values, and a review of body systems, surgical options, and statistical probabilities. This type of encounter shifts the focus from the overall prognosis to the details, which though factual, obscure the big picture of a patient who is not expected to recover. Avoiding a frank disclosure of the fact that a patient is doing poorly doesn’t help the patient, and does not help anyone make informed decisions. But it serves a purpose in the moment. Sidestepping the straightforward presentation of bad news may avert or postpone the experience of delivering upsetting news and witnessing the emotional suffering of others who hear it. I get it. It is stressful and distressing to be the source of often devastating news. Yet, we must keep in mind that the news itself is the source of the upset, and the bearer of the news need not feel morally culpably for the facts. The old adage applies, 'it’s not what you say, it is how you say it.' We owe it to medical providers to give them adequate practice and training in delivering bad news as well as opportunities to observe experienced practitioners talk with patients and families when critical conversations are held.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

October 30, 2012 | Posted By Michael Brannigan, PhD

Here is cardiac surgeon Christiaan Barnard's account of his conversation with Louis Washkansky just before he performed on him the first human heart transplant, in 1967:

"'We know you have a heart disease for which we can do nothing more. You have had all possible treatment, and you are getting no better. We can put a normal heart into you, after taking out your heart that's no longer any good, and there's a chance you can get back to normal life again.'

"'So they told me. So I'm ready to go ahead.'

"Washkansky said no more. His eyes remained on me but with no indication he wanted to know anything more.

"'Well, then ... goodbye,' I said.

"'Goodbye.'"

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit ourwebsite.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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