Learning about Ethics and Professionalism through Vignettes
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Learning about Ethics and Professionalism through Vignettes
John Spandorfer MDJefferson Medical College
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At Jefferson, we use written vignettes and At Jefferson, we use written vignettes and trigger videos to begin discussions of trigger videos to begin discussions of challenging topics in professionalism and challenging topics in professionalism and ethicsethics
Small group meetings – year 1-3Small group meetings – year 1-3 Large group – all day professionalism Large group – all day professionalism
session, spring year 3session, spring year 3 Project with the Annals of IM and Michael Project with the Annals of IM and Michael
LacombeLacombe
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Honesty with patientsHonesty with patients
http://professionalism.jefferson.edu/http://professionalism.jefferson.edu/video1/ video1/
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Professionalism in Professionalism in MedicineMedicine
A Case-based Guide for Medical StudentsA Case-based Guide for Medical StudentsCasesCases
Commentaries Commentaries
Literature-based reviews of professionalism Literature-based reviews of professionalism topicstopics
VideosVideos
http://professionalism.jefferson.edu/http://professionalism.jefferson.edu/
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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
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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.
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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
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Patient confidentialityPatient confidentiality
http://professionalism.jefferson.edu/http://professionalism.jefferson.edu/video6/ video6/
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Maintaining appropriate Maintaining appropriate relations with patientsrelations with patients
http://professionalism.jefferson.edu/video9/ http://professionalism.jefferson.edu/video9/
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Students only: Was it appropriate or inappropriate for the student to have disclosed her past smoking history?
1 2 3
78%
8%14%
1. Appropriate2. Inappropriate3. Unsure
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Students only: Was it appropriate or inappropriate for the student to have disclosed her relationship difficulties
related to smoking cessation?
1 2 3
34%
9%
57%1. Appropriate2. Inappropriate3. Unsure
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Students only: Should the student allow the patient to “friend her” on
Facebook?
1 2 3
3% 6%
91%1. Yes2. No3. Unsure
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Commitment to Professional Responsibilities
Observation of Unprofessional Behavior
http://professionalism.jefferson.edu/video15
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Students only: If you were this student, in the OR, how would you
most likely respond to the surgeon’s behavior?
1 2 3 4
13%
4%
50%
34%
1. Stand by quietly2. Name a fattening
food3. Deflect or avoid
the question4. Respectfully
question the appropriateness
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Students only: After the case, how would you respond to the surgeon’s behavior? You
would discuss your concern with the…
1 2 3 4 5
0%
8%
21%
51%
21%
1. surgeon.
2. clerkship director or a Jefferson Dean.
3. resident and not an attending.
4. a friend or family member
5. keep it to yourself.
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Students only: In the operating room setting only, how would you characterize the
surgeon’s behavior?
1 2 3 4 5
2%5%
2%
47%45%
1. Professional2. Somewhat
professional3. Somewhat
unprofessional4. Very
unprofessional5. Unsure
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Students only: How often have you seen similar behavior in physicians
other than surgeons?
1 2 3 4
5%
20%
45%
31%
1. Never2. Rarely3. Occasionally4. Frequently
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ON BEING A DOCTOR
© Copyright Annals of Internal Medicine, 2011
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
Nielufar Variavand, M.D.
Drexel University College of Medicine
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ON BEING A DOCTOR
© Copyright Annals of Internal Medicine, 2011
Playing Godhttp://annals.org/public/onbeingdoctor.aspx
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ON BEING A DOCTOR
© Copyright Annals of Internal Medicine, 2011
Obligation of the Physician
Legal obligations
Physician codes (e.g. ACP, AMA)
Ethical approaches
Consequentialist, Deontological, Casuistry, Virtue Ethics
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ON BEING A DOCTOR
© Copyright Annals of Internal Medicine, 2011
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
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ON BEING A DOCTOR
© Copyright Annals of Internal Medicine, 2011
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
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ON BEING A DOCTOR
© Copyright Annals of Internal Medicine, 2011
Obligation of the Physician
Ethical approaches
Consequentialist
Deontological
Casuistry
Virtue Ethics
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ON BEING A DOCTOR
© Copyright Annals of Internal Medicine, 2011
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