opinion : lowered residency work hours makes better physicians

A recent discussion with an attending highlighted an important generational gap in academic medicine, one that has become much more pronounced with the changing resident work hour requirements. The issue is that older doctors feel that the end-all of learning as a student and a resident is achieved by maximizing the hours spent in the supervised clinical setting (“on call”). Most younger doctors tend to avoid these on-call hours, which the older attendings often believe is because of laziness or lack of dedication to medicine. This is a misconception that needs to be corrected however. Young doctors do not like structured clinical on-call hours because we recognize that they are sub optimal for learning.

The first reason that traditional on-call hours are sub optimal for learning has to do with what is expected of doctors during those hours. Most of the work done during these hours is “scut” work, both patient and institutional paperwork that had nothing to education. The second and more important reason however is that people in my generation who have grown up with computers and online resources have come to realize that self-directed, active learning is by far the most effective means to learn the vast quantity of data required to be a competent physician.” Back in the day”, the only way to get information from a good medical lecture was to sit physically in the room and listen to that person talk(some hospitals had physical tape recordings?). Today almost all lectures from any medical school are available to be instantly streamed on the Internet. Throughout medical school, most students have learned to maximize their study time by using their personal preferred online resources. While current residents often spend 100 hours per week learning medicine just as their predecessors did, we understand that is much more effective to have less time with direct patient care and more time in front of our computers studying in the areas that we are weakest on. While this does not necessarily apply to procedure oriented specialties such as surgery, information oriented specialties such as medicine and radiology clearly benefit from residents having extra time when they're not on duty to study as they see fit. In this light, it is easy to see that a resident who spends 80 hours on call and 20 hours studying on their own time is going to be a more knowledgeable resident and one who spends 100 hours on call faxing pharmacy requests and rewriting safety checks. There was a time when the only way to see rare cases was to be on call when these cases came to the hospital, but instant access to electronic resources has made this an issue of the past, especially in radiology.

The idea that you can be a better resident in less time is hard to understand to someone who grew up in an era where commitment and quality were measured by number of cases seen and amount of time put in. It is difficult for many old-timers understand that you can be a better doctor by putting in less time as long as that extra time is used correctly. Young doctors can in fact be better trained in fewer hours.

Opinion : A plan to get rid of undue Pharmaceutical influence

In the last two years or so, there has been a lot of progress and publicity on the issue of pharmaceutical companies influencing medical trials. This article in Slate adds some useful information to the debate by uncovering new insidious ways that pharmaceutical companies are wielding influence on science. While the author's solution of making journals follow the same disclosure that scientists do is a good start, I think that there is a much better way to solve the whole situation. The best way to promote full disclosure in the pharmaceutical industry is simply to require each pharmaceutical company to submit a detailed and itemized list of all the parties that they have spent promotional or development money on for each budget year.

I would imagine that this is neither a difficult solution to legislate, or to comply with. It could be a simple form that is attached to the company's regular SEC filings for each fiscal year. This would create a government mandate for public disclosure that could be reviewed by accountants and for which executives could be held accountable. I am sure that some place in each company there exists a detailed lists of expenditures so that each company can track how effective these are. I cannot think of any objections to the public interest for mandating that each company make these itemized reports available to the public. While I realize that few people would bother to look their doctor up, it would give activists and investigators an important tool to demand accountability of healthcare professionals. This tool would also enable stronger peer review as conflicts of interest would be readily apparent to other scientists and scientific editors.

Opinion : Smart people live longer

A study described in this article claims that people who are "medically illiterate" die faster (see study for more technical description). I tend to question whether "medically illiterate" couldn't just be replaced by the more genaralized "ignorant". I realize there is something to be said for following directions, and I realize that people who don't understand physicians may be good at understanding other things, but I think that in some of these academic studies, scientists miss the big picture.
A good example was a study at a brain aging conference last year where a researcher reported that people with higher mental abilities (which he measured by level of education attained) had less rapid brain deterioration over time. The scientist indulged some theory about "reserve" which he could neither measure of explain. Let me propose a more obvious theory (but alas, one that will not win any grant money): Smarter people do less stupid things. "Stupid things" in this case are actions which cause brain damage. Unfortunately, I cant find any study that shows that PhD's get into less bar fights or are less likely to be professional boxers, but the anecdotal evidence is there....
Back to the study on medical literacy, I can't think of how they could have separated the effect of not understanding medical directions vs the effect of not understanding other directions in life. If a patient doesn't understand "take twice a day", do they understand "use by 7/23"? Not taking antibiotics for a GI infection and eating spoiled food will have the same effect. The fact is that ignorant people frequently make choices that shorten their life compared to their peers. This is as clear today as it was to social darwinists in past centuries. We need to fix the problem through better education, and also by identifying who the susceptible people are and treating them differently. The different treatment must be in the benevolent sense however, otherwise the identification will lead to unfair discrimination.

Opinion : Physician's role in preventing violence

Submitted for a grade as part of my medical ethics class:

There is a serious crime problem in the United States. Crime rates are much higher in the US than in other developed countries. (Mercy et.al., 10). It has been proposed that action should be taken at all areas of society, and that physicians have a significant part to play.(Mercy et.al., 1) To determine this part, it has been proposed that violence should be treated as a public health problem. This distinction of violence as a public health crisis is dubious however, as it misrepresents the purpose of medicine and distracts attention and money away from those whose job it is to fix the problem. Physicians do not have the time, resources, or enforcement power to treat the violence problem, nor do they provide an efficient means to do so.
The role of doctors in treating society's problem is controversial. People are always trying to expand physician's roles past their obvious expertise. It has been suggested in Medicine and Society this year that physicians should try to fix the problems of poor education, wage disparity, drug use, and sexual promiscuity among others; and now we are adding violence. As a caring human being, physicians should certainly be concerned about all these issues, but fixing abstract social problems is not what medicine is about. Medicine is about diagnosing and treating illness acutely, not eradicating the long-term, possible causes of illness. Our society trains and maintains a large number of police officers, social workers, public health authorities, legal advocates, therapists, teachers, and councilors whose job it is to fix these problems. Just as social workers should not administer therapy for lead poisoning or be resetting broken arms, physicians should not be deciding if a child is fit to live in a certain household.
One major reason that physicians should be a focus of violence prevention programs is simply that other trained professionals would likely do a better job working on the problem. The constraints of modern medical practice would make physicians an inefficient resource for identifying, counseling, or intervening in situations where violence is involved. The time limits placed on doctor and clinic visits make physicians unable to provide proper support and counseling to victims (psychologists should do this). Inability to track patients outside of their practices also does not allow physicians to identify of those at risk (social workers should do this).
Some studies claim that physicians should help to prevent gun violence and take steps to help patients who may show risk factors towards violence (Christoffel et.al). This can be counter productive and even unethical for physicians, however. The researchers claim that physicians can help by sharing data on the effects of gun violence and modifying their treatment for those who may be at risk (Christoffel et.al). Sharing patient data violates patient privacy, however. In addition, treating a patient differently because of a risk factor based on other people, or that you are only assuming is discrimination. It is not a physician's place to judge patients or their family's behavior and social situations, and to the extent that it can be avoided, these factors should not influence routine medical care.
Violence is a problem that society needs to deal with, but not by throwing medical resources at it. Society should work to solve the problem through trained dedicated professionals whose concentrate on this area. Physicians should not encroach on the territory of social workers, therapists, and law enforcement. A focused campaign is needed to end violence, with moral support from the community for the directed actions of those trained to intervene.

Opinion : Research on vulnerable populations

Submitted for a grade as part of my medical ethics class:

Medical research in the western world (supposedly everywhere) is bound by local laws to adhere to a set of human rights protection guidelines modeled after the Nuremberg code. (Murray 792) In the United States, these ethics laws are also supplemented with rules to prevent egregious cases of misconduct such as the Tuskegee trials. (London 790) The general aim of these laws is that the researchers should always minimize the harm to potential subjects. (Friedman et. al 805) The problem is that these laws are too restrictive and can get in the way of beneficial research. This becomes an issue when a small amount of potential harm can bring a large amount of potential good, a classic "the ends justify the means" problem.
The first group of vulnerable subjects is children. It is clearly necessary to determine the effects of medicine or treatments on children before it is given to them, but to determine these effects, clinical trials are needed. Clinical trials all carry some level of risk, and therefore the trial can be generally defined as child endangerment. This line of reasoning however leads to the absurd view that it is not ethical to give any medical treatment to children, yet of course, it is not ethical to let them suffer either. Edward Jenner's vaccine experiments on local children would now be considered a serious ethical violation, yet that violation has saved millions of lives. The key to vulnerable populations who are mentally incapable of consenting themselves (children, mentally handicapped), is who should be allowed to consent for them. (Murray 794) The clear answer should be someone who has the child's best interests in mind. This can be the parents, government social workers, or an independent counsel appointed on behalf of the child. It should not be someone who has a financial stake in the outcome of the trial, however. The problem is that parents may second-guess themselves (as in the KKI trial) and an independent advocate should see little reason to put a child in a potentially risk experiment. When the researchers pay the family on behalf of the children, this just further complicates the issue. A possible solution to this problem is to pay the child with a deferred annuity (maturing when the child turns 18 or so) so that the financial incentive is for the subject and the guardian's actions are forced to be altruistic.
Another population of vulnerable subjects is prisoners. This is different from children in two key ways: first, the prisoners do have the ability to consent, but second, their personal freedom is restricted. The freedom restriction gives the researchers a greater level of control, even if that control is only perceived. Unlike the children, the prisoners cannot simply walk away from the experiments, and their level of personal responsibility is diminished. On the other hand, prisoners have other civil rights restricted, such as the rights of privacy, freedom, voting, and in some cases life. As society already considers prisoners less "human" than the general population, it may be justifiable to use this population for particularly high-risk trials. The only way to justify any clinical trial, or any action that can cause harm for that matter, is that the outcome will be of a greater good. In this light, the intentions of the researcher must be benevolent. The intent or the researcher is how a trial should ultimately be judged. If unexpected side effects occur, if mistakes are made, if the treatment does not work, or even if a vulnerable population was exploited, this is the inevitable consequences of scientific-medical progress. As long as the mistakes and exploitation was not driven by greed or anger, then the researchers should take note and not be held liable.

Disclaimer: I am currently NIH certified in human clinical trials and have helped to conduct trials in children

Opinion : Physician addicts

Submitted for a grade as part of my medical ethics class:

Drug addiction is a serious problem in all parts of society, and medicine is no exception. Despite the image of a noble and beneficial profession, physicians frequently become addicts. These addictions are fueled by stressful jobs, easy access to narcotics, and often an irrational sense that their use is not a problem. Considering these factors, more needs to be done to eliminate this problem so that both patients and physicians are protected from the horrible struggle that characterizes addiction.

To understand why a successful, benevolent person would turn to drugs, we must consider the risk factors that are inherent in medical practice. First of all, there is the stress and negative emotional toll that comes with the job. Everyone responds to stress differently, and some people will respond by self-medicating. Stress is a problem with almost any job, yet the impulse towards self-medication is particularly a problem in physicians because they have easy access to powerful narcotics. If a lawyer or pilot was stressed for instance, they may have a drink after work or take too many aspirin, but it is unlikely that they would have Vicadin or codeine readily available at their workplace. This access lowers the opportunity barrier to addictions for physicians and often starts them along a downward spiral.

Once they are addicted to drugs, being a physician can also hinder the ability for others to help. Physicians are generally respected and trusted in the community so outsiders are often reluctant to step in. Physicians can be insulated from the consequences of their actions by the work of their colleagues (to fix mistakes) or their licensure (to mitigate legal consequences). There is often a culture of acceptance among colleagues who want to help, but not hurt, their friends. The stereotypes surrounding drug addicts will also help to defer suspicion and give the impression that the drug habit is not a problem. A physician who is addicted may feel that as long as they can pay their bills and do their job, there is no problem. Addiction is ultimately a downward spiral, however, and the earlier the intervention, the better it is for everyone involved.

Everyone will agree that this drug problem needs to be wiped out, but there is little agreement or action on the subject. One reason for the inaction is that outing large numbers of physician addicts would damage reputations, and no one from hospitals to medical schools to the AMA wants to do that. To solve the problem, however, reputations will need to be damaged. Patient safety is simply more important than reputation, and any short-term damage will be outweighed by the long-term benefits of deterrence and breaking the culture of acceptance. First there needs to be a system of random drug tests to catch physicians in the act. Second, hospitals or other employers must be required to report the results of these tests (unlike baseball) and the hospitals must be held accountable for their employees. Finally, a system of amnesty must be in place to encourage physicians to seek rehab treatments. Physicians should be allowed to resume practice as long as they can stay clean. In addition, the systems to track and distribute medicines in a hospital should be revised so that the pharmacy can keep tighter control on supplies and drugs can be tracked more readily. Electronic prescription dispensing should help reduce the opportunity that physicians have to take the first fateful hit, and also catch the problem sooner.

Addicted physicians are a serious problem, but a solvable one. If the medical establishment puts aside its ego and reputation and implements specific and strict policies, this problem can be greatly reduced, and many lives will be saved.

Opinion : Emergency CPR

Submitted as part of my medical ethics class:

Many people would agree that there are many cases of waste in the American healthcare system that could be reduced if physicians would back down from using aggressive treatments. Often these treatments are costly and have low probability of success, wasting both staff and financial resources. A good example of this is the emergency cardiopulmonary resuscitations (E-CPR) outlined in this week's article. I believe that these are a waste of resources and should not be performed until further technology is developed that significantly improves outcomes.

Many physicians consider death as a failure and do anything to prevent it. Unfortunately, in cardiac resuscitations, they are rarely successful. According to this study, only about 10% of patients successfully have their heart restarted, less than 1% ever regains consciousness, and no one in this study survived to be discharged. (1) The co-morbidities and causes of the arrest ranged from nothing, to Cancer to CAD, and only congestive heart failure showed any survival improvement, and even then lee than half the patients survived. No one with stroke or hypertension was successfully resuscitated. (1) With present techniques and technology, E-CPR is simply ineffective as a medical treatment.

If E-CPR were cheap and easy, or we had unlimited resources, then we might argue that it can't do any harm, so why not give it a try on everyone, even if it rarely helps. Unfortunately, these ideal conditions do not exist, and resources that are used on ineffective treatments are resources that are wasted. In this case, it is estimated that taking care of those who were successfully resuscitated averaged over $5000 (removing an outlier who cost over $95k) (1). The hospital also spent almost $150,000 just to get to those few successful cases (1). That is a steep bill for treatment that did not actually save any lives. It is not clear whether that accounts for staff costs, but it clearly does not take into account the other hospital resources that were used, including ER beds and equipment. The end result of providing E-CPR to all these patients was likely to cause longer ER wait times for the other (presumably surviving) patients and ultimately raise insurance premiums. This clearly does not benefit the community, although this would be more difficult to determine if even one life had been saved.

This study indicates that E-CPR is an ineffective and wasteful treatment. Its use should be restricted immediately and further research should be performed to determine ways to improve cardiac arrest outcomes.

1. Gray, WA. Capone, RJ. Most, AS. Unsuccessful Emergency Medical Resuscitations: Are continued efforts in the ED justified?. NEJM. 1991. pp1393-1398

Opinion : Abortion

Submitted as a position paper for my Med. and Society ethics class:

I believe that abortion is an issue for women, and personally, I do not care either way. However, I do like arguing, so for the sake of writing this essay, abortion is wrong. For the sake of argument, I will also try to avoid any Christian morals. Instead, I will site what is my highest personal ethical belief: that individuals need to take responsibility and accept the consequences of their actions. I am not judging people who are careless and casual with sex, I am merely saying that this behavior has biological and social consequences and that abortion is cheating and therefore is wrong.

There are several cases when abortion is clearly justified. These include cases of rape, where the female clearly was not and should not be responsible. In addition, anytime that maternal health is endangered, abortion should be considered a medical procedure and is clearly justified. Slightly more questionable are cases where the pregnancy was planned but early tests show abnormalities (Down's Syndrome for example). I worked with these individuals in the past and question whether these abortions are necessary, yet I would accept the argument that the parents are not responsible (consciously) for bad luck with nature and therefore should be entitled to an abortion. The majority of abortions in this country however do not fall under these circumstances. Most are simply unplanned pregnancies that are unwanted or inconvenient for some reason (1).

First, let's divide the women seeking abortions for unplanned pregnancies into 2 groups. In the first group are girls who fooled around without being in a serious relationship and got pregnant. This group likely covers the majority of abortions, as the average person seeking an abortion is young and unmarried. (1) The second group includes couples who got pregnant but do not want the child for lifestyle or economic reasons. We will assume for the sake of argument that all of the women in these groups had sex consensually and have no medical indications against childbirth. While there are likely unique mitigating circumstances in every case, in general, the abortions for all these women represent a way to evade the consequences for their actions.

Any woman seeking an abortion will be bypassing the pain of labor and childbirth, as well as the life disruption that pregnancy brings. These are the natural biological consequences of their decision to engage in unprotected intercourse. Furthermore, the specific consequences that these women are evading depend on which group they are in. Women in the first group were likely not expected to get pregnant, especially if they are in their teens. If allowed to carry the pregnancy, there will likely be social consequences varying from rejection by family and friends to disruption in their education or job. Yet if their education or family is that important to them, then they should have risked it for one night of fun. There may also be physiological consequences of having to give the baby up for adoption, and financial consequences from the healthcare involved or if the decision is made to keep the child. These are simply the price that must be paid however for the selfish and dangerous choice to have unprotected intercourse, and hopefully these consequences will inspire a better decision in the future.

As for the women in the second group, the specific consequences are less serious but more selfish. Women in stable relationships are likely seeking to avoid having the child because having a baby would affect their lifestyle. The child would disrupt their education or job, and leave them with less disposable income. Again, abortion is a cheap way to evade parental responsibilities. Condoms or the pill cost a lot less than raising a child, so they knowingly took a risk by not using them. That risk has potential consequences; personal greed and convenience are no excuse to evade those consequences.

Many of the problems facing the US today are caused by a general attitude that no one has to be responsible for their actions. It is in this justification that millions of people are have unprotected sex and subsequently abortions. Abortion is a cheap and convenient way to evade responsibility for ones actions, therefore I believe that it is ethically wrong if rape and medical indications are not involved.

1. Trupin, RS. E-medicine: Abortion. Available at : http://www.emedicine.com/med/topic5.htm. 2006.

Opinion : Right to refuse treatment

Submitted as part of my medical ethics class:

When a physician is providing treatment to a patient, the goal is generally to make the patient better. A physician will typically use any means at their disposal and a good doctor will never give up on a patient. Yet sometimes the patient may want to give up on treatment themselves. Just as it has been argued that a patient has autonomy to choose the treatment option that they feel is best (even if against the physician's wishes), we must also consider that the patients can choose no treatment as an option. It may seem counterintuitive that a person would deny even a slight possibility of recovery, but there are many reasons that a patient may choose to for go treatment.

Reasons for denying treatment vary from person to person, and may involve good or bad decisions from an ethics point of view. Reasons may include fear of unpleasant side effects, religious or moral objections, and simply personal preference if the positive outcome is remote. These are all good objections and should be honored by the physician. Physicians should recognize that sometimes palliative care is the best option and should cease more conventional treatments in terminal cases. Another reason for treatment refusal is financial or economic concerns. These reasons are an unfortunate reality in our profit-driven capitalist health care system and warrant a separate discussion from this one. Another set of reasons includes the patients refusing care because of fear, duress or the influence of others, their ignorance of the options or out of an irrational state of mind. These options are not acceptable for a physician and care needs to be taken that they do not cause bad outcomes.

Avoiding the reason of irrational refusal or any irrational decision can be a serious problem for physicians. Most physicians are in a bad place to make judgments about a patient’s capacity for decision, and their can be a lot of mitigating factors. A perfectly competent person who was just told they have a serious disease may be devastated and may instantly become irrational. Letting patients take time to think about a decision (at least 1 day) is a good idea in general but not possible in all cases. It is also hard to tell if the irrational decision may be caused by an underlying problem such as ignorance of the subject (which can be fixed if the physician embraces their role as an educator) or a mental illness. The mental illness problem is especially serious if it is separate from but interferes with the treatment of an illness such as cancer.

The options for a physician in the case of irrational decisions come down to whether the patient can be brought to a rational state of mind or simply taking the authority of autonomy away from them. Removing a patient’s autonomy and treating them against their will is an extreme case and should only be done if the patient is clearly not able to comprehend their situation and the treatment has an estimated positive outcome of at least 50%. All attempts must be made to educate the patient but the patient’s comprehension must be tested by having them explain their situation and the outcomes in their own words. If they are unable to demonstrate comprehension and continue to refuse treatment against good odds of recovery, they should be referred to a mental health professional for an evaluation. If the evaluation comes back that they are mentally incompetent, then a physician should make the treatment decisions for this individual. If a psychology evaluation comes back negative, than the patient’s wish must be honored, as long as the sign some sort of waiver absolving the physician of outcome responsibility. A patient always has the right to refuse treatment unless it can be shown that they are not mentally competent.

Opinion : Population medicine

Submitted as a position paper for my Med. and Society ethics class:

In traditional health care delivery, the role of the physician has been to look after the health of the small group of patients who regularly come into his office. This model works great as long as everyone in a given area has a physician and goes to see them regularly. Physicians in this model can work together to solve local problems and can quickly implement public health policies by coordinating informative office visits. This model applies poorly to current healthcare in the US however, and therefore works poorly to implement change. The traditional model is poorly representative because not everyone in society has a physician and many people do not go regularly. Traditional models are also affected by current economic realities and modern health communication techniques that do not involve physicians. The reason that these realities are important is that patients do not live in a vacuum. Each person's health and actions affect the health and welfare of others in the general community. To serve the health interests of their patients, therefore, modern physicians must take on a public health role and tend to the needs of the community at large.

To serve the needs of the community, physicians should strive to achieve 4 things: rational, proactive, public policies that promote health and safety, expanded access to health care for all individuals, public education, and minimizing the cost of healthcare to society. While these imperatives do not trump the care that needs to be provided to an individual, these ideals must influence decisions and guide the actions of physicians in their private lives.

As far as influencing public policy, physicians have a duty to promote government policies and organizations that improve public health. They must use expertise and influence to gain benefits for everyone and to counteract economic and social forces that may seek to hurt patients for profit. This may include lobbying for clinics for the underserved, lobbying for healthcare reform, and supporting research in the public interest. Expanding healthcare access follows along the same lines, and may mean moving to underserved areas and supporting charity clinics.

Working to lower the cost of healthcare is another interrelated topic that should be strived for. Physicians should make treatment decisions that keep the cost low, no matter who is paying the bill. Sometimes, financial decisions that benefit patients must be made contrary to physicians own interests, but this is something that physicians owe society as professionals as long as the cost is reasonable.

A final duty of a physician to their community is that of public education. Doctors need to go beyond simply teaching their individual patients and seek ways to spread effective health messages to the community at large. This should be easier with modern media such as the internet, but also old-fashioned lectures should help as well.

To fully serve their patients, physicians have a duty to reach out to others in the community. When people are more educated about their health, have greater access to health care, and live under a government with pro-health policies, everyone benefits.

Opinion : Informed Consent and Error disclosure

Submitted as a position paper for my Med. and Society ethics class:

To respect a patient's rights as discussed previously, informed consent must be received from a patient or the patient's family. While few would argue that consent is a bad idea, the extent to which that consent is informed can be more controversial. In a patient-physician relationship, there is an inherent imbalance of knowledge that clearly favors the physician. The patient will never be able to close the knowledge gap completely, yet the extent to which they are informed of their situation, (the treatment options and possible outcomes) dictates the extent to which they can make the best choice. Problems can arise when patients are unable to grasp the facts of the situation or are unable to make a reasoned or logical choice. More importantly for physicians however, is when problems arise because they have not communicated all the facts, especially when these omissions are important to or may sway the patients choice. Along with the case of non-disclosure of medical errors, this leads to a state of ignorance on the patient's behalf, which can have negative ramifications in both treatment outcomes and especially in legal liability.

It is assumed that in all cases that the physician's goal is to minimize the patient's ignorance and his personal liability. Therefore, I propose a guideline that I will call the George W. Bush disclosure rules, in honor of the president's foreign policy. The rules can be summed up as: 1) Take the moral high ground, 2) stay the course, and 3) damn the consequences (have faith that those consequences will be better than the alternative outcomes would have been).
For part one, we will depart with the President's actual practice and state that the moral high ground is always to tell the entire truth. There should be no manipulating, distorting, or omitting relevant facts. The patient should be told the diagnosis, all the treatment options, and all the outcomes without any interpretation unless that interpretation is specifically requested. The physician's role in this stage will be as an educator, and full disclosure will fulfill his duty to the patient and allow a truly informed consent to be made.

For the second part, the physician must stay the course as far as telling the full truth and complying with the patient's decision. Several mitigating factors may arise as discussed in the text, such as family's wishes, physician's prejudices, economic considerations, or public safety, yet the physician must not allow these influences to effect delivery of the truthful full disclosure. The physician will need courage to deliver the whole truth in some cases, and must accept the old platitude that "truth hurts". It must be held evident that none of these circumstances are more important that the patient's health and human rights. If the patient chooses a treatment that the physician feels is not in their best interest, than the patient's rights are the chief concern and the physician must still comply with the patient's wishes to the best of his abilities.

The most difficult part of the plan may be to accept any consequences and have faith that the right thing was done. Consequences from an error disclosure could damage reputations and consequences from letting the patient choose a non-optimal treatment could be premature death. Full disclosure is always the best policy considering the big picture however; as reputations are made by difficult choices and patient deaths are often inevitable. Second guessing decisions will cause stress and not fix the past, and therefore should be avoided as useless. If applied consistently, the George Bush disclosure rules should minimize physician legal liability and empower patients. These rules are easy to remember and almost universally applicable. They provide a clear and decisive guide through the often conflicting and controversial issue of informed consent and disclosure.

Opinion : Patient Autonomy and Physician Paternalism

Submitted as a position paper for my Med. and Society ethics class:

When a major disease or condition is diagnosed, there are often several treatment options, each with their own strengths and weaknesses. The important question that arises is who gets to chose the ultimate course of treatment, the patient, or the physician. This question is complicated by two other issues in medical care, knowledge and responsibility.

It is usually safe to assume that the physician knows more about the treatment than the patients, and is in a better position to make a logical and rational choice, yet there are pertinent life circumstances affecting the choice that are only known to the patient. While it is always optimal to reconcile these differences with communication, this process can never be perfect. The question now becomes how should the physician explain the choices to the patient (objective vs. subjective) and how to evaluate patient comprehension.

As far as responsibility, a physician can certainly be held legally liable for their decisions, yet it is the patient who ultimately has to live with the consequences of any treatment decision. It is hard to argue that a patient could be responsible for a decision when they don't completely understand the facts however. Physicians also have trouble accepting responsibility after getting overruled by a patient and carrying out a treatment option that they know is not optimal.

This brings us back to the question of what role a physician should play in choosing the treatment options for their patients. I believe that a physician should make every attempt to educate the patient on the condition and the treatment options. They should not withhold any possibilities or outcomes and should explain when the literature is ambiguous or contradictory. Physicians should say what they think is the proper course of action only if they thoroughly explain their choice. They should also give other opinions if requested by the patient. If a patient makes an irrational choice, the physician should explain why this is the case, but should not resist implementing that treatment or putting the patient in any type of duress. If the patient chooses says at the beginning that the physician should just do whatever he feels is best, the physician should still explain what this is and what the risks are, as well as why he would choose that treatment over others.

If the physician is an effective communicator, than the patient will be making an informed decision about their health. If the patient chooses to disagree with the physician, hopefully they will be able to communicate the reasons that decision. Once a consensus has been reached, the physician will take responsibility for the effective delivery of services, and the patient will have to live with the outcome. If the patient chooses to go against the physician's advice, than they are mitigating the physician's responsibility for the outcome of the treatment, although not the treatment itself. These guidelines allow for a patients rights while making the physician's responsibilities clear.

Opinion : Osteopathic Medicine

Submitted as a position paper for my Med. and Society ethics class:

Osteopathic medicine presents an alternative to the standard (allopathic) medical practice. Its in tenets include a holistic musculoskeletal focus and a type of healing called osteopathic manipulation (OM). It is not quite on the level with allopathic medicine, however and has some serious problems that would keep me from ever pursuing it as a career.

First, modern osteopathic medicine is little more than allopathic medicine with the simple addition of the OM techniques. When the practice was established in the 1800's, the move away from laboratories to hands on healing may have made a lot of sense by offering patients more tangible results. This is simply not the case with modern medicine however, as the advent of antibiotics, chemical therapies, genetics, imaging, etc. have proved that scientific techniques provide much more effective healing. To stay relevant, the osteopathic practice adapted by adopting theses techniques. This raises the question, what is the point of having an "alternative" set of physicians if they are doing the same thing?

This question gets to the real problem with current osteopathic medicine. Its education system exists mainly as a way to help less qualified students get into a medical school. In both personal experience and in the assessment offered by Dr. Howell, many of the students who apply to and enroll in DO schools do so because they were unable to gain admission to allopathic schools, not because they believe in a holistic approach to medicine. The Osteopathic schools also continue to reinforce this by admitting weaker candidates and letting their students take allopathic residencies after 3 years. Dr. Howell sites the AOA's own studies that most of its members do not use their specialized OM skill. While the holistic approach may have merit as a treatment option when used by a skilled practitioner and OM may have therapeutic value, Osteopathic medicine will not be respectable until it ceases to be a backdoor entrance for less qualified people to become physicians.