Current Topics in Healthcare

Tuskegee Syphilis Experiment: history of scientific medicine and racism

"Bad Blood" study aimed at black people actually was a *secret experiment by US public health service to study effects of syphilis without any treatment* Bill Clinton apologized, but the mistrust blacks have towards medicine persists Never obtained informed consent, never told them they weren't being treated...literally waited for them to die and just looked at their bodies afterwards At checkups, the men were told they had bad blood At first, the treatment wasn't 100% good...but even after penicillin was discovered to work the men still weren't given it The study was meant for 6 mos...lasted 40 years When Penicillin was found to work, everyone in America was helped...except the Tuskegee men Eventually, it was found out and leaked to the press, front page of the New York Times Huge Civil Rights lawsuit, millions were given as settlement National Research Act passed 2 years later to prevent exploitation of human subjects

White Coat Ceremony

"The Practice of Medicine is an art, not a trade; a calling, not a business" White Coat Ceremony ushers in med students and gives people expectations and responsibilities Short white coat for med students People like the white coat

Advance Directives

*Advance Directives: legal documents that allow you to spell out your decisions about end-of-life care ahead of time...tell your wishes to family, friends, and health care professionals now so that there's no confusion later on* Examples: dialysis/breathing machines, DNR forms, tube feeding, organ/tissue donation Lots and lots of examples given to help out

Rural Health Concerns

*Getting healthcare can be a problem in a remote area* maybe *can't get to the hospital in an emergency* or don't want to drive long distances to do checkups or screening rural areas also have *fewer doctors/dentists*, and some specialities might not even exist this means *health problems in rural areas are likely more serious by the time they are diagnosed* - have *higher rates of chronic diseases than urban people*, such as *cancers* formed by exposure to chemicals used in farming

HMO and PPO Insurance Plans

*Health Maintenance Organization: locked/low $* -gives you access to doctors/hospitals in its network, which lowers rates for plan members -care is only covered if you see a provider in that HMO's network -more restrictions for coverage such as # of visits/tests/treatments -Some plans require you get a primary care physician (PCP) who needs to refer you elsewhere before you go see someone -if you see a doctor outside HMO you get no coverage and must pay it all out of pocket -premiums are generally lower for HMOs *Preferred Provider Organization: freedom/$$$* -more flexibility when picking doctor/hospital -it also has a provider network but has fewer restrictions for seeing non-network people -PPO insurance will actually pay for if you go outside the network, but maybe won't cover everything -you can see a doctor/specialist without a referral from PCP -benefits will be better if you see a doctor within the PPO network -Premiums tend to be higher (Justin has this) Quick Plan comparison: Both HMOs and PPOs have provider network PPOs allow you to see doctor without PCP's OK (same goes for specialist) HMOs have low/no deductible and lower prem. PPOs might allow coverage outside of plan

The Doctor-Patient Relationship: Effects of Managed Care

*Managed Care Organization (MCO)* serves people with limited resources in an integrated system of care...provide and pay for care many *inherent conflicts - patient vs. profit...unrestricted patient advocacy is never really achievable* but it's all about finding the proper balance How doctors are paid affects the health care they deliver...hard to do research on this *"Whose doctor is it anyway" is one of the biggest inherent problems of MCO's effect on DPR - is the doctor caring for them? the plan? their own jobs/careers?*...this ambiguity erodes trust, ruins DPR...really hard to strike the balance Most MCOs have Primary Care emphasis, so the PCP manages and restricts access to certain services...*having a PCP could mean stronger DPR so the patient doesn't leave the MCO*...but this is *not necessarily a real consequence* (only assumed) Integrated systems within MCOs allow improvement in continuity across the spectrum of care...requires more teamwork and communication...this is threatened if the teams change *Standardized practices/Evidence Based Medicine is often used to minimize cost and maximize Quality of care*...often *touted as being fair* because everyone's treated the same...but this relies on value judgments...*ignores variation* in patients...*treats the Disease without any reference to the Illness*...if you discount the person, you worsen the DPR Continuous quality improvement/mass accreditation - this could either help or hinder the DPR depending on how it's used Doctors are encouraged to be more "productive" which means they see patients faster...less psychosocial discussion...this hasn't actually happened yet but *everyone feels a sense of time pressure and patients feel like they're on an assembly line*...*if you go faster you damage the care, get worse data, can't ID the real problems, heal less, trust less, make more errors, and waste* OVERALL: *you need trust to make DPR work*, and the way industrialized *MCOs work is currently or will likely damage care*. the *DPR must be maintained*

When the Patient is Non-Compliant

*Noncompliant: patients who don't take medications or follow medical recommendations* *Lots of stereotypes*, label sticks (probably better to say "nonadherent" but people still use it) Possibly 50% of patients are noncompliant to some degree We *shouldn't oversimplify* it to a Yes/No because following all the recommendations can be like 3000 behavior changes a year (which is hard)...they could do well in some areas but still, get criticized for not doing everything they can *You should Be Compassionate and understand what a complicated balancing act it is for patients* Doctors and patients need to work together to find realistic and reasonable treatments, by prioritizing which measures are most important (like the most general cultural competency) Improving adherence is a team sport for all members of the healthcare industry There can be some wisdom in noncompliance, its not simple

Role of A Physician

*Role: performing a history and physician to determine a differential diagnosis for the patient, including the most likely diagnosis, and then developing management and treatment plans for those conditions and diseases* Role of physician on a healthcare team is multifaceted and based on regulated scopes of practice, ultimately trained to provide leadership in developing and supervising the patient's overall health care plan Role is divided into 5 General Areas 1) Taking histories/doing exams/determine diagnosis based on strong assessment and cognitive skills based on knowledge and judgment 2) Provide continuous care for the patient/manage and treat variety of medical conditions/manage complexity and risk in often uncertain and changing situations 3) Works collaboratively with health care team for optimal care/provides referrals/provides reports 4) Provides education to patients, families, and support staff as it relates to patient condition/diagnosis/treatment, and offers resources so the patient is informed, and educates all others on team 5) Importantly advocates for patients and families to attain the most patient-centered care in a cost-effective manner/works to identify and meet needs of patient, the practice population, and the community by working together in a big group

Social Determinants of Health (SDOH): Know what affects health

*SDOH: Conditions in the places where people live/learn/work/play that affect health* I.e., Poverty decreases food access, and education predicts better health Differences in health are striking in poor SDOH communities Apply what we know to improve these The website has many resources/tools

Medicaid

*federal-state safety net for those who can't pay healthcare* seniors can use this if they meet 3 requirements: medical necessity test: requires skilled nursing asset test: limits how much property can own income test: limits how much income can have - the only way to get past this is by using an "elder care" lawyer, which is tricky getting this is way more complicated, the program can refuse you for even the smallest thing

Medicare

*gov't health insurance for 65+-year-olds on social security, their spouses, or people on disability* Part A: hospital in patient, Part B: hospital out patient/doctor's visits/lab work/vaccines, Part C: medicare advantage program Everyone can be eligible, irrelevant of income Covers only SMALL part of nursing home stay, which forces families to pay out of pocket

History of HIV and AIDS Overview

*pre-1980*: HIV started in Congo in ~1920s, likely first major infection in the mid-70s but no deaths *1980s*: rare lung infection found in gay men and IV drug users...disease called Gay-related immune deficiency (GRID)...then called AIDS and nobody knew the cause...organizations started...now straight people getting it and kids...found it was virus caused...Ryan White (a straight young teenager) got AIDS from a blood transfusion...gay celebrities start dying...AIDS is worldwide...virus now called HIV...WHO raising awareness...first AIDS drug developed (called AZT)...World AIDS day founded...Ryan White CARE Act made...CDC now releasing guidelines to stop it...100,000 people in the US have died from AIDS *1990s*: Ryan White dies from AIDS at 18...those with AIDS getting discrimination protection from the law...red ribbon is an international symbol...Magic Johnson announces he has HIV which dispels the stereotype of it being a "gay disease"...Freddie Mercury announces he has AIDS and dies the next day...those with HIV banned from entering the USA...HAART treatment in action and very promising...UN devoted to global health AIDS reduction...AIDS determined as #1 killer in Africa *2000s*: Drugs cheaper now...global fund developed...20 minute AIDS detection test made...George W Bush creates PEPFAR...WHO develops 3x5 program...male circumcision found to be great preventative measure *2010s*: no more HIV travel ban...PrEP developed so HIV-negative people can prevent sexual transmission of HIV...AIDS deaths are falling rapidly...UNAIDS fast tracks preventions starts ambitious goal of 90% gone...now anyone living with HIV is eligible for treatment by law...more people of all ages have received treatment

Why Doctors Hate Obamacare

25% of those surveyed would give the ACA an A or B grade, while 46% would give Obamacare a grade of D or F...still the law is that 81% of physicians described themselves as either overextended or at full capacity with regard to treating patients. This figure is up notably from 75% in 2012...doctors don't like that obamacare adds more patients to bedside 44% of physicians noted that they planned to take one or more steps to reduce patient access to their services...39% of physicians surveyed indicated their intent to accelerate their retirement plans so they could retire early. Why overworked: more people, baby boomers and their needs increasing, job growth for doctors just isnt happening 38%, or nearly two in five, either refused to see Medicare/Medicaid patients or limited how many government-sponsored patients they saw. "The ACA took this terrible broken health care system and added a lot of burden onto physicians," Hill says. "We're losing the focus of who we're supposed to be taking care of: the patient. You're not my customer anymore. Now, I've got to respond to the federal bureaucracy, not you." "Older physicians or physicians that have gone into it as a passion want to have the continuity of care for their patients that I think they feel is jeopardized in this system" "it kind of drives their practice away from how they've created it, which was spending time with patients" Note, on the flip side: "Simply repealing the ACA and being devoid of regulation will allow insurance companies to achieve profits over the health care of most Americans"

Opioid Crisis

90 people overdose & die a day, $78.5 billion a year *opioids were over prescribed for pain and people got addicted* (~25% misuse them, 10% get disorder, 5% transition to heroin, and 80% of heroin users started by misusing prescription opioids) US Dept of Health and Human Services are increasing 1) more access to treatment/recovery 2) use of overdose-reversing drugs 3) awareness through public health 4) funding research 5) advancing better practices for pain meds NIH working with Pharm companies and research centers to make 1) safe/non-addictive pain relief 2) new meds/tech to treat opioid use disorder 3) improved overdose prevention/reversal tech

HIV and AIDS bioethics

AIDS epidemic has had a major impact on health care provision; forced the medical community to openly address the needs of historically marginalized populations. - Many effects like changes in public health departments, more rapid approval of drugs by the FDA, etc.

Advanced Care Planning

Advance care planning is a process to help patients with decision-making capacity guide future health care decisions in the event that they become unable to participate directly in their care. - Able to do things and think them through; plan for when they cannot. Focus on: 1. Values/preferences. 2. Talking about values/preferences with a spokesperson 3. Documenting these values/preferences with advance directive. 4. Review directives; update as needed. Advance care planning is the process; advance directives are the written documents that are sometimes created through this process ("advance directives will not be the outcome of most advance care planning.") - Verbal directives are okay ("ethically valid"); written, official documentation is much better. - At a minimum, patients should become familiar with the concept and rationale for advance care planning. Goals/expected outcomes of advance care planning: - Reflect the principles of patient autonomy, beneficence, and non-maleficence. 1. Maximize likelihood that medical care serves the patient's goals. 2. Minimize the likelihood of over- or under-treatment. 3. Reduce likelihood of conflicts between actors (providers, spokespeople, family, etc.) 4. Minimize burden of decision making on these actors. Better understand who your patient wants you to communicate with and their goals for medical treatment when they can no longer make their own decisions. - Example: patient with mild dementia might tell you whether or not they want antibiotics if they later develop pneumonia when they can no longer make their own decisions. It is also the physician's role to clarify misunderstandings! Ex: many patients think that coma patients have high quality of life; need to discuss what exactly one can truly expect if they fall into a coma. Also facilitates better communication, as advance care planning reduces likelihood of conflicts. Introduction of advance care planning has led to inclusion of a standard set of questions at hospital admission. - May also be targeted toward patients with certain conditions that may lead to an inability to make decisions, ex. those at risk for strokes, early dementia, debility/frailty, and chronic progressive/terminal illnesses. There is no ideal time for advance care planning, though it is recommended if there is significant change in a patient's social or health status. Can raise advance care planning as one of many health promotion activities in order to not scare the patient. - Don't make them feel like there is something wrong! - Don't force the issue; understand if they don't want to reach any conclusions. Many good questions to ask when having a discussion about advance care planning, 3 examples: 1. Who should speak on your behalf if you become so sick you can't speak for yourself? 2. Are there any circumstances that you've heard about through the news or TV where you've said to yourself, "I hope that never happens to me" or "I would never want to live like that?" If so, what are they and why do you feel this way about them? 3. For each of the circumstances that you just identified, what do you think should be the goals for your care? For example, should the goal of care be to prolong your life, improve or maintain your function and/or quality of life, provide comfort care, or something else? If the patient has no proxy, they should still fill out a living will with as much detail as possible. Ideally, the primary care physician will initiate discussion. However, it is increasingly common for trainees to engage in this discussion as needed. Advance directives fall into two broad categories: instructive and proxy. - Instructive: allow for preferences regarding the regarding the provision of particular therapies or classes of therapies. Living wills are the most common examples; other examples include no transfusion and no CPR directives. - Proxy: allows for designation of a spokesperson or surrogate medical decision maker of the patient's choosing. - POLST is Physicians Orders for Life-Sustaining Treatment; designed to direct care both in the home and outpatient settings. Advance directives are important to medical care; major ethical argument for their use appeals to the ethical principles of autonomy. - Principle of autonomy requires physicians to respect the wishes of competent adult patients. Continue to respect autonomy even if the patient loses the capacity to be autonomous. - The living will tries to promote patient-centered care. Advance directives can be considered legally binding, if constructed according to outlines provided by pertinent state legislation. Advance directives take effect only in situations where a patient is unable to participate directly in medical decision making; appeals to living wills and surrogate decision makers are ethically and legally inappropriate when individuals remain competent to guide their own care. - Assessment of decisional capacity can be difficult; may require a psychiatric evaluation. - Some directives are written to apply only in particular clinical situations. - Documents are revocable if a patient changes her mind and is able to participate in medical decisions. If a family disagrees with the living well, the medical team should meet with the family and clarify what is at issue; may disagree with what it stated or the physician's interpretation. - If they simply do not like what the patient has requested, they have little or no ethical authority to sway the team. Living wills tend to be written in ambiguous terms and demand interpretation through placement in context. Living wills cannot cover all conceivable end-of-life decisions; there is too much variability in clinical decision-making. Urge them to clearly communicate preferences and values to medical providers and the family.

The Doctor-Patient Relationship: Conclusions

Call out DPR problems, then solve them DPR problems are high priority Obtain appropriate consultation and choose solutions to the problems, often via training Must be an ongoing commitment for improvement Must do research and ensure that the patients follow principles of quality of care DPR has been defined, what affects it is described, and ways to protect and sustain it have been outlined There is an opportunity for DPR change, let's take it

Clinical Ethics and Law

Clinical ethics and law are distinct disciplines with overlapping concepts. - Law may ultimately resolve a clinical ethics dilemma with a court order. Clinical ethics = discipline or methodology for considering ethical implications of medical technologies, policies, treatments, etc. Law = established and enforced social rules for conduct or non-conduct. Risk management = method of reducing risk of liability through institutional policies/practices. Ethics is the moral conscience; described as "beginning where the law ends". Ethical norms may be derived from law/policies/professional standards; laws may be derived from constitutions/statutes/case law/ordinances; risk management can be derived from law, professional standards, and even missions. Can be thought of as a Venn diagram. Two primary types of potential civil actions against health care providers for injuries resulting from health care: 1. Informed consent. This is a process, and not just a required form for the patient's signature! Ethical and legal standards require that the patient provide informed consent. 2. Failure to follow standard of care. A person who is injured during medical treatment may be able to bring a successful claim against a health care provider if the patient can prove that the injury resulted from the provider's failure to follow the accepted standard of care. Standard of care derives from many sources. A "national standard of care" may be used for comparison, though it is often adjusted to take into account availability of staff, equipment, etc. 3 parts to the litigation process: 1. Initiation phase. Plaintiff files a complaint; serves the defendant with a summons. Presents the facts that are the basis for the lawsuit. 2. Pre-trial phase. Both sides gather information; can include interrogation or requests for production. Settling often occurs during this phase. 3. Trial and post-trial phase. Cases involving injuries are typically decided by a jury. Even after a jury verdict, post-trial motions to the judge can alter the outcome! Remember: law is dynamic and changing, particularly in health law. May be helpful/necessary to confirm something with a practicing attorney. Surrogate decision-making: - Determination whether a patient has the capacity to provide informed consent is generally a professional judgment made and documented by the treating health care provider. Designation of a surrogate decision-maker can be authorized by court order or specified in state statutes. - If the patient is incompetent, a health care provider must obtain informed consent from that decision-maker. Usually an immediate family member, but may also be selected by the patient with appropriate documentation. - In Washington: guardian > holder of durable power of attorney > spouse > adult children > parents > adult brothers/sisters. Other consent provisions apply for minors. - Parents may not be permitted in certain situations to consent to non-treatment of their minor child where the decision could significantly impact them or result in death! Examples: Jehovah's Witnesses, Christian Scientists. Called the "best interest" standard. Advance directives, living wills, POLST discussed as above. - Complicated when a previously made advance directive may or may not apply to a particular clinical scenario. Provider-patient communications: disclosing medical error. - Honest communication to patients by health care providers is an ethical imperative; excellent communication makes everything easier. But! When should providers disclose medical error? Creates a conflict; many cite a fear of litigation as a reason for non-disclosure. - Apology coupled with disclosure and prompt payment may decrease either the likelihood or amount of legal claim. Still generally advisable to involve risk management and legal counsel in decision-making regarding error disclosure.

Confidentiality

Confidentiality is important because patients routinely share personal information with health care providers; need to protect this confidentiality to protect trust, thus protecting excellent care. - Extremely important for conditions that may be stigmatizing such as reproductive, sexual, and psychiatric health concerns. The obligation of confidentiality prohibits the health care provider from disclosing information about the patient's case to others without permission; take precaution to ensure that others cannot access it without permission. - Not ethically justifiable to share information, even with a patient's spouse, unless the patient has explicitly stated their permission to do so. Exception: if the spouse's wellbeing is directly related to the diagnosis (HIV/AIDS/infectious disease diagnosis?) Many ways for unintended disclosure to occur. Example: discussing patient care in elevators or other public places, extra copies of handouts from teaching conferences. Certain exceptions to confidentiality do exist. 1. Concern for the safety of other specific persons. Clinicians have a duty to protect identifiable individuals from any serious, credible threat of harm if they have information that could prevent the harm. The duty to warn third parties of imminent threats trumps a duty to protect patient confidentiality, though the exact extent of the threat is often hard to ascertain. 2. Legal requirements to report certain conditions or circumstances. State law requires the report of certain communicable/infectious diseases to the public health authorities; interest in protecting public health is an interest that outweighs individual liberties in certain cases. In situations where you believe an ethical or legal exception to confidentiality exists, ask yourself the following question: will lack of this specific patient information put another person or group you can identify at high risk of serious harm? In many states, adolescents may seek treatment without the permission of their parents for certain conditions such as treatment for pregnancy, sexually transmitted infections, mental health concerns and substance abuse.

Difficult Patient Encounters

Difficult patients can be seen as a problem to be tolerated or terminated from practice, but the difficulty is in the relationship and not simply the patient. Many techniques exist to help clinicians improve that relationship. Difficult patient-clinician relationships arise when physicians encounter patients with complex, often chronic medical issues often exacerbated by social factors. May lead to the physician being guarded or distant, which can be interpreted by the patient as distrust. - Patient may not heed advice or take action; leads to all sorts of symptoms of a difficult relationship. Health care providers have professional and ethical obligations to care for patients because of the clinician-patient relationship. Provider has knowledge, influence, and power, thus giving them special responsibilities. Need to help these patients, but they should also find trusted colleagues with whom they can share frustrations. - Clinicians must try to address or manage their own attitudes and behaviors that contribute to the problem! Do everything they can to maintain a therapeutic relationship. Patients who appear ungrateful or frivolously utilize medical are most likely to be described as difficult. May seek medical attention but not heed the advice they are given. - May often have multiple medical complaints. - Often make requests that clinicians think are inappropriate, such as requests for additional pain medicine. Physician attitudes, biases, fatigue, stress, burn-out, and language and cultural barriers can also negatively impact the relationship. - Angry, defensive, fatigued, harried, dogmatic, or arrogant physicians are more likely to see patient encounters at difficult. - Physicians are more likely to describe difficult patient encounters when they have lower job satisfaction, less experience, and poorer psychosocial attitudes. - Physicians with low tolerance for illnesses that are incurable or untreatable can find patients with these illnesses difficult to manage. Recognize frustration and realize that you are an integral part of their care network! - Be alert when you feel anger, resentment, fear, dread, or excessive anxiety about seeing a patient. Strategies for maintaining a therapeutic relationship: 1. Be compassionate and empathic. Patients who you find frustrating often have had to deal with significant adversity in their lives. 2. Acknowledge and address underlying mental health issues early in the relationship. 3. Prioritize the patient's immediate concerns. 4. Set clear expectations, ground rules, and boundaries. Stick to them. 5. Be aware that strong negative emotions directed at you are often misplaced. Patient may transferring their feelings to you. 6. Be aware of your own emotional reactions. Objectively reflect on the situation; involve colleagues. 7. Recognize your own biases. Patients with addictions may have erratic or vexing behavior, but they need medical care more than most. Be attentive to their vulnerability rather than focusing on manipulative behaviors! 8. Avoid being directive with patients. Tentative style tends to work better. 9. Prepare for these visits. Keep your goals in mind.

Human Dignity in Health Care: Abstract

Dignity is always used to attribute or recognize some status in the person This paper concerns itself with the virtue of acknowledging that status = observantia As a general virtue, observantia is the respect for human dignity that is implicit in all acts of justice As a special virtue, observantia concerns the specific way we show esteem for people Healthcare represents a challenge to observantia because those in need of healthcare are doubly restricted in expressing their dignity in action -in the first place by their ill health -in the second place by the conditions required by health care (which is why sick people are patients not agents) The virtue of observantia needs both to quality and to be qualified by the virtue of misericordia = empathy or compassion for affliction The unity of the virtues requires simultaneous recognition of the common dignity and common neediness of human existence

Do Not Resuscitate (DNAR) Orders

Do Not Attempt Resuscitation Orders are written by a licensed physician in consultation with a patient or surrogate decision-maker; states that the patient should not receive CPR in the event of cardiac or respiratory arrest. - CPR often causes significant morbidities; resuscitation may leave patients with a significantly lowered quality of life. May instead allow a natural death without attempts to resuscitate. Patient autonomy has been emphasized since DNAR orders were first implemented. - If patients are unable to participate in decision-making, surrogate decision-makers and advance directives are used to ascertain the best course of action. A hierarchy exists for surrogate decision-makers. They are expected to make decisions using a substituted judgment standard based on what the patient would wish if they could express their wishes. If there is no valid physician's order to forgo CPR, the standard of care is to attempt it. Responding paramedics are required to administer CPR unless the injured individual has a bracelet indicating the DNAR order. CPR needs careful consideration; CPR is not always beneficial. Evaluating proximal and distal causes of the cardiac arrest is necessary to determine whether or not CPR will provide direct medical benefit. - Because defining a "direct medical benefit" can be challenging, one approach is to define it as the probability of an intervention leading to a desirable outcome. Use statistics. Be careful when evaluating a patient's quality of life. There is evidence that patients with chronic conditions often rate their quality of life much higher than would healthy people. CPR is withheld in two general situations: - If CPR is unlikely to be effective - When the patient with intact decision-making capacity or a surrogate decision-maker explicitly requests to forgo CPR. Prior to writing a DNAR order, physicians should discuss resuscitation preferences with the patient. The conversation should be documented. - Partner with the patient's family to determine clinical interventions achieving these goals. Clinicians are not obligated to perform CPR if health care providers unanimously agree that CPR would be medically futile. However, it is still respectful to involve the patient or surrogate decision maker. - DNAR order can be written after a transparent and honest discussion regarding the clinical situation. A patient may request that CPR not be performed, even if it would not be futile, if they are able to make that decision for themselves. If the family disagrees with a DNAR order, attempt to clarify and communicate with them! "Show code" is a short, vigorous resuscitation performed to benefit the family while minimizing harm to the patient. Ethically problematic. Considered to be deceptive, undermining the rights of patients to be involved in clinical decisions and violating the trust that patients have in health care providers.

The Doctor-Patient Relationship: Intro

Doctor-Patient Relationship (DPR) is keystone of care: it's how data is gathered, diagnoses are made, compliance happens, and healing occurs Also relies on market skills: satisfaction with DPR is the critical factor in people's decisions to join and stay with a specific organization It's worrisome how healthcare management, which cares about these market skills/satisfaction ratings, can negatively affect health care

Bodily Integrity

Each human has rights of autonomy and self-determination over their own body, so any unconsented physical intrusion is a human rights violation In particular, with respect to children, practices that violate this bodily integrity include: violence, forced medical treatment, unconsented surgeries i.e. corrective genital surgery for intersex kids, gender reassignment surgery, female and male circumcision, and sterilization of those with learning disabilities Children are vulterable to such practices because they are too young to speak up and give or refuse consent

Mistakes

Errors are inevitable; physicians must face situations where they address mistakes with their patients. All physicians make mistakes, and most mistakes are not the result of negligence. Mistakes may arise from incomplete knowledge bases, errors in perception, or lapse in attention. - Many independent stressors such as lack of sleep, pressure, and distraction can contribute to mistakes. Physicians have an obligation to be truthful with their patients; includes situations where patients suffer serious consequences as a result of mistakes. - Generally, even trivial medical errors should be disclosed to patients. If the physician feels that there is justification for withholding information, their judgment should be reviewed by another physician or an ethics board. - Hiding information can lead to a lack of trust in the physician-patient relationship. See another physician making a mistake? Awkward situation, but there is an obligation to make sure that the patient knows the truth. Should be done in a non-intrusive manner, I.E. encouraging the other physician to disclose the mistake to his or her patient.

Ethics Committees, Programs, and Consultation

Ethics committees involve individuals from diverse backgrounds; support health care institutions by providing clinical ethics consultation, developing and/or revising policies pertaining to clinical ethics and hospital policy, and facilitating education about topical issues in clinical ethics. Underlying goals include promotion of patient rights, promotion of shared decision making, promotion of fair policies/procedures, and enhancement of the ethical environment for health care professionals. Ethics committees often help resolve ethical conflicts. - May expand ethics programs; address both clinical and organizational ethics issues. Ethics committee members usually represent major clinical services and other stakeholders; can include clinicians, chaplains, social workers, and others. - Can even allow guests. Ethics consultants may also be used as experts; generally better to have committees to introduce multiple perspectives. - Committees can, however, cause logistical issues. Consider asking for a case consultation when two conditions are met: 1. You perceive that there is an ethical problem in the care of patients. 2. Health care providers have not been able to establish a resolution that is universally agreed upon. At most hospitals, anyone may request an ethics consultation. - May request even if not about patient care, ex. questions about professionalism and patient privacy. Ethics consultant will generally review all the information available before making a decision; may meet with many individuals. - There may exist several ethically permissible options.

Physician-Patient Relationship

Fiduciary relationship is the bond of trust between the patient and the physician that is vital to the diagnostic and therapeutic process. - In order for the physician to make accurate diagnoses and provide optimal treatment recommendations, the patient must be able to communicate all relevant information about an illness or injury. Traditionally, the historical model for the physician-patient relationship has involved dependence on the physician's professional authority. However, we have recently moved more towards shared decision-making, respecting the person as an autonomous agent with a right to hold views and take actions based on personal values and beliefs. May feel awkward interacting with patients as a student! However, just need to introduce oneself. Many patients like working with students because they typically have more time to spend with them. Patients often feel more connected with the physician when they know something about their life: may be appropriate to share information about family or personal matters to establish rapport. However, it is essential that the patient and their concerns are at the center of every visit! Possible to be asked to provide medical services in opposition of one's personal beliefs: okay to have a nonjudgmental discussion, but it is never okay to proselytize! Physician-patient communication can be hindered in many ways: patients feel they are wasting the physician's valuable time, omit details, or simply think that the physician isn't listening to them. - To facilitate better communication, physicians can do a number of things: sit down, attend to patient comfort, establish eye contact, listen without interrupting, acknowledge and legitimizing feelings. Automatically labeling patients who don't follow treatment recommendations as noncompliant implicitly supports an attitude of paternalism; patients are independent thinkers who can decide whether or not to follow treatment plans. - Compliance can be improved by using shared decision-making! Difficult (ex: many problems) patients? Have an honest discussion about boundaries: state that you can only work through a set number of their problems during your short 15 minute appointment. - Under certain conditions, physicians should strongly encourage specific actions. However, they must not use coercion or manipulation! Important that the patient reaches that decision of their own volition. Confidentiality provides the foundation for the physician-patient relationship! Patient needs to know that they can trust the physician with potentially sensitive information without feeling concerned or threatened that it might enter the public sphere. - Need for confidentiality extends from respect for the patient's autonomy. - Mandatory reporting should be done in a manner that minimizes invasion of privacy, and with notification to the patient. When a physician has relationships with multiple family members, they must honor each individual's confidentiality. - This can be difficult, as in the case of domestic violence. May need to break confidentiality if harm is imminent.

Truth-telling and Withholding Information

Honesty is critical for fostering trust with and showing respect toward patients! However, need to disclose the truth in a way that does not have a negative impact on them or their current health. - 90% of patients surveyed said they want to know the truth of their conditions. Patients should be told all relevant aspects of their illness; does not need to be brutal! Be sure to practice sensitivity. - Truth is not harmful if sensitivity is employed correctly. If patient's family asks you to withhold the truth, a discussion will usually suffice, as fears are often unfounded. Two main situations where the truth may be withheld from a patient: - If physician has compelling evidence that disclosure will cause real and predictable harm. - If the patient themselves states an informed preference not to be told the truth. Dialogue should be sensitive to cross-cultural differences! Ex. Navajo believe that hearing about risks invites them to occur. Placebos are generally not ethically justifiable; certain circumstances can permit them, like if the condition is known to have a high placebo response rate.

Termination of Life-Sustaining Treatment

If a treatment is no longer of benefit, it can sometimes necessitate discontinuation of those treatments. - Justifiable if the patient has the ability to make decisions and no longer wants the treatment. Withdrawal is justifiable if the treatment no longer offers benefit to the patient. Treatment may be considered futile if they offer no benefit. There is no ethical distinction between withholding (not starting) and withdrawing (stopping)! Terminally ill patients can refuse treatment. However, other can as well! Many court cases have affirmed the right of competent patients to refuse medical treatment. Patient is not competent to make that decision? Can either make use of an advance directive or a surrogate decision-maker. If the person is questionably competent, it is important to distinguish between simple disagreement and an irrational decision. - Patients are presumed to be competent! Capacity to make treatment decisions is considered intact if the patient understands information, appreciates their situation, can display reason, and can clearly communicate their choice. Psychiatric consults are not required but can be helpful; they are trained in interviewing people about sensitive issues. People with mental illnesses such as depression should have their decision-making capacity evaluated carefully - should not presume that they are unable to make treatment decisions. It is in fact justifiable to withhold food and fluids! Technically considered medical treatments. Rarely justifiable to discontinue life-sustaining treatment for cost reasons alone; may be justifiable in certain situations where the life of another patient relies on withdrawal of treatment for that patient, but this is exceedingly rare.

End-of-Life Issues

In caring for a person who is dying, knowing what would make the experience of dying "good" is an important goal for physicians and other members of the care team. Examples of working clinical goals when caring for someone near the end of life: 1. Control of pain and other physical symptoms. 2. Involvement of people important to the patient. Death is not an individual experience. 3. A degree of acceptance by the patient. Acceptance is not liking what is going on; it is being realistic about the situation. 4. A medical understanding of the patient's disease. Most patients come to physicians to learn something about what is happening medically. 5. A process of care that guides patient understanding and decision-making. Need a coordinated system/team of providers! It is often hard for physicians to predict that a particular patient is about to die. - Look at common clinical paths taken by dying patients; design contingency plans. Can include DNAR orders and advance directives. The hospice framework can be useful. Emphasizes symptom control and attention to psychological and spiritual issues. Pathophysiology less important; personal meaning more important. - Hospice care is often provided by multidisciplinary teams who go to patients' homes. Provided by Medicaid for patients judged to have less than six months to live. - Often underutilized as it involves switching care from curative to palliative medicine. Joanne Lynn suggests that there are four things clinicians must know to care for the dying. 1. The patient's story. Includes how that person has viewed her life, other people important to her, and how she could bring her life to a close in a way that would be true to herself. 2. The body. Covers the biomedical understanding of disease; the limits and possibilities that exist for that person. 3. The medical care system available for this particular patient. Make the system work for that patient. 4. Understand yourself. As a physician, you can be an instrument of healing, or an instrument that does damage. Physicians who care for the dying need to find a type of self-care that will enable them to develop their gifts as a physician and continue to use them in practice. - Strategy of detachment is not necessarily good.

Maternal-Fetal Conflict

In caring for pregnant women, the physician must consider the health of two patients who are biologically linked, yet individually viable. - Most women accept risk to their own health for the sake of the fetus, yet some refuse. Can be a major ethical dilemma. New conflict due to increasing views of duality instead of unity. Need to consider the effects on both; if mother refuses treatment, the ethical injunction against harming them is absolute. Women can be charged with fetal abuse! US courts have ruled that a child has a legal right to begin life with a sound body and mind. - Pregnant women's refusals of hospitalization have been legally challenged on the grounds of an obligation to the fetus. Use of court orders to force treatment on pregnant women raises many ethical concerns. - Can we allow competent adults to refuse therapy in all cases but pregnancy?

Informed Consent

Informed consent is the process by which the treating health care provider discloses appropriate information to a competent patient so that the patient may make a voluntary choice to accept or refuse treatment. - Originates from legal and ethical right that patients have to direct what happens to their body. Full informed consent has many elements; includes discussion of the nature of the procedure, reasonable alternatives, risks, benefits, assessment of their understanding, and acceptance of the intervention by the patient. Patient must be competent and capable of making the decision at hand in order for their consent to be valid. - Situation should not be coercive! Should be a decision-making process rather than merely signing a form. Even when consent is implied, explanation of the elements of the procedure remain necessary. "Adequate" information given can be measured through comparison to standards such as the reasonable patient standard, and the subjective standard. - Reasonable patient standard is used in Washington; what would an average patient need to know to be an informed participant in the decision. All health care interventions require some kind of consent by the patient. Exceptions to full informed consent are if the patient does not have decision-making capacity, if they have waived consent, or if they trust a loved one to make treatment decisions for them. Precautions should be taken to ensure that a patient has the ability to understand their situation, understand the risks associated with the decision they are making, and communicate a decision based on their understanding. - Psychiatric consultation can be helpful for tis determination. - Surrogate decision-makers may be used otherwise. If their decision-making capacity varies from day to day, make an effort to catch them in a lucid state! Make sure they can understand and fully consent at the time. Children do not have the decision-making capacity to provide informed consent; parents can provide informed permission for treatment. Patient consent should only be presumed in emergency situations where the patient is unconscious or incompetent and no surrogate decision-maker is available.

Graham-Cassidy

Last chance to repeal obamacare Repeal Obamacare individual and employer mandates...no more tax to not have any Repeals Obamacare subsidies and ends Medicaid expansion funding...no more lower premiums...states given leeway to spend it (equalized) Loosens Obamacare's regulations regarding pre-existing conditions Revamps funding for Medicaid overall Allows states to institute work requirements for Medicaid Permits everyone in the individual market to buy catastrophic plans Repeals a handful of taxes: Defunds Planned Parenthood Increases maximum contributions to health savings accounts

The Doctor-Patient Relationship: Strategies for MCOs

MCOs must train doctors to deal with difficult patients and dealing with difficult situations/bad news MCOs must promote patient-centered culture MCOs must separate patient care from administrative issues so that doctors aren't bearing the bad news that they can't treat a patient because of plan cost/restrictions...this means having someone else let the patient know what they can realistically expect MCOs must ensure their members have a voice MCOs must eliminate incentive conflict of interests wherever possible MCOs can standardize if they factor in compassion and not just profit, and really make an effort to not raise expectations of the patient for things they can't deliver...this honesty would increase trust MCOs must promote patient privacy and confidentiality MCOs must respect the time the patients are at the organization receiving or waiting for care MCOs must encourage psychosocial considerations in all forms of patient care MCOs must avoid business decisions that erode the DPR and its continuity

Malpractice and its Effects on The Healthcare Industry

Malpractice is always more complex than it's taken for, but it's still controversial *Medical Malpractice (MM): "improper, unskilled, or negligent treatment of a patient by a physician, dentist, nurse, pharmacist, or other healthcare professionals"* *MM affects DPR, cost via legal suits, insurance premiums for patients (which could make doctors move, which affects health care access), increases "defensive medicine" which is over-testing just to be sure and causes great stress for the doctor* Health care admin should be familiar with MM's effects, so there are MBA programs to learn

Physician Assisted Suicide Fast Facts

Mandated by state law in Oregon, Vermont, Washington, California, Colorado, and Washington DC (sometimes allowed in Montana) must have the terminal illness as well as prognosis of fewer than 6 months to live *Doctors can't go to jail for giving medications to hasten death in the states where it's legal* Note: this is *different than euthanasia* which is the act of assisting people with their death in order to end their suffering without legal OK Fun fact: these laws started very recently, in the 90s, but Dr. Kevorkian is famous for euthanizing someone and being sentenced to 8 years in prison in 1998

Student Issues

Medical students often encounter issues related to their position as a physician-in-training. Doctor introduces you as doctor? Talk with your preceptor in advance; don't want to give a false impression or damage patient trust by correcting him Practicing with a recently dead cadaver is not necessarily a problem, though your actions should be respectful and only as invasive as necessary. See a resident doing something unethical? Talk to them about it and approach them honestly for a dialogue. - Often a lesson in what not to do; however, it can also be more serious and require reporting for patient safety. If you've never done something before, it is your responsibility to ask for supervision before beginning a procedure. Feeling uncomfortable about practicing on a patient? Treat them with respect; convey gratitude to patients. - Attend to all patients with respect and compassion, especially the homeless man in the ER. Should intervene in some manner if a classmate seems to be exhibiting addictive behavior!

The Doctor-Patient Relationship: What Practitioners Can Do

Must enhance knowledge/skills/attitudes of all involved in DPR...this is severely lacking Doctors should focus on continuity in all DPR aspects because trust comes from reliable good will - allows for greater advocacy Doctors should work to protect interests/preferences of individuals because standardization and non-varied things are morally neutral...health care managers should be wide spread but doctors should work with individuals primarily Health care managers/administrators need to work with competence, compassion, and individualization - help physicians work on the individual level Physicians should be quality police, improving it when they can Physicians should be prudent in not wasting their resources/over using x-rays or blood tests, etc...because as dependent doctors seem to be on technological fancy tests, 80% of all diagnoses are still made just by talking to the patient and taking their history Physicians must talk to the patients and see which forms of treatment are most beneficial for them - this is dependent on underlying concerns, cultural background, and life history Physicians must pay attention to all $ and non-$ incentives that could pose conflicts of interests and affect their care Physicians should educate patients on their diseases and how to properly go about their treatments, as well as how to prevent future ailments

Neonatal ICU Issues

Neonatal care is responsible for the survival of a significant number of infants who formerly would not have survived; relatively new development! - Others disagree; state that the burdens outweigh the benefits. Primary justification for existence of neonatal intensive care units is increased survival for all babies, from premature to complex congenital anomalies. Though very low birth weight survivors are more in number, a significant number suffer from handicapping conditions, including major neurodevelopmental handicaps like cerebral palsy, mental retardation, blindness, and deafness. Surveys of these children indicate that their view of their quality of life is quite satisfactory; comparable to the satisfaction of the overall population. - Physicians judge former premature infants' quality of life lower than former premature infants and their families judge themselves. There are no successful models showing individualized predictability of death or disability. Ultimately, the biological parents or parent have authority regarding the decisions for their child; universally granted right. 23-24 weeks is a gray area with respect to resuscitation. Child's best interest is legally and ethically primary! Should be weighed over the family's well-being or societal concerns. - Are there concerns of excessive cost for aggressive care? Should be addressed at the policy level. - Preterm infants generate a huge cost-burden on the health care system. Extremely premature infants cost an average of $65,000/patient.

Complementary Medicine

Non-traditional medical practices are increasingly being used to complement more traditional medical care. - CAM whole medical systems include naturopathic medicine, homeopathy, Ayurveda, and traditional Chinese medicine including acupuncture. - NIH even doing some research through "Office of Alternative Medicine"; annual budget of ~$130 million. Many people seeking CAM treatment have back pain and other musculoskeletal complaints. - 40% of Americans use some form of CAM. Allopathic medicine was initially directly opposed to homeopathy, but integrative practices offering both approaches are becoming more commonplace. Many studies indicate that CAM is efficient in certain situations; ex. medicinal mushrooms are being studied in cancer patients with promising results. In vitro studies indicate that certain botanical compounds could even induce apoptosis in cancer cells. However, there are still many methodological issues in determining the efficacy of CAM. 1. Plants often used whole; complex mixtures of many different molecular constituents make them difficult to standardize and characterize. 2. Often treat individual patients in a very individualized way, using multiple interventions simultaneously. What is doing what? 3. Often difficult to define appropriate control groups. CAM therapies can violate the tenet of do no harm; difficult to know when to do what because the treatments are often poorly characterized due to the lack of established literature. - Integrative medical clinics do take some of the guesswork out of this. Can be well supervised. Many of the dangers can be mitigated if the patient is supervised by a trained CAM professional. Certain ethical issues arise in the context of CAM research: 1. Informed consent; impossible to inform them of what exactly the treatment is if it is not well characterized in the first place. 2. Misconceptions; widely held notion that if something is "natural" then it must be safe or beneficial. 3. Study design; simply hard to design an adequate study. Very important to track the patient's use of all CAM therapies! Food-drug interactions are very real possibilities. CAM therapies provide useful tools, but they must be used safely and cautiously.

FAKE NEWS about Obamacare (things people have actually said in criticism)

Obamacare has death panels! Obamacare gives free insurance to illegal immigrants! Obamacare uses taxpayer money for abortions! Obamacare forces churches/taxpayers to pay for women to have free birth control! Obamacare won't let me keep the insurance I have! Obamacare will make the government get between me and my doctor! Obamacare has a public option! That makes it bad! Obamacare will cost trillions and put us in massive debt! Obamacare is twice as long as War and Peace! The people who passed Obamacare didn't even read it! Obamacare was signed quietly in the middle of the night! Obamacare is a government takeover of the health industry! Obamacare cuts $700 Billion dollars from Medicare! Obamacare takes money from Medicare to pay for Obamacare! Obamacare is going to make hospitals drop support for Medicare and Medicaid! Obamacare allows Barack Obama to create a secret health care army!

The Hippocratic Oath

Overview: Greek medical text, swear to the healing gods that you will *uphold ethics*, binds student to teacher/other doctors as if they were family (early stages of med school), surprisingly not required by most modern med schools, and even more surprisingly *it doesn't have explicitly use the phrase "First, do no harm"* Summary: I swear to gods...I love my teacher like family and I'll teach others after me...I'll benefit patients to best of my ability and do no harm to them...I won't give lethal drugs to patients or cause abortions...I will act according to divine law...I won't perform surgery unless I'm a surgeon...if I go to peoples homes I'm only there to heal them not sleep with them or receive bribes from them...I will keep anything between the patient and myself a confidential secret...so long as I uphold this can I be a doctor and get respect from others, but if I break it I will receive the opposite

Interdisciplinary Team Issues

Patient care now routinely combines the efforts of many health care professionals: need to be a good member of a team. Physicians need to adjust to this team approach! Often used to making the decisions and having them carried out by others. - Need to be flexible; work as a team. Surgeon as the "captain of the ship" is no longer maintained. Members of the operating room team have separate obligations, as well as obligations to each other. - Each team member brings different knowledge, skills, and strengths. Must be cognizant and respectful of this. Don't agree with your attending? Have a respectful exchange of views rather than acting recklessly! Members of the team will disagree at times - this is normal and expected. However, it is still important to remain respectful! - Listen and consider the input of others! Respect can also be demonstrated through language, gestures, and actions. - Still can't reach a consensus? Maybe consult an outside source.

Cross-cultural Issues and Diverse Belief

Patients may bring cultural, religious, and ideological beliefs with them as they enter into a relationship with the physician; can often conflict with what is considered to be "good medical care". - Principle of autonomy requires that a physician respect the medical decisions of a competent adult patient; the physician also has an independent duty to guard the interests of the patient. Respecting beliefs and values of patients is an important part of establishing an effective therapeutic relationship; failure to take their beliefs seriously can undermine their ability to trust you as their physician. Knowledge of beliefs and the reasonable range of interpretation of doctrine can be helpful in deciding is unusual beliefs should be respected. - Unusual beliefs falling outside known belief systems should prompt more in-depth discussions to insure they are reasonable. Adults have a moral and legal right to make decisions about their own health care, including the right to refuse treatments that may be life-saving. The role of the physician is to make sure that the patient understands the possible and probable outcomes of refusing that treatment. Try to understand the basis of their refusal; enlisting the aid of a leader in their cultural or religious community can be helpful. Parents do have a legal and moral authority to make health care decisions for their children, but should not be permitted to deny their children medical care that is likely to prevent substantial harm or suffering. Should always show respect for family's beliefs and work with them. Parents can refuse treatment if refusal does not pose significant risk; have a right to refuse routine immunizations on religious or cultural grounds. Physicians are not morally obligated to provide treatment modalities that they do not believe offer a benefit to the patient or that they believe may harm the patient.

Physician Aid-in-Dying

Physician aid-in-dying is the practice in which a physician provides a competent, terminally ill patient with a prescription for a lethal dose of medication upon their request. - Various language has been used to describe PAD throughout the years; used to include suicide, though this had negative connotations and has since been discontinued out of respect for those who participate in PAD. - Recent research continues to detail the need for open and honest discussion on end of life issues. Physician aid-in-dying is NOT euthanasia. - Euthanasia is illegal in every state; occurs when a third party administers the lethal dosage of medication or otherwise acts directly to end the patient's life. With physician aid-in-dying, the physician provides the medication but the patient decides whether and when to ingest the lethal medication. Physician aid-in-dying is also not the same as withholding/withdrawing life-sustaining treatment, giving pain medication that may hasten death, or palliative sedation. Ethics continue to be debated: some argue that PAD is ethically permissible as the rational choice for a dying person who is choosing to escape unbearable suffering at the end of their life. It is the physician's duty to alleviate suffering, justifying aid-in-dying. - Relies on respect for individual autonomy. Others argue against PAD being ethically permissible by stating that it runs directly counter to the duty of the physician to preserve life and to do no harm. Arguments in favor of PAD: 1. Respect for autonomy 2. Justice 3. Compassion 4. Individual liberty vs. state interest 5. Honesty and transparency Arguments against PAD: 1. Sanctity of life 2. Passive vs. active distinction. 3. Potential for abuse. 4. Professional integrity. 5. Fallibility of the profession PAD is legal in Oregon, Washington, and Vermont where voter-approved initiatives or legislative action have legalized aid-in-dying under very specific circumstances. - Also permissible in Montana. - PAD would likely considered illegal in most other states without corresponding legislature; it is explicitly illegal in many other states. Laws in these three states have strict patient eligibility criteria, limiting access to competent, legal residents of the state over age 18 with a terminal illness confirmed by two independent physicians. Professional organizations such as the American Medical Association have generally argued against PAD on the grounds that it undermines the integrity of the profession. - About half of individual physicians believe that PAD is ethically justifiable in certain cases. About 1 in 5 physicians will receive a request for PAD sometime in their career. If asked for PAD, the most important aspect of the response is to be respectful and caring: virtually every request is a profound event for the patient. - Request should be explored to better understand the origin and find out if there are other interventions that might help ameliorate their concerns. If their request persists, each clinician must decide his or her own position and choose a course of action that is ethically justifiable and legally permissible. - Be clear and transparent about your position; be willing to have a dialogue. Many specific duties and responsibilities under the Washington Death with Dignity Act.

Professionalism

Physicians belong to a profession; need to adhere to that profession's standards of conduct. - Professionals have a fiduciary duty toward those they serve. Have codes of ethics which specify the obligations arising from this fiduciary duties. Professionalism requires that physicians strive for excellence in many areas. - Altruism - Accountability - Excellence - Duty - Honor and integrity - Respect for others

Pros and Cons of Obamacare

Pros: 1. Lowers overall cost by insuring everyone and making preventative care free 2. insurance covers 10 basic health things 3. no denying for pre-existing conditions 4. eliminates lifetime/coverage limits 5. kids can stay on parents' plan until 26 6. easier to shop around for insurance plans 7. eliminates donut hole gap 8. businesses must provide health insurance 9. expands medicaid range/middle class cuts 10. lowers budget deficit by: reducing health care costs, taxing the rich, and shifts cost to health care providers Cons: 1. 3-5 million lost their job's healthcare for worse one 2. 30 million private insurance plans were cancelled for not meeting requirements 3. overall health care costs raised in short term 4. ACA taxes those who don't get insurance 5. 4 million just pick the tax over the coverage 6. income taxes raised for 200-250K and up 7. excise tax 8. families can deduct more expensive treatment 9. Big pharma pays way more in fees 10. huge tax on "Cadillac" plans Summary: On one side are consumers who previously had no access to health insurance because of their income or a pre-existing health condition. For these individuals, Obamacare has been a welcome overhaul to the nation's healthcare framework as the individual mandate has required insurers to welcome these individuals into their member network with open arms. On the other side of the equation are primarily younger adults who don't like the idea of being required to purchase health insurance that they will only minimally use. Though the premise of the ACA is to spread medical costs over a greater swath of the American public so as to reduce medical inflationary costs, people who oppose the individual mandate would prefer to have no part of it.

Public Health Ethics

Public health has been defined many ways. One example: what we, as a society, do collectively to assure the conditions in which people can be healthy. Public health is distinct from medicine in several ways: it is oriented toward the health of populations or groups rather than individuals, prevention of disease rather than treatment, and elimination of systematic inequalities in population health. - Must address a broad array of social conditions extending beyond medical services. Social conditions have been recognized as basic causes of illness and disease. Public health ethics include producing benefits, preventing harms, distributing health benefits fairly, and procedural justice, among others. Harm principle: the only purpose for which power can be rightfully exercised over any member of a civilized community against his will is to prevent harm to others. - Does this work: can we distinguish clearly between behavior affecting the self and behavior affecting others? Example: obesity epidemic. Argued that individual choices contributing to overweight and obesity constitute an economic harm to others who share in the costs of their health care. - Examples of apparently self-regarding choices might be other-regarding in significant respects. Paternalism occurs when the state or an individual interferes with the preferences of a person for her own benefit. - Much public health research and action seeks to change behaviors whose ill effects are felt primarily by those who engage in them. Least controversial tactics for promoting behavior change are educational in nature; however, often fail to produce behavior change. Can make the government regulate (sodium levels, soda in school, etc.), though this is criticized where personal responsibility and individualism are highly valued. - Incentives can be used to promote the adoption of health-enhancing behaviors. Claim of social responsibility is a critical plank in a larger argument stating that health should be subject to considerations of social justice. Maximizing benefits and removing harms is a utilitarian goal that aims to maximize aggregate health; distinct from the distributive goal to produce a fair distribution of health. - Health initiatives often reproduce or exacerbate disparities because better off people tend to benefit sooner and disproportionately from many health promotion interventions. - One common strategy to address this problem is implementing interventions that target vulnerable subgroups. Pursuit of social justice also entails recognition goals. Communicable diseases may need to be reported to public health authorities when specific diseases with public health implications are found. However, still need to be respectful of patient confidentiality. Medical treatment can be provided against a patient's will if it is in the best interests of the public: however, one should first try to use less coercive methods.

Medical Futility

Refers to interventions that are unlikely to produce any significant benefit for the patient. - Quantitative futility: likelihood that an intervention will benefit the patient is exceedingly poor. - Qualitative futility: quality of benefit an intervention will produce is exceedingly poor. Does not apply globally! Applies to a particular intervention at a particular time. The goal of medicine is to help the sick; physicians have no obligation to offer treatments that do not benefit patients. Futile interventions can increase pain and discomfort, give false hope, and expend resources. - However, it can be difficult to determine which interventions are futile. Obligations of physicians are limited to offering treatments that are consistent with professional standards of care and that confer benefit to the patient. Medical futility applies when, based on medical data and professional experience, a treating health care provider determines that an intervention is no longer beneficial. - Ideally: all health care providers reach consensus. - Very necessary to communicate with other colleagues involved with care, patients, and family. It may be appropriate to continue with a futile intervention to provide closure (I.E; keep grandma alive until her granddaughter can come see her). However, this should not be considered if usage of the futile intervention would cause the patient substantial suffering. Futility is not rationality; central question is not about how much money treatment costs or who else might benefit from it. Futility is based on empirical evidence; experimental treatments lack empirical evidence demonstrating their effects. Futility has no correlation with age! Simply based on whether or not the intervention will help the patient. Medical futility has been criticized for giving free rein to the doctor's interpretation; not a valid criticism because medical futility would ideally reach a consensus amongst multiple health care professionals. - Some doctors and practitioners have used the term "medically inappropriate" in an attempt to avoid language that is harmful to their case.

Spirituality and Medicine

Religious and spiritual beliefs are important in the lives of many patients, yet physicians are often uncertain about whether, when, or how to address spiritual or religious issues. - Physicians used to focus only on biological side of things; now recognize that engaging the spiritual beliefs of patients may assist in the healing process. Religiosity is pervasive in the United States: 93% believe in a higher power/78% believe in God. - Physicians as a group are less inclined to believe in God. It is important to attend to spirituality in medicine because religion and spiritual beliefs play an important role for many patients. When illness threatens health, patients are likely to have both physical and spiritual issues. - Religious practices and beliefs have a profound effect upon the existential experiences of patients with illness and the threat of dying. Religious and spiritual factors often figure into their coping strategies and influence important decisions. - Religious struggle can have deleterious health impacts: patients who feel alienated from God were associated with 20% increased risk of dying during a 2 year follow up period. Medical students often gain exposure to the idea of spiritual inquiry in courses like introduction to clinical medicine. Learn about the various components of the doctor-patient interview, including religious and belief-based inquiries. - Can be incorporated into the bio-psycho-social-spiritual patient history! HOPE questions help begin the process of incorporating a spiritual assessment into the patient interview: H: sources of hope: comfort, strength, peace, love, connection. O: Organized religion. P: Personal spirituality and practices. E: effects on medical care and end-of-life issues. Open-ended questions! Chaplains are well-trained and can help meet the spiritual needs of patients when they are outside the competence of the physician. Play an important role in a team approach to caring for patients as patients ask difficult questions when faced with illness and also have many practical questions, concerning pregnancy termination and blood transfusion for example. - Also a helpful resource in providing or arranging for rituals that are important to patients under particular circumstances. For nonreligious physicians, it is important to not underestimate the importance of the patient's belief system. Must not impose beliefs onto the patient, particularly at vulnerable times! - General consensus: physicians should take their cues from the patient, with care not to impose their own beliefs. Many obstacles to discussing spirituality with patients, such as scarcity of time in office visits, lack of familiarity with the subject matter, or lack of knowledge of various religious expressions. Elective courses can help raise awareness here! Situation is changing; most medical schools now offer electives on religion.

Resource Allocation

Scarcity of resources can be a big issue in medicine. Must consider certain issues when facing these difficult allocation decisions. Scarcity can often be alleviated by improved efficiency or expanded investment. If practical solutions cannot solve the problem, a rationing decision must be made. - Many reasons for why things might be in short supply. - Need to figure out how to ration equitably. Should not be a "merit" system. - Criteria for matching organs with people for transplantation is based on objective grounds like tissue type, body size, time on waiting list, and seriousness of need. Triage is required when many patients simultaneously need medical attention. Those who need the treatment most are clearly prioritized. - Disaster triage: commanders, fire fighters, etc. treated first so that they may return to duty and help others. One of the few times where a utilitarian rule governs medicine, as the greater good of the greater number is rationalized over the particular good of the patient at hand. Quality of life judgments are often based on prejudices and biases; should not be used explicitly or implicitly as the basis for rationing medical services. Ideally, all persons should have access to a decent minimum of health care necessary to sustain life, prevent illness, relieve distress and disability. - Many questions about to health care; impossible to say for certain whether or not it exists.

Human Genetic Engineering

Someday, scientists might be able to genetically engineer humans to possess certain desired traits...insert legal and ethical questions Starts with preimplantation genetic diagnoses of in vitro embryos...ethical questions for genetic testing for adults if the disease is incurable (like are you harming the person)...some say yes and others no...some want to know and other dread it...look for SNPs...very culturally tricky Sport-doping is prohibited, but now they must deal with gene-doping (hard to test for) Creating designer babies is quasi-eugenics...this is problematic

Organ Trafficking: A Deadly Trade

Story of woman whose son was murdered by organ traffickers Causes of trafficking growth: 1) reduction of # of legitimate organs available for transplant, for example, because cars are safer and accidents are less frequent 2) increase in # of people waiting for transplants Results: criminals can make $$ for organs You can order online or broker with traffickers Victims can be kidnapped & cut up, or some people sell their organs for $$, or some are duped into a fake operation where their organ is removed, or some are murdered to order if a large sum is paid in advance Organ trafficking is illegal, and more than 1 an hour are sold Kids are often targetted, some criminals are found out and sentenced, very mafia-like Hearts can get up to $1 million, Some evil scientists ask for whole body cadavers, some genitals/fetuses are harvested for ritual purposes/black magic Some sell their own organs online, some due it because they can't pay the bills any more

Patient Protection and Affordable Care Act (Obamacare) Summary

The PPACA made a bunch of new rules regarding health care, with the purpose of making health care more affordable for everyone. Opponents of the PPACA, on the other hand, feel that the rules it makes take away too many freedoms and force people (both individuals and businesses) to do things they shouldn't have to. Already in Effect: -FDA approve drugs -Drugs cost less -makes a non-profit group, that the government doesn't directly control, PCORI, to study different kinds of treatments to see what works better and is the best use of money -restaurants show calories now -It makes a "high-risk pool" for people with pre-existing conditions. Basically, this is a way to slowly ease into getting rid of "pre-existing conditions" altogether. For now, people who already have health issues that would be considered "pre-existing conditions" can still get insurance, but at different rates than people without them. -Forbids insurance companies from discriminating based on a disability, or because they were the victim of domestic abuse in the past -creates a new 10% tax on indoor tanning booths -says that health insurance companies can no longer tell customers that they won't get any more coverage because they have hit a "lifetime limit". Basically, if someone has paid for health insurance, that company can't tell that person that he's used that insurance too much throughout his life so they won't cover him any more. They can't do this for lifetime spending, and they're limited in how much they can do this for yearly spending -Kids can continue to be covered by their parents' health insurance until they're 26 -No more "pre-existing conditions" for kids under the age of 19. -Insurers have less ability to change the amount customers have to pay for their plans. -People in the "Medicare Part D Coverage Gap" (also referred to as the "Donut Hole") get a rebate to make up for the extra money they would otherwise have to spend. -Insurers can't just drop customers once they get sick. -Insurers have to tell customers what they're spending money on. (Instead of just "administrative fee", they have to be more specific). -Insurers need to have an appeals process for when they turn down a claim, so customers have some manner of recourse other than a lawsuit when they're turned down. -Anti-fraud funding is increased and new ways to stop fraud are created. -Medicare extends to smaller hospitals. -Medicare patients with chronic illnesses must be monitored more thoroughly. -Reduces the costs for some companies that handle benefits for the elderly. -A new website is made to give people insurance and health information. -A temporary credit program is made that will make it easier for business to invest in new ways to treat illness by paying half the cost of the investment. -A limit is placed on just how much of a percentage of the money an insurer makes can be profit, to make sure they're not price-gouging customers. -A limit is placed on what type of insurance accounts can be used to pay for over-the-counter drugs without a prescription. Basically, your insurer isn't paying for the Aspirin you bought for that hangover -Employers need to list the benefits they provided to employees on their tax forms. -Any new health plans must provide preventive care (mammograms, colonoscopies, etc.) without requiring any sort of co-pay or charge. -If you make over $200,000 a year, your taxes go up a tiny bit (0.9%) Eventually in Effect: -*No more "pre-existing conditions". At all. People will be charged the same regardless of their medical history.* -*If you can afford insurance but do not get it, you will be charged a fee.* This is the "mandate" that people are talking about. Basically, it's a trade-off for the "pre-existing conditions" bit, saying that since insurers now have to cover you regardless of what you have, you can't just wait to buy insurance until you get sick. Otherwise no one would buy insurance until they needed it. You can opt not to get insurance, but you'll have to pay the fee instead, unless of course you're not buying insurance because you just can't afford it. -*Doctors' pay will be determined by the quality of their care, not how many people they treat.* -If any state can come up with their own plan, one which gives citizens the same level of care at the same price as the PPACA, they can ask the Secretary of Health and Human Resources for permission to do their plan instead of the PPACA. So if they can get the same results without, say, the mandate, they can be allowed to do so. Vermont, for example, has expressed a desire to just go straight to single-payer (in simple terms, everyone is covered, and medical expenses are paid by taxpayers). -All health care plans must now cover preventive care (not just the new ones). -A new tax on "Cadillac" health care plans (more expensive plans for rich people who want fancier coverage) -The elimination of the "Medicare gap"

The Doctor-Patient Relationship: A Special Relationship

We know much about the DPR and can teach it Medical interview is the major medium of healthcare with 3 functions: *gather info, develop & maintain a therapeutic relationship, and communicating info* -this DPR determines quality and completeness of these three things -if you actively engage with the patient, they do better biologically, in life quality, and satisfaction Effective use of the interview gives patients sense that they are heard, respected, cared for, etc. so *they feel important*...the *time spent doing this is irrelevant* *Accessibility and courtesy level of healthcare organization affects DPR*, like waiting times and how well it's staffed...want user-friendliness and nice reminders...DPR is affected if organization is patient driven or profit driven...want long-term It's disappointing to patients when doctors can't provide all the health care they want because their insurance won't cover it...barrier to DPR *DPR crucial for vulnerable patients depending on the doctors' skill* - power struggles arise, but *a doctor is expected by law to do what the patient wants and expects even if it's against the doctor's own wishes* (i.e. Jehovah's Witness but Hospitals have special lawyers to overcome this via a court-order, but it's super duper rare) *DPR is a moral enterprise, so a bad doctor isn't just a bad professional but a morally horrible person in the patient's eyes* - Trust is fragile

Breaking Bad News

While breaking bad news, physician competence is critical to establishing trust. - Communication skills can and should be learned. Robert Buckman's Six Step Protocol for Breaking Bad News: 1. Getting started. Setting should be private; should ask the patient who else they would like to be present. Use questions to indicate that the conversation goes both ways. 2. Find out how much the patient already knows. Begin to understand what they've been told, how much they understand, level of technical sophistication, and their emotional state. 3. Finding out how much the patient wants to know. Ask patients what level of detail you should cover: big picture or every medical detail? 4. Sharing the information. Decide on the agenda before sitting down; have relevant information at hand. Topics to consider are diagnosis, treatment, prognosis, and support/coping. Appropriate agendas tend to focus on one or two topics. Give small chunks of information, translate medical terms into English, and don't try to teach pathophysiology. 5. Responding to the patients feelings. Best opportunity to be a caring physician; be attentive, but can also simply ask them how they are feeling. 6. Planning and follow-through. Synthesize the patient's concern and medical issues into a concrete, step-by-step plan that may be explained to the patient. Be explicit and clear about next contact. If the patient starts to cry while you're taking, it is often best to simply wait for them to stop crying. Never assume you know precisely why they are crying! Offer tissues if available; tears are not an emergency to be stopped. Do not run out of the room. Be patient. Patients don't remember or understand everything. If someone else is rude or insensitive to the patient, consider acknowledging without slandering the other caregiver.

Research Ethics

Within institutions where clinical research is conducted, responsibility for the interpretation and application of ethical principles rests with committees composed of scientists and non-scientists, called Institutional Review Boards. General ethical principles applied to research with human subjects: - Autonomy: right of an individual to determine what activities they will or will not participate in. - Beneficence: obligation on the part of the investigator to maximize benefits for the individual participant and/or society while minimizing risk of harm to the individual. - Justice: demands equitable selection of participation; avoid participant populations that may be unfairly coerced into participating. Investigators should be primarily concerned with the safety of the research participant; must obtain informed consent, protect subject's privacy and confidentiality, consider how adverse events will be handled, and strive for clinical equipoise. Components of ethically valid informed consent for research: - Disclosure: informed consent document must make clear that the study is a research study and not clinical therapy. - Understanding: participant must understand what has been explained and must be given the opportunity to ask questions. - Voluntariness: the participant's consent to participate in the research must be voluntary and free of any coercion. - Competence: participant must be competent to give consent. - Consent: potential human subject must authorize his/her participation in the research study. - Exculpatory language: no informed consent may contain any exculpatory language by which the participant waives any legal right. IRBS can be full, expedited, or exempt, depending on the amount of risk that subjects are exposed to as a result of participation in the research. Deception is generally not acceptable, though it is sometimes integral to the research itself.

Parental Decision Making

Young children are not able to make complex decisions for themselves: the authority to make medical decisions on behalf of a child usually falls to the child's parents. - Parents have the responsibility and authority to make medical decisions on behalf of their children. Includes the right to refuse or discontinue treatments! Should still be guided by the best interests of the child. - Parents having medical decision-making authority results from the fact that in most cases, they are the people who care most about their child and know the most about him or her. Medical caretakers have an ethical and legal duty to advocate for the best interests of the child when parental decisions are potentially dangerous to the child's health. Should challenge parental decisions if they place the child at a significant risk of serious harm. - Childhood vaccination is an example of a decision that places a child at significant risk of serious harm: however, this decision is usually not legally challenged. If parents are not available to make decisions about a child's treatment, medical caretakers may provide treatment necessary to prevent harm to the child's health. - Should only administer treatments necessary to prevent harm until parental permission can be obtained. - Examining a child who presents to medical attention is always appropriate. Children with the ability to understand what is happening to them should be allowed to participate in discussions about their care. - Usually still lack capacity to make complex medical decisions; final authority remains with parents. - If an older child has wishes regarding their medical care, they should be taken seriously - the medical caretaker should assure that their voice is heard and advocate for the child. Emancipated minors have the right to make their own decisions; are either economically self-supporting, married, a parent, or active duty in the armed services. - Others minor who are deemed sufficiently mature can make decisions with respect to their own care. - All states allow adolescents to seek treatment without parental consent for transmitted diseases, pregnancy, contraception, psychiatric disorders, and drug or alcohol abuse.