Soc 3630: Study guide test 3
When did Somali people begin writing their own language? Why might this be important?
60-70s. Somalis speak different dialects of the language so depending on where you are from one meaning is different from another. This is important when offering interpreting service
Technological imperative
If we have the technology to do something, then we should do it
Privileged communication
comes from the legal system, which operates on the basis of testimonial compulsion—individuals with pertinent information can be required to present that information in a court of law.
What are the factors in building trust? (remember the grid)
competence and caring
Define advance directive.
decisions regarding life-saving or life sustaining care that are recorded in legal documents
Infertility
defined as the absence of pregnancy after one year of regular sexual intercourse without contraception, is increasing in the United States.
Beneficence
doing good for the patient. While the general meaning of the concept is to promote goodness, kindness, or charity, in the medical context it refers to physicians taking whatever actions—for example, surgery or prescribing a medication—that are considered to be in the patient's best interest.
Strong required request
every citizen asked to indicate willingness (organ donation).
Nancy Cruzan....
fell into a coma after she lost control of her car, diagnosed to be in a persistent vegetative state, taken off life support when parents found proof that she would have wanted to die (8 years later) •First right to die case to reach the US Supreme Court •(last name) v. Missouri, brought forth the right-to-die movement, ability of the family to decide whether their children should live on life support or die • Parents wanted the feeding tube removed, brought to the Supreme Court • Ruled that the tube was to be removed, ruled that states could regulate circumstances under which a life-sustaining machine could be removed
Physician-assisted suicide
occurs when a physician provides a means of death (e.g., a particular drug) and instructions (e.g., how much of the drug would need to be taken for it to be lethal) to a patient but does not actually administer the cause of death. This is different than active euthanasia—a situation in which the physician directly administers the causes of death. Physician-assisted suicide is legal in some countries in the world (e.g., the Netherlands and Belgium) but not in most.
Commodification of life
surrogate motherhood devalues people and creates a "commodification of life—treating people and parts of people as marketable commodities"
Engineering model
Decision making shift to patient, doctor implements decision - skilled professional able to carry out tasks - doctor gives up moral authority (medical care as a commodity to be bought)
Guidance-cooperation model
Doctor as coordinator - Ex. Doctor tells patient what to do.. - Szasz-Hollender Model (more likley for older population and not questioning if doctor is correct)
What is the mutual participation model?
Doctor helps patients to help themselves (good communication) What might be the building blocks to this relationship? Good listener, communicator, motivational perspective (doctor will ask how do you want you communication to be handled (mail/email) Who do you want to be present when a doctor treats you How much information about the case do you want to know In which of the clinical decisions do you want to participate Chief criticism-Model best suits mature, educated patients Patient at the center! The doctor helps the patients to help themselves by relying on good communication and motivational interviewing
Tarasoff case: What is a conscience clause? When can it be used and by whom?
Don't make your choice my choice
Therapeutic communication
Effective and meaningful communication between physician and patient. Physician engages in full and open communication with the patient and feels free to ask questions to seek clarifications. There are 3 components of therapeutic communication: (1) The physician engages in full and open communication with the patient and feels free to ask questions about psychosocial as well as physical conditions (2) the patient provides full and open information to the physician and feels free to ask questions and seek clarifications, and (3) a genuine rapport develops between physician and patient.
Tarasoff case: What are some reasons for not treating a patient?
Excessive risk: could worsen patient and exceeds potential for patient improvements Questionable benefits: treatment may be futile in effort to enhance and prolong life Obligation to treat others" patient withdrawal from physician perceived to be taking unnecessary risk Obligation to family and self: Health of physician placed before health needs of patients Conscience Clause: Dont make your choice my choice And reasons for treating the patient: Nature of profession: rooted in a special ideal of service to others Social contract: obligation to treat based on the power of physicians The dependent patient - physicians are linked to patients in ways that extend beyond a contact; a moral dimension ----- Patients with stigmatic diseases ----- Doc: rewarding work, 60% report patient gratitude, 57% intellectual challenge, 30% desire to serve the underserved
HW-Chapter 11: Give three examples of medical experimentation and studies that focused on black boys. Discuss the studies and the effects on the black community. Use at least two concepts from related text chapter(s) (WL) to relate to these examples.
Fenfluramine; XYY; Brain (1) 1992-1997: New York State Psychiatric Institute (NYSPI) and Columbia University conducted several research studies to establish a link between genetics and violence; Performed experiments on 126 boys, most of whom were black/hispanic using the drug Fenfluramine; 44% were black and 56% were Hispanic, but those of Hispanic descent were black Hispanics (Black Dominicans) (2) XYY syndrome study; Scientists believed that this extra Y contributed to aggressiveness and individuals that had this were more violent and more likely to become criminals;6,000 boys were selected for this 85% black, most of whom were in Maryland state institutions (3) "born criminal" medical trend; this involved experimental brain surgeries; J.M. a 9 year old boy subject to this surgery had some of his brain tissue removed to help remedy seizures and his aggressiveness; Areas removed from his brain crucial to emotion, expression, cognitive function etc; No medical intervention at all just portions of brain were removed; These lobotomies were often recommended to black children Effects on black community: Stigmatized blacks as criminals, violent, and aggressive The ones who participated in the Fenfluramine study -- gave them a label that they possibly may be criminals if they tested positive for the studies which could affect their future. priestly model: Hippocratic oath, doctor makes all decisions, patients as illness not person, medical model driven - patient gives up moral authority. While the patient provides full and open information to the physician & feels free to ask activity passivity model: Patient unable to respond and the doctor does something to the patient
Privacy
Freedom from unauthorized intrusion into one's life
Persistent vegetative state (PVS)
a disorder of consciousness in which patients with severe brain damage are in a state of partial arousal rather than true awareness. the patient is not conscious, is irretrievably comatose, is nourished artificially, but is respirating on his or her own. This happens when the brain stem is functioning, but the cerebrum is not.
Intrauterine insemination (IUI)
a fertility treatment that involves placing sperm inside a woman's uterus to facilitate fertilization. The goal of IUI is to increase the number of sperm that reach the fallopian tubes and subsequently increase the chance of fertilization.
Procreative liberty....
a fundamental right not to procreate. The right to procreate has not received the same explicit judicial endorsement because states have not challenged married couples' efforts to give birth. Nevertheless, the Supreme Court, on several occasions, has indicated strong support for procreative liberty—especially for married persons. a right against interference by the state or others with reproductive decisions
Jack Kevorkian
a retired Michigan pathologist who assisted more than 100 people to end their lives by providing a painless means to do so and by being present at the time of death. Each of the persons contacted Kevorkian (none were patients of his) and convinced him that they had made a rational choice to die.
Pure voluntarism
1950s-1960s, volunteers came forward for organ donation.
Weak presumed consent
hospitals would salvage organs and not use them only if family requests.
Medical futility
"an expectation of success that is either predictably or empirically so unlikely that its exact probability is often incalculable"
Patient activation
"the skills and confidence that equip patients to become actively engaged in their health care" (Management and responsibility)
Epilouge: Discuss how the medical exploitation of black bodies has been reduced in the US but has been exported to the continent of Africa. Give three specific examples medical and pharmaceutical research, medical intervention, or treatments that have been exploitative of current African people. Use at least two concepts from related text chapter(s) (WL) to relate to these examples.
(1) 2002: hormones of "Bushmen" were mined for potential weight loss therapies (2) human growth factor was tested on Pygmies before being used on Western children (3) Depo-Provera, although a carcinogen, was tested on Zimbabwean women before it was introduced into the US as a reproductive injection Medications considered far too dangerous or too hopelessly tainted for testing in the West have been introduced into clinical trials with unsuspecting African patients. Within the past decade, even the infamously teratogenic drug thalidomide has been tried on Africans as a treatment for leprosy— forty years after it produced twelve thousand horribly deformed babies around the world
What are the five components of comprehensive Patient Care (CPC) and care delivery transformation?
(1) Access and continuity 24/7 access to care Expanding office hours, offer alternative visit types, prove patients with access to patient portals, using Haiku and Canto (digital access) (2) Care management Following up with patients Calculating complexity of care and assigning a nurse for them Personalized care (3) Patient and caregiver engagement (4) Planned care and population health (5) Comprehensive and coordination Assess caregiver social and emotional needs and provide support
Know the five technological advances in the past century.
(1) Cardiac technology (pacemaker, defibrillator, Heart Box) (2) Critical care medicine (ICU, respiratory therapy, physical therapy, and mechanical ventilation) (3) Medical imaging (CT scan, MRI) (4) Healthcare computers (information technology - - databases, diagnostics, telemedicine) (5) Genomic medicine (gene therapy/tests)
Analyze the key components of therapeutic communication.
(1) The physician engages in full and open communication with the patient and feels free to ask questions about psychosocial as well as physical conditions, (2) the patient provides full and open information to the physician and feels free to ask questions and seek clarifications, (3) a genuine rapport develops between physician and patient.
Tarasoff case: What are the arguments for lying to the patient?
- Most common reason is due to Benevolent deception, which is when a physician lies to a patient because it is believed to be in the patient's best interest. Also that patients are unable to comprehend the whole truth Some patients prefer not to hear the whole truth
Helga Wanglie
- Suffered a stroke which left her in a persistent vegetative state after which doctors suggested suspending treatment - Her husband refused and was appointed her legal guardian while the medical center petitioned the court - She died before legal resolution defined medical futility as "an expectation of success that is either predictably or empirically so unlikely that its exact probability is often incalculable"
Tarasoff case: What are the arguments against lying to the patient?
- Truth telling is an unconditional duty of medical professionals and are morally obligated to give all information to the patient -Truth telling is part of the respect owed to all people - The physician entered into a contract when the patient was seeking medical care and so any information learned is owed to the patient -Lying undermines a trusting relationship -Telling the truth offers clear benefits to the patient
Define telemedicine.
- Uses computers and telecommunications lines to deliver health care at a distance - May us store-and-forward technology or interactive videoconferencing the remote diagnosis and treatment of patients by means of telecommunications technology.
Terri Schiavo....
-Terri collapsed, experiencing cardiac arrest, that led to a coma and then a vegetative state. -8 years later, Terri's husband petitioned a Florida court to remove her feeding tube, an action opposed by Terri's parents. -There were arguments over the next several years about what Terri would have wanted (she had not completed an advanced directive) feeding tube removed Intervention by Jeb Bush, George Bush, congress sought to overturn court rulings that that allowed withdrawal of feeding tube
Dr. Tayal's presentation: Doctor Patient relationship in transition
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Chapter 13: Weiss
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Chapter 16: Weiss
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Guest Speakers: Jesus, Hibo, Lindsey--Cultural Humility
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Chapter 12: Weiss
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Explain the factors related to patient satisfaction
1) interpersonal skills 2) technical quality 3)accessibility 4)availability 5)physical environment 6) continuity 7) health outcome 8)cost 9)demographics.......
What are the factors that influence patient compliance?
1. Sociodemographic characteristics of patients such as age, gender, education, and social class are not reliable predictors of compliance behavior. 2. Patient knowledge of the disease or illness that has prompted the instructions does not accurately predict compliance. For many years, clinicians and social scientists believed that compliance rates could be increased by creating better-informed, more knowledgeable patients. However, many noncompliers are very knowledgeable about their condition but still choose not to follow instructions. 3. The seriousness of the patient's disease or illness is not strongly related to compliance behavior; that is, more seriously ill patients are not more likely to be compilers. 4. The complexity of the medical regimen does influence compliance behavior. More complex regimens (e.g., medications that must be taken several times per day in restricted situations for a long period of time) are less likely to be fully followed than simpler, more short-term medication orders. 5. The most important factor affecting compliance is the extent of change required in the patient's life. Regimens that require significant life change (e.g., a major change in diet, a significant increase in exercise, and a significant reduction or elimination of alcohol or tobacco products)— especially those that require giving something up as opposed to adding something— are least likely to be followed.
HW-Chapter 13: How differently were black men and women treated from other patients who contracted TB and HIV? Discuss two examples of unethical treatment that criminalized this vulnerable population. Use at least two concepts from related text chapter (2) (WL) to relate to these examples.
1988-April 1991: New York City health commissioner ordered 33 TB patients to be held in hospitals against their will until they were no longer infectious; 79% of them Black; Black more frequently presented as vectors of disease posing a threat of infection to whites. Blacks can be detained by hospitals for having TB; individuals can be Jailed for having tuberculosis; Locking up patients was often last resort but procedures weren't in place so this option was used more often. HIV: white gay men were first associated with HIV/Aids, but weren't as scrutinized as much for it; later started affecting blacks; news outlets showed that it affected Blacks/Hispanics more than whites, labelling them as potential carriers; Orphan children with HIV became testers of drugs (many black), but couldn't give/refuse consent since they have no parents If the children in the HIV study refused to take the drugs they were tied down and forced to take them against their will for study sake; From then on the the drugs were directly injected to their intestines; Many blacks on medicaid could not afford the AIDS medicine; Medicaid was not able to provide the high amount needed for people so in a sense poor people were shielded from this important drug. lack of confidentiality when reporting who had HIV
Surrogate motherhood
3rd party female carries the baby that is hers genetically.
What is the number interpreter requests that CPH gets each month?
400-700 per month
Video clip 20/20 on how end of life becomes medicalized.
55 billion in medicare in one year for last two months of a person's life. 20-30% of these expenses had no real impact on health. 18-20% of americans spend last days in ICU. Costs around $10,000 a day to maintain a patient in the ICU. Most americans say they want to die at home, but 75% die in hospital or other facility
What are the key dimensions of the physician-patient relationship?
A model of the physician-patient relationship must acknowledge that differences exist among physicians and their patients about what should occur within the relationship Three key dimensions: The appropriate model of _health (biomedical or biopsychosocial)_ The primary __ethical obligation __of the physician The extent of commitment to and realization of genuine __therapeutic communication__
Principlism
A system of ethics based on four principles: Autonomy, Beneficence, Non-maleficence, & Justice. Morality is fully codifiable • Autonomy—the right of competent individuals to be self-determining • Beneficence—the commitment to doing good for others • Nonmaleficence—the commitment not to harm others • Justice—fair distribution of social benefits and burdens
Tarasoff case: What are the laws pertaining to the obligation to treat?
AMA: 1847- establishing duty to treat 1912- "provide appropriate patient care, except in emergencies, be free to choose whom to serve" American common law- "no duty rule" doc is not obligated to treat in the absence of a prior contractual agreement or doc-patient relationship BUT, EMTALA: Emergency Medicine Treatment and Labor Act Hospitals that accept medicare must provide assessment and treatment to emergency cases without regard to citizenship, legal status, ability to pay (COBRA) Consolidated Omnibus Budget Reconciliation Act Medical Codes Hippocratic Oath- unclear whether it specifies an obligation to treat The AMA's Code of Medical Ethics- conflict between the "duty to face danger" phrase in the "free to choose" phrase 1986 reaffirming treating contagious patient and offering a method of exemption to doctors Backlash from other medical professionals and public 1987 AMA swayed to duty to treat but still gives option "incompetent ro treat" GOES from "must" to "want"
What is the Parsonian model? Which sociological perspective was Parsons an adherent of, and how might that have affected his perspective?
According to Parsons, the physician-patient relationship is inevitably (and fortunately) an asymmetrical one. Parsons believed that three circumstances dictated that physicians play the key, powerful role within the dyad and govern the relationship with patients. 1. Professional prestige. This is based on the physician's medical expertise, years of training, and the societal legitimation of the physician as the ultimate authority on health matters. 2. Situational authority. It is the physician who has established the medical practice and is offering her or his services to patients who have admitted their own inadequacies by soliciting the physician. 3. Situational dependency. It is the patient who has assumed the role of supplicant by seeking out service, scheduling an appointment, often waiting past the scheduled time, answering the physician's questions, and allowing an examination to occur. Throughout each encounter, the "competency gap" between physician and patient is highlighted as the patient is dependent on the physician and the resources of the physician's office. Functionalism, overstated the "mutuality of interests" between doc and pts
Health Insurance Portability and Accountability Act (HIPAA)
Act of 1996 - Significant restrictions on information sharing
What was the change in the 2010 census that addresses the issue of race/ethnicity identification?
Allows people to write on a line to add detail about their origin, tribe, or race Prevent from selecting "some other race"
What is the difference between cultural humility and cultural competence?
Cultural competence: Belief that differences are valuable and change is necessary and positive. You can never be culturally competent because you can never be fully aware of what other people might be experiencing. Cultural Humility: Awareness of personal biases and you listen rather than assuming Cultural humility (knowing you don't know everything) Cultural competence (knowing pieces of different aspects of culture) **competence is knowing a lot about the culture, but you are never an EXPERT, always more to learn (If you think you know a lot, you may lose a lot of info)
The concept of autonomy makes three key assumptions:
An autonomous person is able to make rational and competent decisions following contemplative thought. People who are incapable of acting autonomously include those who are too young, or who are severely mentally retarded or have some significant mental disability, or who are coerced or unduly pressured into a decision by physicians or other health care professionals or, more commonly, by family members—"You have the surgery or the kids and I are leaving." 2. A second assumption is that an action does not cause harm to others. The freedom of any individual to act stops short of causing harm a to another; a decision to harm another incurs no obligation of respect. Patients do not have the right to demand that physicians or other health care professionals violate a personal or professional moral code. For example, patients cannot make an unrestricted claim on some scarce resource (such as demanding a liver transplant). This assumption was clearly expressed in the Elizabeth Bouvia case described in the accompanying box "The Case of Elizabeth Bouvia."
What is Jinn?
An intelligent spirit of lower rank than the angels, able to appear in human and animal forms and to possess humans.
What is the principle of autonomy?
Autonomy - assumption of patient __rationality and competence__ (patient has ability to make decisions about their overall health), protection of others from harm, and limitations on patient claims on practitioners
Tarasoff case: What are the grounds for breaking confidentiality?
Benefit to patient -principle of beneficence (disclosure effect to protect and promote patient needs) Conflict with reasonable rights of an innocent 3rd party Danger or threat to rights or interests of society in general (potential for spread of disease or injury to society)
Describe the Veatch model.
Captures the moral relationship between physicians and patients. There are four possible relationships that can occur, engineering model, priestly model, collegial model, and contractual model _Priestly Model__Hippocratic oath, doctor makes all decisions, patient as illness not person, medical model driven—patient gives up moral authority __Engineering Model___decision making shift to patient, doctor implements decision—skilled professional able to carry out tasks—doctor gives up moral authority (medical care a commodity to be bought) _Collegial Model__: both doctor and patient are colleagues pursuing a common goal. Equals __Contractual Model___: mutually agreeable contract and sharing of decisions allows for both to retaining their moral integrity
Which sociological perspective was Parsons an adherent of, and how might that have affected his perspective?
Functionalism, overstated the "mutuality of interests" between doc and pts
Describe gender stereotyping.
Health-related stereotypes of women: Higher levels of emotional illness and instability Exaggerate medical symptoms More demanding patients Demand excessive physician time Gender bias in management of coronary heart disease - women receive __less treatment__
Gender stereotyping
Higher levels of emotional illness and instability -Exaggerate medical symptoms -More demanding patients -Demanding excessive physician time (Gender bias in management of coronary heart disease - women receive less aggressive treatment.)
Priestly model
Hippocratic oath, doctor makes all decisions, patients as illness not person, medical model driven - patient gives up moral authority. While the patient provides full and open information to the physician & feels free to ask Hippocratic oath, doctor makes all decisions, patient as illness not person, medical model driven--patient gives up moral authority
Define persistent vegetative state.
In PVS the patient is not conscious, is irretrievable comatose, is nourished artificially, but is respirating on his or her own. This happens when brain stem is functioning but the cerebrum is not
Health literacy
Increase pathways to patient activation. Only about 12-13% of US adults are proficient in health literacy. ⅓ have difficulty understanding handouts and medical directions.
Strong market approach
Individuals or next of kin would be able to auction organs to the highest bidder.
HW-Chapter 14: Discuss the use of deception and lack of consent used by AbioCor corporation and the use of PolyHeme to move to forward with advancement of these types of medical technology. Use at least two concepts from related text chapter(s) (WL) to relate to these examples.
James Quinn -- only 52 at death; was implanted with an artificial heart; doomed for heart failure and was told this was his last chance at a meaningful life; also told it was going to make him freely mobile; Lived with the artificial heart for 9 months; post surgical life was overrun by pain, disappointment and despair; suffered many strokes as well; everything was experimental and it was not explained well to the Polyheme was administered to those at random from accidents in the ER without their permission. Many of the cases human blood could be administered to save lives as this was still experimental. Many of those who were involved in this random study were African Americans. People who were given this observed a 49% higher death rate. Concepts: informed consent, activity-passivity model
Tarasoff case: Define confidentiality and its limits.
Knowledge shared by the physician and patient and not with others Three Factors: 1) Privacy - freedom from unauthorized intrusion into one's life 2) Privileged communication: legal term related "testimonial compulsion" 3) Professional secrecy - exempt from "testimonial compulsion"
What the general barriers to working with patients from culturally different communities?
Lack of culturally and linguistically appropriate health services Lack of knowledge of services that are offered Legal status → fear Lack of health insurance Childcare Transportation
What are machismo, respeto, familismo, personalismo?
Machismo: Masculinity Respeto (respect): Mutual regard that develops between Latinos and others Familismo (family): Contribution of the extended family Personalismo (personal): Importance of close personal relationships
Confidentiality
Maintenance of confidence in the face of the need for disclosure (1) knowledge shared by the physician and patient and not with others (2) Privacy - freedom from unauthorized intrusion into one's life (3) Privileged communication: legal term related "testimonial compulsion" (4) Professional secrecy - exempt from "testimonial compulsion" 14 yo goes to doctor without parental knowledge; can doctor treat? Answer → YES (Can see mental health counselor for short treatment process (limited sessions)) If it becomes clear that the 14 yo is severe or if there is abuse (sexual, physical, etc), counselors will report to protect 14 yo
Casuistry
Moral rules come from particular cases and determination of whether particular actions are "moral" or not come from the nature of the case itself.
What is the sociological explanation for compliance behavior?
One explanation locates the problem within the communication process between physicians and patients— that is, noncompliance results from inadequate or poorly communicated information from physician to patient about the nature or rationale of the regimen (in particular) or in the lack of physician-patient rapport (in general). A second explanation traces noncompliance to the health beliefs of the patient. Some research has found that compliance is more likely when the patient feels heightened susceptibility to the disease or illness, the condition is believed to negatively affect daily functioning, and the medical regimen is considered to be an efficacious method of deterring or eliminating the health problem. When views between physicians and patients on these beliefs match, compliance is higher Third, Peter Conrad (1987) has suggested that noncompliance be viewed as a matter of patient self-regulation. Rather than viewing noncompliance as a matter of deviance needing correction, this view sees noncompliance as a matter of patients tailoring their medical regimens to their lifestyles and life responsibilities.
Reading #5: Preference for Same-Race Health Care Providers and Perceptions of Interpersonal Discrimination in Health Care*
Overall, the belief that discrimination is frequent in different-race doctor-patient dyads is associated with greater preference for a same-race provider However; the belief that discrimination occurs regardless of a doctor's race reduces preference for a same-race provider Finally, general perceptions of discrimination are distinct from concerns about personally being treated unfairly, and low personal concern about unfair treatment reduces preference for a same-race provider among those who believe that interpersonal discrimination occurs frequently. These results suggest a complex picture of how perceptions of discrimination influence preferred race of health care provider among blacks in the United States.
Explain the biopsychosocial model.
Patient is someone with symptoms that may have root in biological body, but also something stimulated by psycho and social factors (how the live, where, SES, etc) Half of patients present __psychosocial issues__, not just medical ones Patients __want discussion__- Hesitant to bring up these issues Physicians not good at _detecting psychosocial___ Not: _related to "disease", their role, not trained__ Response? Team based model The quiet revolution
Freedom from information
Patient's right not to know information (e.g. patient's @ end of life may refuse information/notifications) In Chinese culture this can be quite prominent
Define informed consent.
Patients must be given all relevant information regarding their condition and alternative treatments (1) Competent/rational - give patients all relevant information so patient can make choice (2) All information must be given (good AND bad, alternatives) (Hard for doctors because they want the patients to be hopeful) (3) Patients must understand information (4) Consent must be voluntary Factors impacting information gathering and decision making should be minimized Braddock et.al. (1999): audio tapes of doc and patients 9% of decisions made were complete through informed consent Doctors ASSUMED informed consent - made decision and just expected patient to acquiesce Patients that assert themselves and initiate their participation make up a lot of 9%
Cultural health capital
Patients who demonstrate health literacy and an understanding of scientific rationality, who communicate in a medically intelligible and efficient manner, who take a proactive stance toward their health, who value self-discipline and who reflect social and economic status are rewarded in medical encounters by more attentive and invested physicians This is the attitudes, behaviors, and interactional styles that people have to one degree or another. Physicians may relate better to individuals with more cultural health capital. There is an unconscious bias against black patients by white physicians.
What might be the issues in working with an interpreter in the medical setting?
People might not want to discuss medical matters through a 3rd party. There is also the availability of the interpreter.
How is death defined?
Permanently nonfunctioning whole brain (cerebrum and stem), including no reflexes, no spontaneous breathing, no cerebral function, and no awareness of externally applied stimuli (Harvard Medical School, 1968)
How do race, social class, and symptomology impact the physician-patient relationship?
Physician difficulty connecting with patients with (end of life, psychotic with pain not being able to measure or see it, pain in general, : Little hope _for cure___ _Devalued lifestyles__ Vague, _difficult to describe symptoms__________________ Symptoms having a ___psychosocial____________basis ___lower-class patients__- physicians hold stereotypes (level of knowledge, afraid of suing) More anxiety and frustration working with lower-SES populations Black patients - _many culturally-sheltered white physicians__- feel discomfort working with black patients Study: Penner of cancer institute: Effects: implicit bias impacts on oncology care for black patients: 18 non black oncologist with patients who has signs of cancer: doctors took implicit bias test and a few weeks later started seeing patients. They found bias regarding amount in time with each patient, doctors interest with each patient. Doctors who had racial bias spent less time with black patients and less likely to show symptoms and being supportive. Patients themselves who had bias doctors also rated doctors as poor and not as trusting. Study: "Racial Bias May Be Conveyed By Doctor's Body Language" Dr. Barnato et. Al. 33 ER docs, internists (majority white) Actors (Black and white) with comparable med conditions with forms of end stage cancer(docs unaware of trial purpose) Verbal and nonverbal responses (scored 7 points less on non-verbals with black patients) Believe in Black and Latino non compliance Unconcious bias Doctors might engage better with patients who have cultural health capital Race between patient and doctor: Race concordance yields greater satisfaction More likely to be race concordant if choice is available Services more likely to be used when race concordant and less likely to delay or postpone care
Dependent patient
Physicians are linked to patients in ways that extend beyond an explicit or implicit contract - Patients with stigmatic diseases - Doc: rewarding work, 60% report patient gratitude, 57% intellectual challenge, 30% desire to serve the under-served
Noncompliance
Physicians believe that they give sufficient information and rationals information to patients to comply with medication. Noncompliance is seen as an irrational response by the patient.
Social contract
Physicians have an obligation to treat the sick and vulnerable in exchange for the discretionary power they have been given over the practice of medicine.
Technological determinism
Power and deterministic effect on culture and social structures
Technology
Practical application of scientific or other forms of knowledge can save lives but makes medicine more expensive and create ethical issues
What usually comes to mind when people think of culture? What are the often "hidden" aspects?
Surface vs. deep Surface: food, literature, performance Deep: communication styles and rules; concepts of time; fairness and justice; rules about age, sex, gender
Patient centered care
Respectful/responsive to the needs of the patient - preferences in clinical relationships
What are the barriers to therapeutic communication?
Setting of the medical encounter_- hospital/office setting discourages comfort _Length of the medical encounter_- abbreviated time discourages open exchange: average time is about __20__ minutes (1992 about 70% were _15___ minutes 2010 only about ½ were 15 minutes) _Mental state of patient__- anxiety increases discomfort and distracts from exchange process _Mismatched expectations_- patient seeks psychological reassurance; physicians seeks clinical diagnosis _Language Barriers__- non-English speakers frequently not proficient in communicating with physicians 35 million plus bilingual with many not fluent in English Use of medical jargon...patient might not understand the terminology Columbus fields 400 to 700 interpretive language requests (language barriers) Physician communication style__- physician abruptness/condescension __Interrupt patients__ Marvel. Et.al 1999—doctors interruption of patients Standing over patient Spatial distance/reinforcing social distance__ " control style"__ Beckmann and Frankel (1984) Doctors didn't allow patients to complete opening statement (69% of visits) Baker, Yoels and Clair (1996) only 20% of patients statements of anxiety were responded to Males more likely to interrupt; docs ask most of questions; patients invites laugher more often—with no response "_Affiliation style"_genuine, friendly, openness, non-judgmental
What is the guidance-cooperation model?
Szasz and Hollender view this form of interaction as typical of most medical encounters. The patient is acknowledged to have feelings, may be alarmed by the medical problem, and has certain hopes and aspirations for the outcome of the medical encounter. Compared to the activity-passivity model, the patient has increased involvement in providing information and making decisions with regard to treatment. While the physician is still in charge and has responsibility for guiding the encounter, the cooperation of the patient is sought.
Tarasoff case: Know some of the outcomes of the cases discussed in class (docs and vaccinations, reporting gun shot, etc)
The God Committee- 1961-1962 created procedure tried to manage treatment for kidney disease, Seattle, selected 7 people from community to be representative, minister, baker, housewife, labor leader, state official, attorney, Cost of Dying 55 billion dollar in medicare last 2 months of life , 60% die in acute care 20-30% of medical expenses had no meaningful impact, no questions asked Costs 10,000 a day to maintain a person in ICU 18-20% of americans spend last days in ICU 75% die in hospitals, 83% of hospice paid for by medicare, 4% by medicaid, 8% private insurances Public opinion supports PAS: Gallop poll 68% Americans, 7 in 10 support it
Encouraged voluntarism
The UAGA permitted adults to donate all or part of their body after death through donor cards and living wills and gave next of kin authority to donate after an individual's death, as long as no contrary instructions had been given.
Situational dependency
The patient is the one who has assumed the role of supplicant by seeking out the doctor, making an appointment, and allowing an examination to occur.
Situational authority
The physician is offering services to patients who have admitted their own inadequacies by soliciting the physician
What is the principle of beneficence?
While the general meaning of the concept is to promote goodness, kindness, or charity, in the medical context it refers to physicians taking whatever actions— for example, surgery or prescribing a medication— that are considered to be in the patient's best interest.
Activity-passive model
The physician represents medical expertise, controls the communication flow between the two parties, and makes all important decisions. The patient is the supplicant, regarded as lacking in important information and necessarily relying on the knowledge and judgment of the physician. The relationship is akin to that of a parent and infant in which the parent takes actions without need of explanation. Patient unable to respond, doctor does something to patient
Reading #4: The doctor and nurse relationship: how easy is it to be a female doctor co-operating with a female nurse? Elisabeth Gjerberga, et. Al.
The results show that in the experience of many doctors, male and female, the doctor-nurse relationship is influenced by the doctor's gender. Female doctors often find that they are met with less respect and confidence and are given less help than their male colleagues. The doctors' own interpretation of this is partly that the nurses' wish to reduce status differences between the two groups affects female doctors more than male, and partly that there is an "erotic game" taking place between male doctors and female nurses. In order to tackle the experience of differential treatment, the strategies chosen by female doctors include doing as much as possible themselves and making friends with the nurses.
Tarasoff case: Know the Tarasoff case and know how it relates to medical professionals.
The university, police, and Podder therapists did not inform Ms. Tarasoff that there was a threat against her life and unable to detain the person in question (even though Podder had indicated he was planning to kill Ms. Tarasoff). This led to her murder by Poddar and a lawsuit by her family against the university of California Berkeley in which the university was cleared but had to had to pay general damages for their failure to report the incident to the family or Ms. Tarasoff.
Tarasoff case: What are the laws pertaining to confidentiality?
There is no constitutional provision covering confidentiality of information shared with physicians. However, there are certain things physicians must report such as TB, gunshot wounds, STDs, and suspected abuse against children. Health Insurance Portability and Accountability Act of 1996 (HIPAA): protect privacy of patients American Recovery Act of 2009: reports about breaching of personal health information The Health info Technology for Economic and Clinical Health Act (2013): Encourage medical facilities to strength data security
Professional prestige
This is based on the physician's medical expertise, years of training, and the societal legitimation of the physician as the ultimate authority on health matters.
Paternalism
This is when a physician overrides a patient's wishes and takes actions presumed to be in the patient's best interest, but is unwanted by the patient. Overriding patients wishes When "best interest" is unwanted by patient
Explain the Szasz-Hollender model.
This model argued that Parsons model gave too little attention to the important influence of physiological symptoms, and they developed their own idea about the physician-patient relationship which includes 3 models, the Activity-passivity model, the guidance-cooperation model, and the mutual participation model.
What is the activity-passivity model.
This model closely parallels the asymmetrical relationship described by Parsons. The physician represents medical expertise, controls the communication flow between the two parties, and makes all important decisions. The patient is the supplicant, regarded as lacking in important information and necessarily relying on the knowledge and judgment of the physician. The relationship is akin to that of a parent and infant in which the parent takes actions without need of explanation.
Ovum donation
This procedure can occur in any one of three ways: (1) transfer of a donor's egg to the woman's fallopian tube followed by sexual intercourse, (2) in vitro fertilization of a donor's egg with the male's sperm followed by insertion in the woman, and (3) artificial insemination of an egg donor with the male's sperm producing fertilization and then washing the embryo out of the donor and transferring it to the woman's uterus.
How does gender affect the physician-patient relationship?
Three ways Doctor's gender influences the relationship: Systematic differences between male and female physicians in _personality, attitudes, or interpersonal skills__ Many aspects of practice style unaffected by gender (eval, dx, # of hospitalizations; coping with and caring for dying and bereaved Differences: _females__better communication skills, more patient time, more egalitarian More sensitive to women's issues Alternation of the expectations that__patients bring to the encounter _1/3 - 1/2__have gender preference Self-fulfilling prophecy See what they want to see in the _"nurturing" doctor__- . Alteration of the __"status relationship" between physician and patient___ Gender status congruence could influence rapport and patient participation Satisfaction of male patients _unrelated to gender_____
Benevolent deception
When a physician lies to a patient because it is believed to be in the patients best interest.
Tyranny of the gift
When the donation and transplant occur, a type of "obligation to repay" is incurred by the recipient. Having received something so profoundly important, the recipient becomes, in a sense, a debtor—owing something back to the donor (Shaw, 2010). Fox and Swazey (1978) referred to this as the tyranny of the gift.
Fetal tissue transplants
a surgical procedure in which tissue from an aborted fetus is grafted into a patient to replace or improve defective tissue, especially to treat Parkinson's disease or other neurological disorders.
Living will
a written statement detailing a person's desires regarding their medical treatment in circumstances in which they are no longer able to express informed consent, especially an advance directive. is a document signed by a competent person that provides explicit instructions about desired end-of-life treatment if the person is unconscious or unable to express his or her wishes.
Advance directives
a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor.
What is autonomy?
assumption of patient __rationality and competence__ (patient has ability to make decisions about their overall health), protection of others from harm, and limitations on patient claims on practitioners
Cultural competency
awareness and knowledge of cultural differences that impact understanding, trust, bias, and stereotyping _New Jersey first to require cultural competence for license__
Collegial model
both doctor and patient are colleagues pursuing a common goal. Equals
Karen Ann Quinlan
brain injured woman whose parents wanted to disconnect the artificial ventilator but the hospital refused (Removed from ventilator after NJ supreme court granted guardianship to father and concluded that patients have the right to privacy and the right to refuse medical intervention (competent and incompetent patients) Remained in PVS for 10 years before her death
Strong presumed consent
hospitals would remove all organs regardless of family's consents.
Weak market approach
individual or family would receive a tax break for organ donation.
Brain death
irreversible brain damage causing the end of independent respiration, regarded as indicative of death.
Biopsychosocial model
is a broad view that attributes disease outcome to the intricate, variable interaction of biological factors (genetic, biochemical, etc), psychological factors (mood, personality, behavior, etc.), and social factors (cultural, familial, socioeconomic, medical, etc.). Patient is someone with symptoms that may have root in biological body, but also something stimulated by psycho and social factors; have to judge social setting where they live/how they live etc. Half of patients present psychosocial, not just medical ones Patients want discussion but hesitant to bring up these issues (B/C involves financial issues (may feel shamed), doctors may brush over patient concerns "just stop smoking" (not as simple)) Physicians not good at detecting psychosocial (if not taught and trained to) Not related to "disease," their role, not trained Response: team-based model
Autonomy
is a term derived from the Greek words for "self" and "rule, governance, or law." When applied to individuals, it refers to the concept of self-determination. Autonomous individuals are able to make their own choices and decisions and have them respected by others. Assumption of patient rationality and competence, protection of others from harm, and limitations on patient claims on practitioners Key -- informed consent
What is presumed consent?
is alternatively known as an 'opt-out' system and means that unless the deceased has expressed a wish in life not to be an organ donor then consent will be assumed.
Biomedical model
is essentially disease oriented or illness oriented rather than patient oriented. The key to effective medical care is believed to be correct diagnosis of some physiological aberration followed by proper application of the curative agent. Physicians seek to learn all they can about symptoms and abnormalities so that they can provide the appropriate "magic bullet." patient is seen as illness (devaluing patient because you see illness before patient/you just see them as a collection of symptoms.)
"Duty to face danger" phrase
it is unethical to refuse care to the sick or dying The AMA's Code of Medical Ethics - conflict between the "duty to face danger" phrase and the "free to choose" phrase Having to treat even if risky 1986: reaffirming treating contagious patients and offering a method of exemption to doctors 1987: AMA swayed to duty to treat but still gives option "incompetent" to treat Goes from "must" to "wants" Limit scope to their specialty (allowed them to not have to do certain treatments against their religion/beliefs)
Issues that might impact the doctor patient relationship in both communities?
lack of culturally and linguistically appropriate health services; a doctor may go to shake hands with a woman who won't want to make contact because of culture and the doctor may feel offended, etc language and literacy
What is the concern with medication use in both Latino/Somali communities?
lack of language and health literacy lack of education transportation
Contractual model
mutually agreeable contract and sharing of decisions allows for both to retaining their moral integrity
"Free to choose" phrase
no responsibility to treat if no prior contract patient-physician relationship exists
Mutual participation model
patient at center Doctor helps patients to help themselves (good communication) What might be the building blocks to this relationship? Good listener, communicator, motivational perspective (doctor will ask how do you want you communication to be handled (mail/email) Who do you want to be present when a doctor treats you How much information about the case do you want to know In which of the clinical decisions do you want to participate Chief criticism-Model best suits mature, educated patients
Informed consent
patients must be given all relevant information regarding their condition and alternative treatments _competent/rational________________ All _information (incl. alternatives) must be given__ must __understand the information____ ___consent must be voluntary_voluntary Factors impacting information gathering and decision making Braddock et.al. (1999): audio tapes of doc and patients _9% of decisions__made were complete through informed consent Patients that assert themselves and ___initiate their participation____
Weak required request
patients or their families must be notified about the option of organ donation and a request for donation is to be made.
What are some of the types of services that can add up to burn out for doctors, but increase patient connection?
phone calls prescirptions phone calls lab reports consultation High workload → spending a lot of time on patients (home visits, allowing calls at anytime even when the doctor isn't at work)
What's the difference between fee for service and value based payments
the biggest difference between fee-for-service and fee-for-value is reimbursement. In the former, providers get paid based on services, regardless of patient improvement. In the latter, reimbursement corresponds to patient outcomes. Patients matter in value-based approaches-throughout the healthcare system. Fee for service: Volume based $ per service Incentive to put hospital in areas with a lot of private coverage and many people since state insurance covers less than private insurance companies Value based payments: Payments tied to the quality of the care Use incentives to motivate higher value care Changing the way care is delivered through more teamwork and integration for more effective coordination and care of the patient More attention to population health
Genomics
the branch of molecular biology concerned with the structure, function, evolution, and mapping of genomes. examines the interaction of multiple genes together and in interaction with the environment.
Describe the biomedical model.
the conventional approach to medicine in western societies, based on the diagnosis and explanation of illness as a malfunction of the bodys biological mechanisms." This approach underpins most health professions and health sources, which focus on treating individuals and generally ignore the social origins of illness and prevention
In vitro fertilization (IVF)
the woman is given a reproductive hormone to stimulate her ovaries to produce multiple eggs.
