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4th semester 2006 Midterm 1 BS/Ethics Review

OUTLINE TOPICS ON EXAMS:

What I did: Here is the outline of the review. At the end of the review, is the complete review based on the outline. Good luck. I wish you the best.

50 questions:


40 behavioral science
25 BS made by Dr. Omar & 10 ethics Omar

Therefore 15 additional questions made by other professors.


Topics for medical ethics:

  • most are in clinical case scenario i.e. USMLE step 1

  • topics covered in 4 lectures:

    • are important: 5 lectures

  • apply that knowledge in clinical scenario:

    • introduction:

      • general principle of ethics

        • read it and the primary principles of ethics: and special issues we discussed: i.e. abortion, pediatric cases

    • malpractice:

      • what you can do to decrease your chances in being involved in malpractice cases

        • hand writing, and communication

      • the 4 D’s associated with malpractice

        • duty: deviating the duty or dereliction and cause damage and directly b/c the PT deviated from his duty

        • damage

        • deviation

        • dereliction

          • if someone cases against doctor, the physician was deviating his duty, caused damage, and deviated against his duty

      • DONALD COWART: involved with 3rd degrees burnt: and withdrawal of life support: but physician imposed treatment and the court and the PT has the right for their treatment and can refuse treatment if they are well oriented and know the consequences and he is a practicing lawyer: and what the physicians did was wrong.

    • Importance of Hippocratic oath: apply those point and read from different sources,

      • JUST READ THE POWERPOINTS and apply them.

    • DISCLOSURE: Tuskegee case: about syphilis and PT African American not provided with treatment: and filed against class discrimination

    • Importance of regulatory bodies:

      • AMA: American medical association and licensing body and THEIR ROLE!!!

        • i.e. GMC, AMA, American psychiatry association

        • focus on AMA and state licensing body

    • ABORTION: when the PT has the right for Abortion, what is the significance of the 1st, 2nd 3rd trimester

Termination of pregnancy
1st trimester: PT has right for abortion, regardless of reason


2nd trimmest: have right of abortion if it is not endangering their life:

3rd trimester: abortion is illegal, unless continuation will cause some threat for the mother

before 21 weeks, PT can go for abortion

After 21 weeks, PT cannot have abortion

  • this may be modified later on




    • Jehovah witness: SHOULD BE able to apply the information in clinical scenario: there were 4 or 5 examples: if they are wearing a bracelet or t-shirt: just read that.

    • ELEMENT OF CONSENT: of informed consent: prerequisites

    • Today we will cover two more cases:

      • ROE VERSUS WADE case

      • TYRELL DUECK case

Tyrel Dueck: 1999

  • Parents refused medical treatment for 13 y.o.boy

  • parents are in charged: GIVE THE treatment for the child,

  • refer it to a court

  • if you had this PT earlier: and the court decided earlier


ROE vs WADE:
-child may have meningitst: mom calls and says baby has meningitis: brief history of PT and symptoms, then maybe child may have meningitis:

meningoc cocus is important Neisir. Mengingitis and can cause skin rash:

  • ask about skin rash and orientation of child and symptoms

  • if life threating refer for emergency and do not advice for a RX

  • if child needs emergency RX refer to emergency, you can ask for a follow up

  • parents usually call 911, but if you are a family practitionare ask them to go to emergency

For behavioral science we will discuss those on Thursday; for BS


09-02-06 BS review tt1
There are 40 questions from BS:

What to focus on:

All 40 are not from topics, but most of them from the things I’m telling you: if you focus on this you’ll be alright
Doctor patient relationship: questions about what the right answer is to give patients and right response: briefly on history taking
KNOW THESE TERMS:

Transference:

counter transference

Illusion


delusion

hallucination

formation on how you would develop a rapport with your patient

what’s the meaning of these terms and significance of these terms: i.e. different types of dlusion and illusion and their significance
dr. gall: growth and development:

focus on developmental milestones: very important: interpret the age of the pt depending on the mile stone and the age and the findings and development of milestones


Tannis stage of development:: what stage has child reached: stage 1, 2 or 3: depending on findings of examination of extragenital: be able to differentiate the different stages
Learning theories and conditions:

Difference between operant and classical conditioning

Psychoanalytic theory and ALL THE DEFENSE MECHANISMS!!!

Should be able to differentiate: some examples and asked what defense mechanism is showing:

Then Freud’s theory: toprogialh and

Super ego, ego: what’s the difference between superego and ego,

What the difference is between conscious, unconscious

Differentiate between amnesia: i.e. mini status examination


Biological assessment of psychiatric PT’s:

Ie.. significance of CT scan, GCS (glascow scale) what are the scoring system:


Then aging death and bereavement:

Cobler Ross:

Stages of death and dying:

-she intervied many PT what the response wherei ie.. denial, anger, bargaining, how you would differnetiatewhether they are grieve or major depression and focus on the class i.e.major depression i.e. committing suicide and different between grieve and major depression.


How you manage a person or person: loved one died in family: what support you can provide for those circumstances
Gorss anatomy and biochemistr y and behaviour: focus on anaomtical difference based on gender: in CNS: if you do a CT scan: anatomically differences:

Maybe few neurotransmitters that play an important rule in psychiatry

-role of neurotransmitter
brain lesion: depending on portion of scar and cerebral hemisphere: i.e. frontal lobe lesion, parietal, or occipital lesion, what are the findings.
Mini mental status examination:

Mental status examination:


What is the significance of a MMSE: why do we do it? And what is the significance if it’s impaired…!!!
How do you differentiate between dementia and pseudodementia
Then sleep:

EEG is very important: asked what are the finding in different cases of sleep: REM, nonREM sleep what are the phases, what are the EEG finding?

What are th changes that do occur that correspond to the phases of the sleep: i.e. REM, PT may move eyelids: i.e. excitation of body, palpitations, bodily changes that occur
Pathology:

All the disorders discussed by DR. Gall: i.e. sleep disorders


You can leave CFS and Neurostamia:

I WILL BE SUCCESSFUL


NOW FOR THE REAL COMPETE REVIEW

Topics for medical ethics:


  • most are in clinical case scenario i.e. USMLE step 1

  • topics covered in 4 lectures:

    • are important: 5 lectures

  • apply that knowledge in clinical scenario:



    • introduction:

      • general principle of ethics

        • read it and the primary principles of ethics: and special issues we discussed: i.e. abortion, pediatric cases

Definition of clinical ethics-
Clinical ethics is the systematic identification, analysis and resolution of ethical problems associated with patient care. Its goal includes protecting the rights and interests of patients, assisting clinicians in ethical decision making and encouraging co-operative relationships among patients and those close to patients, clinicians and health care institutions.

Introduction & principles

Medical Ethics

Course objective

• Intended to develop a knowledge base of

the basic legal & ethical principals which

govern practice in the USA.

• Review established legal parameters in US

court system & engage student in a personal

debate over issues which physicians face

daily.

• Issues: death,dying, end of life care, living



wills, power of attorney, malpractice

• Medical insurance & hospital based

committee which insure physician & patient

protection from abuse

• Series of cases reviewed which throughout

history have added to the practice

guidelines in place today

Defining clinical ethics

• Clinical ethics is an interdisciplinary

activity to identify,analyze, & resolve

ethical problems that arise in the care of

particular patients (Fletcher,1991)

• Jonsen(1998),LaPuma(1990)

Introduction

• A set of principles guiding a person in his/her

professional decision Making

• Moral is personal and Law is social; Ethics is

between the two

• Law prescribes restriction on behavior; Ethics is

enhancement of appropriate behavior

• What is legal not always ethical and vice versa

• Hippocratic Oath


Medical ethics

• More traditional term than CE

• Ambiguous though
• ME-May refer to rules of conduct of the

formal bodies of medical profession(AMA).

E.g. ethical dilemmas confronting Dr’s -like

decision on the point to cease life-sustaining

measures for dying patients

Clinical ethics

• Similarly, this term which is an outgrowth

of ME can refer either to uncontroversial

codes of conduct governing all clinicians or

to ethical dilemmas.


Advent of Medical ethics

• Hippocratic Oath- dates back around 2,500

yrs ago

• Historical purposes but not technically

binding

• Is for physicians- to guide behavior

• Graduations

I solemnly pledge myself to consecrate my I solemnly pledge myself to consecrate my life to the service of humanity;

I will give to my teachers the respect and gratitude which is their due;

I will practice my profession with conscience and dignity;

The health of my patient will be my first consideration;

I will respect the secrets which are confided in me, even after the patient

has died;

I will maintain by all the means in my power, the honour and the noble

traditions of the medical profession;

My colleagues will be my brothers;

I will not permit considerations of religion, nationality, race, party politics

or social standing to intervene between my duty and my patients;

I will maintain the utmost respect for human life from its beginning even

under threat and I will not use my medical knowledge contrary to the laws

of humanity;

I make these promises solemnly, freely and upon my honour.
Special Issues

• Physician- Patient sexual relationship

• AIDS risk/testing/etc.

• Advertising

• Fee Splitting

• DNR


• The impaired physician

• Resource allocation

• Conflict of interest

Research related problems





    • malpractice:

      • what you can do to decrease your chances in being involved in malpractice cases

        • hand writing, and communication

      • the 4 D’s associated with malpractice

        • duty: deviating the duty or dereliction and cause damage and directly b/c the PT deviated from his duty

        • damage

        • deviation

        • dereliction

          • if someone cases against doctor, the physician was deviating his duty, caused damage, and deviated against his duty

malpractice and 4 D’s associated with malpracticeDereliction or negligence [i.e. deviation from normal standards of care], duty (established patient- physician relationship that causes damages), damage (i.e. injury), directly to the patient [i.e. the damages were caused by the negligence, not by another factor.
Legal Issue: Malpractice

Malpractice

•Definition

•Features/Facts

Malpractice Insurance Crisis

•Consequences

•Solutions

•Avoiding Litigation

•Establishing a Duty of Care

•Emergencies & Non-Patients

•Medical Student Liability



Malpractice: Any deviation from accepted

medical standard of care that causes harm to a

patient.

(4 Ds) of Malpractice

•Duty

•Dereliction

•Damages

•Directly

Key Elements of Malpractice

1) Duty of care: Was there an established

physician-patient relationship?

• What actually creates a PPR– having seen

the patient? Scheduling the patient? Giving

advice about a patient who you’ve never

seen?


2) Dereliction of Duty (negligence): Was there

a deviation from the accepted medical

standard of care?

• need testimony from expert witnesses to

establish current medical custom (i.e., the

quality of care expected of reasonable

practitioners in similar circumstances)

• often must bring in expert from another

community (this can become expensive)

• ethical obligation to participate if asked



3) Damages: Was there harm to the patient?

4) Direct (causation):

Was the harm directly due

to the physician’s dereliction of duty?

(not all adverse outcomes indicate

malpractice— need to show that damages

resulted from negligence)



��If any of 4 Ds are not proven, then there

is no judgment of malpractice.
Features/Facts of Malpractice Cases

Features of Malpractice cases

•malpractice is a tort (i.e., a civil wrong



resulting in personal injury)

•results in financial costs (not jail time):

compensatory damages (including

actual costs & “pain and suffering”)

& sometimes punitive damages.

•Malpractice cases are increasing



(more informed, less tolerant pts.)

•44,000-98,000 deaths/yr due to

medical mistakes

Common reasons for suits:

•Improper dx, failure to dx or to

reveal dx

��Surgical error

��Lack of informed consent

��Medication errors (wrong

prescription, dose, etc.)



1500 pts/yr with tools

Boston Globe Health

Columnist, died of

chemo OD, ‘94

•Surgeons, anesthesiologists & OBGYN

most accused of malpractice

•States are passing legislation to make

malpractice history public knowledge

National Practitioner’s Data Base:

Confidential list of suits that have

resulted in jury awards or $ settlements

Facts about Medical Malpractice Cases

•Time Involved: 1-2 years to resolve a case

•Typical Cost: $40,000-$75,000

Mediation: A settlement conference often

occurring before a trial. Many cases are settled

out of court in this manner.



Medical Malpractice Insurance Crisis

Rates have increased dramatically in the



last few years (rate depends on specialty and

location) – rates range from $5,000/yr to

over $200,000/yr.

Due to:

•Large number of suits

•Large jury awards

Example:

Across the U.S.

•Median jury award in 1999 was $800,000

•45% of awards from ‘98-’99 were $1

million or more

Solutions to Crisis?

1) capping non-economic

damages to $250,000 (known

as “tort reform”)

argument that still want ability



to award large sums if an

egregious error was made

(physicians are striking in various

states in protest of rising premiums–

hoping to catalyze tort reform) Jessica Santillan, heartlung

transplant patient

(wrong blood type)

How to Avoid Malpractice Suits Why do some patients sue after adverse

outcomes and other don’t?

��Depends on the quality of the PPR

(communication and trust)

��For an optimal PPR, physicians need to:

•Convey information at patient’s level of

understanding

•Check patient for understanding

•Show emotional affect (empathize)

•Follow-up (be available, keeping informed if

prolonged situation)

•Discuss problems thoroughly (explain why

adverse outcome occurred)

��Honesty is supposed to reduce likelihood of

being sued

��Important Note:



Documentation: Essential to demonstrate

that care was given. Defense cases are often

compromised due to inadequate

documentation (re: phone calls, consults)

��“if it wasn’t documented… ”

Example case: patient denied informed

consent about procedure, but medical records

had proof that sketch was given.

10

• Communication.

Acronyms

• SOB


• MS

• Acronyms.

• FLK

• GOK


• OAP

• TF BUNDY

11

Establishing a Duty: When does a



physician-patient relationship exist? Do informal consults create a PPR?

Case: Professor lectured to hospital-based

physicians and subsequently gave surgical

advice regarding patient

•professor sued treating physician and

professor for malpractice

Was there a PPR with the professor?

•Court said NO

•No direct contact, no control over treating

physicians

12

Courts have generally ruled that consulting



physicians are NOT liable for subsequent

harm, even if treating physician relied on

negligent advice of consultant.

(liability does exist if consulting physician

accepts a referral, writes orders, or

provides treatment to the patient)

Does acceptance of a referral create a



PPR, even if physician never saw patient?

Case: Physician saw pt in ER

•X-ray showed malignant neoplasm in knee

•Surgeon referred patient to orthopod but

didn’t tell patient the diagnosis

•orthopod was told the patient’s diagnosis and

accepted referral

•pt cancelled appointments (x3) and patient

refused to reschedule

• Pt died— malpractice suit filed by estate

Was there a PPR with the orthopod?

•Court said Yes!

•PPR began when accepted referral and

scheduled patient

•How could have orthopod discharged his

duty?

13

Does having a patient drop-in to your



private-practice office create a PPR?

Case: man brings newborn baby with

respiratory problems into private practice

•physician refused care but referred to peds

hospital

•baby died, lawsuit followed

Was there a PPR?

•Court said “no”

•“A physician is not to be held liable for

arbitrarily refusing to respond to a call of a

person even urgently in need of medical or

surgical assistance provided that the PPR

does not exist at the time.”

Does a PPR exist with a patient who was

referred by a 3rd party for the examination?

(insurance companies, employers, Workers’

Compensation Boards)

14

Case: Pt referred by insurance co. to internist



after woman applied for disability benefit

•Hilary mass on X-ray was found and reported to

insurer but not to patient (or patient’s

physician)– just employer.



Did a PPR exist between the patient and the

examining physician?

Court said No! Physician’s duty was only to the

agency that requested the evaluation.

General: performing an exam at the request of a

3rd party generally does NOT establish a PPR.

However, if a physician offers medical advice or

treatment beyond the scope of the 3rd-party

exam (thus acting as a physician with an

expectation of treatment by the individual), then

courts have found the physician liable.

This trend is changing, as per more



recent court decisions in which PPRs are

considered to be established during 3rd


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