Category Archives: Generic

Fairness

Ethics, Generic

Raanan Gillon campaigned successfully for fairness to be added to the World Medical Association’s International code of medical ethics (with respect to both patients and professionals).

It therefore joins beneficence, non-maleficence and respect for autonomy as one of the cardinal principles (Beauchamp and Childress).

What fairness means is debatable, however. And these different principles can conflict.

But it still has value as a way of analysing ethical problems. Hopefully in advance of the problem becoming real for someone.

Aristotle’s theory of justice or fairness is a good place to start – “equals should be treated equally” is straightforward, but it also includes “unequals should be treated unequally, in proportion to their inequalities). In other words, some people may need to be treated differently (“unequally”) because they need the treatment more.

Circumcision

Ethics, General paediatrics, Neonatology, Sociology, Surgical

Still routine practice in many parts of the world, including the USA. Last figures I can find suggest 56% of US boys circumcised, with higher rates among non-Hispanic white boys, which is down from previous decades.

The Royal Dutch Medical Association declared in 2010 that male circumcision as routine practice or for religious reasons is medically unjustified and therefore an abuse of the rights of the child.

In 2013 the Children’s ombudsmen of the Nordic countries proposed a ban. In Sweden it is illegal in the first 2 months of life, following a death from complications in 2001 (an attempt at an outright ban was watered down).

In the UK there have been legal cases where parents have disagreed on their son having the procedure.

Trials in Africa suggested that circumcision might help prevent spread of HIV (38-66% reduced risk). South African president Jacob Zuma made a point of getting circumcised, to encourage others.

Risks are low in neonates cf adults.

Muslim and Jewish cultures see it as part of cultural identity, of course.

Gaming technology in healthcare

Generic, Teaching and training

Humans, and children in particular, learn through play. Play is how we develop new models to understand the world around us.

Expert game designers are well-versed in sociology, psychology, and the cognitive sciences that underlie motivation and behavior. They know how to achieve the perfect balance between challenge and mastery – too hard is off putting, too easy is uninvolving – and they build reward-driven experiences that capture attention.

Games are ultimately how we work out rules, and hence strategy.

All these things are essential components of learning, and indeed life.

A good game requires intense concentration, and this is where maximally efficient learning occurs, which contributes to better knowledge retention and skill development. And with a game this is almost an unintended consequence.

[Eric Gantwerker]

Faye Hawkins case

Clinical governance, Ethics, General paediatrics, Generic

A consultant paediatrician who received a formal warning from the GMC for missing a case of fatal appendicitis.

Found that she failed to consider possible underlying serious cause for fever, and that lethargy and mildly elevated heart rate are “red flags”. But actually, they are not – common and poorly predictive, and not in NICE Fever in under 5s table. Patient was 5 already, anyway. Did not flag on Sepsis tool.

Also found that she failed to examine again or look for other possible red flags when she discharged Elspeth from hospital; failed to adequately advise parents on how frequently they should monitor her temperature and pain symptoms; and failed to record the advice given in the notes.

British association for general paediatricians complained that the pressure of the acute unit were not taken into account, but GMC response was that tribunal (which is independent from GMC) took this into account, although they could not agree on what standards for a “reasonably competent clinician” could be applied!

Medical Professionalism

Ethics, Generic, Patients

“We teach good communication skills because we accept not everyone has them. But we also need to teach professionalism… We’re happier to challenge poor clinical skills, or to point out a gap in knowledge, than to have a conversation about behaviour or attitudes.”

“We expect learners to improve and progress.  So, by implication, they’re not perfect professionals: they can make mistakes.  It gives people permission to say, “That doesn’t look professional”.”

“We need to work on accepting  constructive feedback for unprofessional behaviours… We want a positive culture, where we teach people to speak up to promote professionalism.”

[Sheona MacLeod, BMJ 2020;368:m768]

Easier to spot when people are being unprofessional than to teach professionalism!

Which makes me think the issue is conflicting values/priorities rather than not knowing what is “good medical practice”.

So dress codes become an issue when someone’s need to express their individuality or fit in with their peer group clashes with public perceptions of what a health care professional should look like.

Or someone complaining about their work place on social media is wanting to assert their independent spirit even as an employee, perhaps also their right to self expression and to attract “likes”.

And professionalism is clearly performative. We can swear all we want in our heads, but to swear out loud (in most cases) would be considered inappropriate. Which also potentially makes class an issue.

Expectations (of the public but also our peers) change over time. Consider suits, white coats, ties, scrubs. Consider also #medbikini twitter controversy – an article by men describes social media posts of women doctors in bikinis as potentially unprofessional.

Rosenthal 2011 – humanism and professionalism student module included blogging about clerkship experiences, debriefing after significant events, and discussing journal articles, fiction, and film. Main focus however was on empathy.

Scott Oliver and Kathleen Collins described differences in attitudes between medical school students which appeared to suggest a hidden curriculum. Students with more knowledge focus failed to identify potential issues of confidentiality, ethics or trust. Students who had not explored such issues struggled to know how to approach such issues even if they did recognise them.

Definition is probably best medical practice but also the duties and responsibilities of being an employee. High level morals/values (as in GMC good medical practice) are uncontroversial but also hard to then produce policies from (and which can then be defended in court when issues arise).

Clearly some personalities can be more playful, or disagreeable, which are not necessarily negative (cf engaging, whistleblowing) so perhaps more about defining the outer limits rather than homogenizing behaviour.

Surveillance capitalism; social dilemma documentary (mental health declines with higher use; disinformation campaigns; extremism encouraged by algorithms)

Social media is performative (Erving Goffman – the presentation of self (name of his book), life as theatre (metaphorically- although some say actual)). 

MedTwitter – now X of course 

Human face vs personality cult and influencers

Social media hygiene. 

Modelling in absence of “official” voices. 

Self curation of brand. Bordieu’s social capital. 

How to teach?

Learn through active reflection on work based learning (cf how artificial PBL etc are).  Think about values, how they shape communication.  Modelling of democratic values.  Appreciation of complexity of communication.

[ Alan Bleakley, Peninsula medical school – Homer as evidence of honour/shame/face directed behaviours, cf feminine, guilt directed behaviours etc]

“We teach good communication skills because we accept not everyone has them. But we also need to teach professionalism… We’re happier to challenge poor clinical skills, or to point out a gap in knowledge, than to have a conversation about behaviour or attitudes.”

“We expect learners to improve and progress.  So, by implication, they’re not perfect professionals: they can make mistakes.  It gives people permission to say, “That doesn’t look professional”.”

“We need to work on accepting  constructive feedback for unprofessional behaviours… We want a positive culture, where we teach people to speak up to promote professionalism.”

[Sheona MacLeod, BMJ 2020;368:m768]

Medical Humanities

Communication, Ethics, Generic, Patients

In education, Johanna Shapiro has done interesting work, for example including relevant poems into objective structured clinical examinations (Female, by Ingrid Hughes, about a woman facing a probable diagnosis of breast cancer; Dear Left Knee by John Davis; Back Pain, by Ingrid Hughes; Night on Call, by Dr Rita Iovino). A large proportion said they felt it increased empathy, and had a significant effect on how they might present bad news, on the ultimate treatment plan. Most felt the Night on call poem helped gain perspective. [Medical Education 2005]

In the same paper, adding some readings led students to say (in 1/3 to 2/3 of cases) that they would be more likely to take into consideration psychosocial insights, or that it increased some dimension of empathy for the patient, including helping them take the patient more seriously.

Themes written by doctors or medical students are commonly about the rewards and stresses, relationships, role models, death, the meaning of life – things not directly addressed in the curriculum.

The quality is less important that the utility to a particular audience.

[BMJ 2010]

Racism in Medicine

Ethics, Generic

Infant mortality for black babies in US double that of white babies.

Newborn mortality in Florida for black babies under care of black doctors 58% lower than those under white doctors. No difference for white babies. Still not as good as white mortality though.

Confidence as a doctor

Generic, Management, Teaching and training

As a doctor, you want to feel confident in your abilities and your diagnosis, you certainly don’t want to question yourself constantly. Equally, your patients want to feel confident that you know what you are talking about, and will probably get better more quickly if they do (placebo effect).

Most people can smell bullsh*t from a mile off if you try to say something you don’t actually think or believe. Typically, your words (vague) and body language (evasive) will give you away.

At the same time, the over confident doctor is dangerous. Arrogance is also very unattractive. So there is a balance.

What do we mean by confident?

Confidence is a sense of belief in one’s own abilities. But of course you can have a strong belief in your own ability when you have no talent at all. So the kind of confidence we want to have is probably the sense of certainty that you can do something reasonably well, even that you can then do it without really needing to think too much about it at all.

It isn’t a character trait! And of course there isn’t such a thing as a “confident person”, because it depends on the skill being considered. Great athletes can be terrible public speakers, for example.

How do get more confident?

It’s cultivated by early childhood experiences of course. How were you encouraged to think about your own efforts and abilities? But no reason you can’t gain in confidence, or at least make your confidence commensurate with your competency. Some people may have more baggage to deal with, of course.

So first step must be to gain competency – which means understanding the basics, practising the skills, and recognizing when things fall outside what you have seen so far. Repetition is key, clearly.

Secondly – if you feel you are straying outside your comfort zone, is there any way to get more information? Do you have notes you can check? Do you know which are the best resources? Do you have a person you can ask safely?

Thirdly – can you see what factors are hindering you from performing at your best? Tiredness? Distraction?

The story you tell yourself

Of course you are not perfect. You will make mistakes. You will forget something. You cannot know everything. But is there anyone other than yourself who expects otherwise?

So rather than concentrating on the negatives (which is probably natural, given that in the evolutionary survival game, you really don’t want to end up wounded, poisoned, lost or dead as often as you get lucky), can you tell yourself that you are ready for this, that you are trained for this, you have worked for this, you work reasonably well in almost all conditions?

That mistakes do not cancel out everything you get right the rest of the time?

Although there is a time to be self critical, there are definitely just as many times if not more to be self friendly, and this can be hard for us if never modelled.

You need to practice positive self affirmations, if you want them to count when under stress. Confidence is like a bank balance that needs constant deposits. List the things you have done well in the past. Spend time each day reflecting on what went well. Spend time looking ahead and envisioning where you want to be. This should be the movie playing in your head.

The “shooter’s mentality” – any missed shot is a temporary slip, and just means the next shot will be successful. Any successful shot confirms that you are on a roll of consistent success.

And how do you think of other people’s success? Do you always equate confidence with arrogance, laziness, complacency?

Stand up straight with your shoulders back

Rule 1 of Jordan B Peterson’s 12 Rules for living.

“Standing up straight with your shoulders back is not something that is only physical, because you’re not only a body. Standing up means voluntarily accepting the burden of Being. You see the gold the dragon hoards, instead of shrinking in terror from the Dragon. It means deciding to transform the chaos of potential into the realities of habitable order. It means willingly undertaking the sacrifices necessary to generate a productive and meaningful reality.

“People, including yourself, will start to assume that you are competent (or at least they will not immediately conclude the reverse). Strengthened and emboldened, you may be able to stand, even during the illness of a loved one, even during the death of a parent, and allow others to find strength alongside you when they would otherwise be overwhelmed by despair.

“Then you may be able to accept the terrible burden of the world, and find joy. Look to the victorious lobster.”

See also the benefits of the Superman pose.

The cherry on top

Put in the work – the studying, the practice, the questioning, the reflection.

Then decide to tell yourself – “I’ve done the work. I know what I need to know. I’m going to deliver now. I am enough for this time and this place.”

Shared Decision Making

Communication, Generic
[NICE guidance 2021] See also participatory medicine and family centred care.

First bullet point is that this should be embedded at organisational level! Includes:

  • provide access to patient decision aids (PDAs) or information about risks and benefits
  • review how “information systems” might help record discussions and decisions, for example through patient held record
  • prompt patients (through media, posters, letters) to ask questions about options, and “making the decision that’s right for me“

Staff training:

  • evidence based model eg three-talk model (introduce choice, describe options, help explore preferences and make decision)
  • communication skills – avoiding jargon, explaining technical terms
  • communicating with families and others the patient would like involved

Note that NHS England has “accessible information standards”.

In practice:

  • Agree an agenda
  • Ensure the person understands they can take part as fully as they want in making choices about their treatment or care
  • When it comes to tests or treatments, explain what the health care aim is of each option, and discuss how that might align with patients “aims, priorities and wider goals”
  • chunk and check information
  • check understanding eg teach back
  • Give information away at time of discussion or very soon after, including contact details
  • Write letters to the patient rather than to their doctor, in line with 2018 Academy of Medical Royal Colleges’ guidance on writing outpatient clinic letters to patients (or at least a copy to patient, unless they expressly don’t want to receive any written information).

Communicating risk:

  • Make clear how information applies to them personally, and how much uncertainty applies
  • Use mixture of numbers, pictograms and “icon arrays” (repeated icons, with different colours, to see proportions), to allow people to see both positive AND negative framing
  • Be aware that different people interpret terms such as ‘risk’, ‘rare’, ‘unusual’ and ‘common’ in different ways
  • Use absolute risk rather than relative risk. For example, the risk of an event increases from 1 in 1,000 to 2 in 1,000, rather than the risk of the event doubles.
  • Use 10 in 100, rather than 10%
  • Use the same denominator
  • State both positive and negative framing

Participatory medicine

Communication, Ethics, Generic, Health Literacy, Patients

Patient led campaign for better involvement of patients in their own care.

Manifesto has 5 principles:

  • Share and listen – acknowledge patients are experts in their own lives and bodies, use plain language.
  • Respect one another
  • Share information responsibly – help patients access the information they need, and respect confidentiality
  • Promote curiosity – be clear even when it is difficult to explain, encourage patients to do their own research and get involved in patient communities
  • Be a teambuilder – treat patients as collaborators, respect their goals, values and preferences

These are shared responsibilities, the patient has their own duty to be honest, ask questions, advocate themselves.

Institute of Medicine describes a continuously learning system (in respect of healthcare in the US), the second feature of which is Patient-clinician partnerships. This is explained as “engaged, empowered patients – a health care system anchored on patient needs and perspectives, and promoting the inclusion of patients, families and other care givers as vital members of the team“.

Unclear this happens on any significant level, especially when it comes to communication outside the hospital or clinic room. Studies have found that when patient portals or messaging systems are used, patients often respond with further questions or comments, which suggests unmet need and desire to engage further. Other studies have found that only a tiny minority of messages in such systems are initiated by the health care team, which suggests a reactive rather than active contribution to the partnership.