If It’s Not Documented, It’s Not Done!

Angelo, T. & AWAC Services Company. (2025).

American Professional Agency.

Link is here.

Documentation is the backbone of effective, ethical and legally sound care in any healthcare setting. The medical record/documentation functions as the legal document that supports the care and treatment provided, demonstrates compliance with both state and federal laws, and validates the professional services rendered for reimbursement. This concept is familiar to any provider, and it is recognized that many healthcare providers view documentation as something that is dreaded. The main obstacle may stem from limited time to provide care and complete thorough documentation, the burdensome clicks and rigid fields of the electronic medical record, or the repeated demands from insurance providers for detailed information to meet reimbursement requirements and prove medical necessity for coverage.

Staying vigilant is necessary along with thinking beyond documentation being an expected task but as a critical safety measure. Thorough documentation protects both parties involved in the patient-provider relationship. Documentation ensures the continuity of care and upholds ethical standards of professional integrity and accountability. The age old adage “if it’s not documented, it’s not done” serves as a stark reminder of the potential consequences of inadequate documentation which can result in fines, penalties and malpractice liability. Documentation failures, particularly omissions, have been known to complicate the defense of any legal matter and can favor a plaintiff or disgruntled patient regardless of whether good care was provided. The following scenarios illustrate the significance of documentation and outline best practices to follow. 

Here are some thoughts:

Nice quick review about documentation requirements. Refreshers are typically helpful!

As AI nurses reshape hospital care, human nurses are pushing back

Perrone, M. (2025, March 16).

AP News.

The article is here.

The next time you’re due for a medical exam you may get a call from someone like Ana: a friendly voice that can help you prepare for your appointment and answer any pressing questions you might have.

With her calm, warm demeanor, Ana has been trained to put patients at ease — like many nurses across the U.S. But unlike them, she is also available to chat 24-7, in multiple languages, from Hindi to Haitian Creole.

That’s because Ana isn’t human, but an artificial intelligence program created by Hippocratic AI, one of a number of new companies offering ways to automate time-consuming tasks usually performed by nurses and medical assistants.

It’s the most visible sign of AI’s inroads into health care, where hundreds of hospitals are using increasingly sophisticated computer programs to monitor patients’ vital signs, flag emergency situations and trigger step-by-step action plans for care — jobs that were all previously handled by nurses and other health professionals.

Hospitals say AI is helping their nurses work more efficiently while addressing burnout and understaffing. But nursing unions argue that this poorly understood technology is overriding nurses’ expertise and degrading the quality of care patients receive.

The info is linked above.

Here are some thoughts:

The article details the increasing use of AI in healthcare to automate nursing tasks, sparking union concerns about patient safety and the risk of AI overriding human expertise. Licensing boards cannot license AI products because licensing is fundamentally designed for individuals, not tools. It establishes accountability based on demonstrated competence, which is difficult to apply to AI due to complex liability issues and the challenge of tracing AI outputs to specific actions. AI lacks the inherent personhood and professional responsibility that licensing demands, making it unaccountable for harm.

Utah Supreme Court Rules That Alleged Sexual Assault by a Doctor Is Not “Health Care”

Jessica Miller

The Salt Lake Tribune

ProPublica

Originally posted 9 August 24

Sexual assault is not health care, and it isn’t covered by Utah’s medical malpractice law, the state’s Supreme Court ruled on Thursday. The decision revives a lawsuit filed by 94 women who allege their OB-GYN sexually abused them during exams or while he delivered their babies.

In 2022, the group of women sued Dr. David Broadbent and two hospitals where he had worked, wanting to seek civil damages. But a judge dismissed their case because he decided they had filed it incorrectly as a civil sexual assault claim rather than a medical malpractice case. The women had all been seeking health care, Judge Robert Lunnen wrote, and Broadbent was providing that when the alleged assaults happened.

The Salt Lake Tribune and ProPublica covered the decision, speaking with women about the lower court ruling that made it harder for them to sue the doctor for his alleged actions. After that story ran, the state Legislature voted to reform medical malpractice law to exclude sexual assault. But the new law didn’t apply retroactively; the women still had no way to sue.

So they took their case to the Utah Supreme Court, where their attorneys argued that the lower court judge had made an error in his decision. The high court agreed. Broadbent’s alleged conduct, it found, was not a part of the women’s health care — and therefore, not covered by Utah’s medical malpractice laws.

The info is here.

Here are some thoughts:

The Utah Supreme Court has ruled that sexual assault does not constitute health care, thereby reviving a lawsuit filed by 94 women against Dr. David Broadbent, an OB-GYN accused of sexually abusing them during medical exams and childbirth. The lawsuit, initially dismissed by a lower court judge who categorized it as a medical malpractice case, was brought back to life by the Supreme Court's decision. The women had sought civil damages against Broadbent and two hospitals where he practiced, but the judge had previously ruled that the alleged assaults occurred during health care provision, thus falling under medical malpractice laws. The Supreme Court, however, found that Broadbent's actions were not part of legitimate medical treatment, allowing the case to proceed outside the constraints of malpractice regulations.

The ruling marks a significant victory for the plaintiffs, who faced limitations on their ability to seek justice due to the initial classification of their claims. The decision follows legislative changes that excluded sexual assault from being considered medical malpractice, though these changes did not apply retroactively to the Broadbent case. The lawsuit alleges inappropriate and harmful conduct by Broadbent, including touching patients without explanation and using his position to commit sexual assaults. Broadbent, who has denied the allegations, has agreed to cease practicing medicine while under investigation and faces criminal charges of forcible sexual abuse. The case will now return to the lower court for further proceedings, offering the plaintiffs a renewed opportunity to seek justice.

Oaths, Conscience, Contracts, and Laws-The Gathering Storm Confronting Medical Professionalism

Gabow, P. A., & Wynia, M. K. (2024).

JAMA, 10.1001/jama.2024.10761.

Advance online publication.

https://doi.org/10.1001/jama.2024.10761

The bond between physicians and their patients has long been considered a unique, even sacred, relationship sealed with publicly professed oaths. Historically, an essential and ubiquitous component of physicians' oaths and their related ethical codes is the promise to place patients' interests above any others, including their own. This is a high bar, but it is the bar physicians swear to meet when entering the profession. For generations, many physicians have courageously met this bar, including putting their lives on the line during pandemics like COVID-19.

Today, physicians face rising challenges in fulfilling this core professional promise not from a virus but from 3 converging fronts: personal conscience, employment contracts, and laws. How these challenges to putting patient interests first have emerged and interrelate deserves elucidation because understanding these dynamics can help shape appropriate professional responses.

Personal Conscience

The First Amendment to the US Constitution forbids the establishment of a state religion (establishment clause) and protects individual religious freedom (free exercise clause). As these paired clauses demonstrate, integral to prohibiting a state religion was establishing respect for individual conscience, and in 1809 Thomas Jefferson declared, "No provision in our constitution ought to be dearer to man than that which protects the rights of conscience...."

Formal support for a physician's conscience to override their commitment to their patient's interests, however, was not codified in federal legislation until the Church Amendments of 1973, which exempted federally funded individuals and entities with moral objections from performing or assisting in abortions or sterilization procedures. This prioritization of physician conscience over patient interests has since been extended by other federal laws and regulations, and many states have passed conscience laws ensuring that physicians can refuse without penalty to provide, or even refer, patients for care a physician deems against his or her conscience.

Here are some thoughts:

The physician-patient relationship, once considered sacred, is facing unprecedented challenges from three converging fronts: personal conscience, employment contracts, and laws. Historically, physicians have sworn oaths to prioritize patients' interests above their own, but recent developments have eroded this commitment. The prioritization of physician conscience over patient interests has been codified in federal laws and regulations, while employment contracts have introduced additional constraints on physicians' ability to put patients first.

To address these challenges, physicians must recommit to their sworn oaths and codes of ethics, examining the difference between professional responsibilities and personal beliefs. They should be aware of ethical guardrails that protect patients' trust, such as informing patients about limitations of care and making referrals when necessary. Furthermore, physicians should carefully examine employment contracts and work collectively through professional organizations to change contracts and laws that privilege institutional or state-level conscience rights over patient-centered care. By vigorously defending their authority to make medical decisions with patients' interests at heart, physicians can reclaim their profession's commitment to prioritizing patients' needs.

State Abortion Policy and Moral Distress Among Clinicians Providing Abortion After the Dobbs Decision

Rivlin, K., Bornstein, M., et al. (2024).

JAMA Network Open, 7(8), e2426248.

https://doi.org/10.1001/jamanetworkopen.2024.26248

Abstract

Importance

Moral distress occurs when individuals feel powerless to do what they think is right, including when clinicians are prevented from providing health care they deem necessary. The loss of federal protections for abortion following the Dobbs v Jackson Women’s Health Organization Supreme Court decision may place clinicians providing abortion at risk of experiencing moral distress, as many could face new legal and civil penalties for providing care in line with professional standards and that they perceive as necessary.

Main Outcomes and Measures

Using descriptive statistics and unadjusted and adjusted negative binomial regression models, the association between self-reported moral distress on the Moral Distress Thermometer (MDT), a validated psychometric tool that scores moral distress from 0 (none) to 10 (worst possible), and state abortion policy was examined.

Conclusions and Relevance 

In this purposive national survey study of clinicians providing abortion, moral distress was elevated among all clinicians and more than twice as high among those practicing in states that restrict abortion compared with those in states that protect abortion. The findings suggest that structural changes addressing bans on necessary health care, such as federal protections for abortion, are needed at institutional, state, and federal policy levels to combat widespread moral distress.

Here are some thoughts:

A national survey of 310 abortion clinicians found that those practicing in states with abortion restrictions experience more moral distress than those in states that protect abortion. This study found that clinicians in restrictive states reported moral distress scores that were more than double those in protective states. The study's authors suggest that structural changes at the state, federal, and institutional levels are needed to address this moral distress, such as federal protections for abortion.

Moral distress can occur when people feel powerless to do what they believe is right, such as when clinicians are prevented from providing care they consider necessary. High levels of moral distress can lead to burnout, errors in patient care, and clinician attrition. In restrictive states, these issues could worsen provider shortages and lead to poor patient outcomes. 

However, some clinicians have found ways to cope with moral distress. For example, one participant said they felt more empowered to provide abortion care after the Dobbs decision, while another described feeling motivated by the support of their team. 

Medical-Targeted Ransomware Is Breaking Records After Change Healthcare’s $22M Payout

Andy Greenberg

wired.com

Originally posted 12 June 24

When Change Healthcare paid $22 million in March to a ransomware gang that had crippled the company along with hundreds of hospitals, medical practices, and pharmacies across the US, the cybersecurity industry warned that Change's extortion payment would only fuel a vicious cycle: Rewarding hackers who had carried out a ruthless act of sabotage against the US health care system nationwide with one of the largest ransomware payments in history, it seemed, was bound to incentivize a new wave of attacks on similarly sensitive victims. Now that wave has arrived.

In April, cybersecurity firm Recorded Future tracked 44 cases of cybercriminal groups targeting health care organizations with ransomware attacks, stealing their data, encrypting their systems, and demanding payments from the companies while holding their networks hostage. That's more health care victims of ransomware than in any month Recorded Future has seen in its four years of collecting that data, says Allan Liska, a threat intelligence analyst at the company. Comparing that number to the 30 incidents in March, it's also the second biggest month-to-month jump in incidents the company has ever tracked.

While Liska notes that he can't be sure of the reason for that spike, he argues it's unlikely to be a coincidence that it follows in the wake of Change Healthcare's eight-figure payout to the hacker group known as AlphV or BlackCat that was tormenting the company.

The info is here.

Here are some thoughts:

The recent record-breaking ransom payment by a healthcare giant raises a troubling question: are profits being prioritized over patient well-being? This approach creates an ethical dilemma and poses serious psychological and public health risks.

Imagine needing urgent medical attention, only to find your records inaccessible due to a cyberattack. Ransomware disrupts services, causing immense anxiety for patients. Disrupted access to data can delay diagnoses, hinder treatment, and even threaten public health initiatives. Furthermore, these attacks essentially blackmail healthcare providers, potentially eroding trust in the medical system.

To combat this growing threat, we need a multi-pronged approach. Healthcare institutions must prioritize robust cybersecurity. International law enforcement collaboration is crucial to hold cybercriminals accountable. Finally, open communication with patients during and after an attack is essential to rebuild trust and minimize stress. By working together, we can build a more resilient healthcare system that safeguards patient data and well-being.

Ethical Considerations When Confronted by Racist Patients

Charles Dike

Psychiatric News

Originally published 26 Feb 24

Here is an excerpt:

Abuse of psychiatrists, mostly verbal but sometimes physical, is common in psychiatric treatment, especially on inpatient units. For psychiatrists trained decades ago, experiencing verbal abuse and name calling from patients—and even senior colleagues and teachers—was the norm. The abuse began in medical school, with unconscionable work hours followed by callous disregard of students’ concerns and disparaging statements suggesting the students were too weak or unfit to be doctors.

This abuse continued into specialty training and practice. It was largely seen as a necessary evil of attaining the privilege of becoming a doctor and treating patients whose uncivil behaviors can be excused on account of their ill health. Doctors were supposed to rise above those indignities, focus on the task at hand, and get the patients better in line with our core ethical principles that place caring for the patient above all else. There was no room for discussion or acknowledgement of the doctors’ underlying life experiences, including past trauma, and how patients’ behavior would affect doctors.

Moreover, even in recent times, racial slurs or attacks against physicians of color were not recognized as abuse by the dominant group of doctors; the affected physicians who complained were dismissed as being too sensitive or worse. Some physicians, often not of color, have explained a manic patient’s racist comments as understandable in the context of disinhibition and poor judgment, which are cardinal symptoms of mania, and they are surprised that physicians of color are not so understanding.

The info is here.

Here is a summary:

This article explores the ethical dilemma healthcare providers face when treating patients who express racist views. It acknowledges the provider's obligation to care for the patient's medical needs, while also considering the emotional toll of racist remarks on both the provider and other staff members.

The article discusses the importance of assessing the urgency of the patient's medical condition and their mental capacity. It explores the option of setting boundaries or termination of treatment in extreme cases, while also acknowledging the potential benefits of attempting a dialogue about the impact of prejudice.

An Expert Who Has Testified in Foster Care Cases Across Colorado Admits Her Evaluations Are Unscientific

Eli Hager

Propublica.com

Originally posted 18 March 24

Diane Baird had spent four decades evaluating the relationships of poor families with their children. But last May, in a downtown Denver conference room, with lawyers surrounding her and a court reporter transcribing, she was the one under the microscope.

Baird, a social worker and professional expert witness, has routinely advocated in juvenile court cases across Colorado that foster children be adopted by or remain in the custody of their foster parents rather than being reunified with their typically lower-income birth parents or other family members.

In the conference room, Baird was questioned for nine hours by a lawyer representing a birth family in a case out of rural Huerfano County, according to a recently released transcript of the deposition obtained by ProPublica.

Was Baird’s method for evaluating these foster and birth families empirically tested? No, Baird answered: Her method is unpublished and unstandardized, and has remained “pretty much unchanged” since the 1980s. It doesn’t have those “standard validity and reliability things,” she admitted. “It’s not a scientific instrument.”

Who hired and was paying her in the case that she was being deposed about? The foster parents, she answered. They wanted to adopt, she said, and had heard about her from other foster parents.

Had she considered or was she even aware of the cultural background of the birth family and child whom she was recommending permanently separating? (The case involved a baby girl of multiracial heritage.) Baird answered that babies have “never possessed” a cultural identity, and therefore are “not losing anything,” at their age, by being adopted. Although when such children grow up, she acknowledged, they might say to their now-adoptive parents, “Oh, I didn’t know we were related to the, you know, Pima tribe in northern California, or whatever the circumstances are.”

The Pima tribe is located in the Phoenix metropolitan area.

The info is here.

Here is my summary:

The article discusses Diane Baird, an expert who has testified in foster care cases across Colorado, admitting that her evaluations are unscientific. Baird, who has spent four decades evaluating the relationships of poor families with their children, labeled her method for assessing families as the "Kempe Protocol." This revelation raises concerns about the validity of her evaluations in foster care cases and highlights the need for more rigorous and scientific approaches in such critical assessments.

Should Patients Be Allowed to Die From Anorexia? Is a 'Palliative' Approach to Mental Illness Ethical?

Katie Engelhart

New York Times Magazine

Originally posted 3 Jan 24

Here is an excerpt:

He came to think that he had been impelled by a kind of professional hubris — a hubris particular to psychiatrists, who never seemed to acknowledge that some patients just could not get better. That psychiatry had actual therapeutic limits. Yager wanted to find a different path. In academic journals, he came across a small body of literature, mostly theoretical, on the idea of palliative psychiatry. The approach offered a way for him to be with patients without trying to make them better: to not abandon the people who couldn’t seem to be fixed. “I developed this phrase of ‘compassionate witnessing,’” he told me. “That’s what priests did. That’s what physicians did 150 years ago when they didn’t have any tools. They would just sit at the bedside and be with somebody.”

Yager believed that a certain kind of patient — maybe 1 or 2 percent of them — would benefit from entirely letting go of standard recovery-oriented care. Yager would want to know that such a patient had insight into her condition and her options. He would want to know that she had been in treatment in the past, not just once but several times. Still, he would not require her to have tried anything and everything before he brought her into palliative care. Even a very mentally ill person, he thought, was allowed to have ideas about what she could and could not tolerate.

If the patient had a comorbidity, like depression, Yager would want to know that it was being treated. Maybe, for some patients, treating their depression would be enough to let them keep fighting. But he wouldn’t insist that a person be depression-free before she left standard treatment. Not all depression can be cured, and many people are depressed and make decisions for themselves every day. It would be Yager’s job to tease out whether what the patient said she wanted was what she authentically desired, or was instead an expression of pathological despair. Or more: a suicidal yearning. Or something different: a cry for help. That was always part of the job: to root around for authenticity in the morass of a disease.

The info is here.

Some thoughts:

The question of whether patients with anorexia nervosa should be allowed to die from their illness or receive palliative care is a complex and emotionally charged one, lacking easy answers. It delves into the profound depths of autonomy, mental health, and the very meaning of life itself.

The Anorexic's Dilemma:

Anorexia nervosa is a severe eating disorder characterized by a relentless pursuit of thinness and an intense fear of weight gain. It often manifests in severe food restriction, excessive exercise, and distorted body image. This relentless control, however, comes at a devastating cost. Organ failure, malnutrition, and even death can be the tragic consequences of the disease's progression.

Palliative Care: Comfort Not Cure:

Palliative care focuses on symptom management and improving quality of life for individuals with life-threatening illnesses. In the context of anorexia, it would involve addressing physical discomfort, emotional distress, and spiritual concerns, but without actively aiming for weight gain or cure. This raises numerous ethical and practical questions:

• Respecting Autonomy: Does respecting a patient's autonomy mean allowing them to choose a path that may lead to death, even if their decision is influenced by a mental illness?
• The Line Between Choice and Coercion: How do we differentiate between a genuine desire for death and succumbing to the distorted thinking patterns of anorexia?
• Futility vs. Hope: When is treatment considered futile, and when should hope for recovery, however slim, be prioritized?

Finding the Middle Ground:

There's no one-size-fits-all answer to this intricate dilemma. Each case demands individual consideration, taking into account the patient's mental capacity, level of understanding, and potential for recovery. Open communication, involving the patient, their family, and a multidisciplinary team of healthcare professionals, is crucial in navigating this sensitive terrain.

Potential Approaches:

• Enhanced Supportive Care: Focusing on improving the patient's quality of life through pain management, emotional support, and addressing underlying psychological issues.
• Conditional Palliative Care: Providing palliative care while continuing to offer and encourage life-sustaining treatment, with the possibility of transitioning back to active recovery if the patient shows signs of willingness.
• Advance Directives: Encouraging patients to discuss their wishes and preferences beforehand, allowing for informed decision-making when faced with difficult choices.

What Is It That You Want Me To Do? Guidance for Ethics Consultants in Complex Discharge Cases

Omelianchuk, A., Ansari, A.A. & Parsi, K.

HEC Forum (2023).

https://doi.org/10.1007/s10730-023-09517-y

Abstract

Some of the most difficult consultations for an ethics consultant to resolve are those in which the patient is ready to leave the acute-care setting, but the patient or family refuses the plan, or the plan is impeded by deficiencies in the healthcare system. Either way, the patient is “stuck” in the hospital and the ethics consultant is called to help get the patient “unstuck.” These encounters, which we call “complex discharges,” are beset with tensions between the interests of the institution and the interests of the patient as well as tensions within the ethics consultant whose commitments are shaped both by the values of the organization and the values of their own profession. The clinical ethics literature on this topic is limited and provides little guidance. What is needed is guidance for consultants operating at the bedside and for those participating at a higher organizational level. To fill this gap, we offer guidance for facilitating a fair process designed to resolve the conflict without resorting to coercive legal measures. We reflect on three cases to argue that the approach of the consultant is generally one of mediation in these types of disputes. For patients who lack decision making capacity and lack a surrogate decision maker, we recommend the creation of a complex discharge committee within the organization so that ethics consultants can properly discharge their duties to assist patients who are unable to advocate for themselves through a fair and transparent process.

The article is paywalled.  Please contact the author for full copy.

Here is my summary:

• Ethics consultants face diverse patient situations, including lack of desire to leave, potential mental health issues, and financial/space constraints.
• Fair discharge processes are crucial, through mediation or multidisciplinary committees, balancing patient needs with system limitations.
• "Conveyor belt" healthcare can strain trust and create discharge complexities.
• The ethics consultant role is valuable but limited, suggesting standing "complex case committees" with diverse expertise for effective, creative solutions.

In essence, this summary highlights the need for a more nuanced and collaborative approach to complex discharges, prioritizing patient well-being while recognizing systemic constraints.

Biden administration rescinds much of Trump ‘conscience’ rule for health workers

Nathan Weixel

The Hill

Originally published 9 Jan 24

The Biden administration will largely undo a Trump-era rule that boosted the rights of medical workers to refuse to perform abortions or other services that conflicted with their religious or moral beliefs.

The final rule released Tuesday partially rescinds the Trump administration’s 2019 policy that would have stripped federal funding from health facilities that required workers to provide any service they objected to, such as abortions, contraception, gender-affirming care and sterilization.

The health care conscience protection statutes represent Congress’s attempt to strike a balance between maintaining access to health care and honoring religious beliefs and moral convictions, the Department of Health and Human Services said in the rule.

“Some doctors, nurses, and hospitals, for example, object for religious or moral reasons to providing or referring for abortions or assisted suicide, among other procedures. Respecting such objections honors liberty and human dignity,” the department said.

But at the same time, Health and Human Services said “patients also have rights and health needs, sometimes urgent ones. The Department will continue to respect the balance Congress struck, work to ensure individuals understand their conscience rights, and enforce the law.”

The info is here.

Summary from Healthcare Dive

The HHS Office of Civil Rights has again updated guidance on providers’ conscience rights. The latest iteration, announced on Tuesday, aims to strike a balance between honoring providers’ religious and moral beliefs and ensuring access to healthcare, according to the agency.

President George W. Bush created conscience rules in 2008, which codify the rights of healthcare workers to refuse to perform medical services that conflict with their religious or moral beliefs. Since then, subsequent administrations have rewritten the rules, with Democrats limiting the scope and Republicans expanding conscience protections. 

The most recent revision largely undoes a 2019 Trump-era policy — which never took effect — that sought to expand the rights of healthcare workers broadly to refuse to perform medical services, such as abortions, on religious or moral grounds.

Physicians’ Refusal to Wear Masks to Protect Vulnerable Patients—An Ethical Dilemma for the Medical Profession

Dorfman D, Raz M, Berger Z.

JAMA Health Forum. 2023;4(11):e233780.

doi:10.1001/jamahealthforum.2023.3780

Here is an excerpt:

In theory, the solution to the problem should be simple: patients who wear masks to protect themselves, as recommended by the CDC, can ask the staff and clinicians to wear a mask as well when seeing them, and the clinicians would oblige given the efficacy masks have shown in reducing the spread of respiratory illnesses. However, disabled patients report physicians and other clinical staff having refused to wear a mask when caring for them. Although it is hard to know how prevalent this phenomenon is, what recourse do patients have? How should health care systems approach clinicians and staff who refuse to mask when treating a disabled patient?

Physicians have a history of antagonism to the idea that they themselves might present a health risk to their patients. Famously, when Hungarian physician Ignaz Semmelweis originally proposed handwashing as a measure to reduce purpureal fever, he was met with ridicule and ostracized from the profession.

Physicians were also historically reluctant to adopt new practices to protect not only patients but also physicians themselves against infection in the midst of the AIDS epidemic. In 1985, the CDC presented its guidance on workplace transmission, instructing physicians to provide care, “regardless of whether HCWs [health care workers] or patients are known to be infected with HTLV-III/LAV [human T-lymphotropic virus type III/lymphadenopathy-associated virus] or HBV [hepatitis B virus].” These CDC guidelines offered universal precautions, common-sense, nonstigmatizing, standardized methods to reduce infection. Yet, some physicians bristled at the idea that they need to take simple, universal public health steps to prevent transmission, even in cases in which infectivity is unknown, and instead advocated for a medicalized approach: testing or masking only in cases when a patient is known to be infected. Such an individualized medicalized approach fails to meet the public health needs of the moment.

Patients are the ones who pay the price for physicians’ objections to changes in practices, whether it is handwashing or the denial of care as an unwarranted HIV precaution. Yet today, with the enactment of disability antidiscrimination law, patients are protected, at least on the books.

As we have written elsewhere, federal law supports the right of a disabled individual to request masking as a reasonable disability accommodation in the workplace and at schools.

The info is here.

Here is my summary:

This article explores the ethical dilemma arising from physicians refusing to wear masks, potentially jeopardizing the protection of vulnerable patients. The author delves into the conflict between personal beliefs and professional responsibilities, questioning the ethical implications of such refusals within the medical profession. The analysis emphasizes the importance of prioritizing patient well-being and public health over individual preferences, calling for a balance between personal freedoms and ethical obligations in healthcare settings.

The Moral Crisis of America’s Doctors

Wendy Dean & Elisabeth Rosenthal

The New York Times

Orignally posted 15 July 23

Here is an excerpt:

Some doctors acknowledged that the pressures of the system had occasionally led them to betray the oaths they took to their patients. Among the physicians I spoke to about this, a 45-year-old critical-care specialist named Keith Corl stood out. Raised in a working-class town in upstate New York, Corl was an idealist who quit a lucrative job in finance in his early 20s because he wanted to do something that would benefit people. During medical school, he felt inspired watching doctors in the E.R. and I.C.U. stretch themselves to the breaking point to treat whoever happened to pass through the doors on a given night. “I want to do that,” he decided instantly. And he did, spending nearly two decades working long shifts as an emergency physician in an array of hospitals, in cities from Providence to Las Vegas to Sacramento, where he now lives. Like many E.R. physicians, Corl viewed his job as a calling. But over time, his idealism gave way to disillusionment, as he struggled to provide patients with the type of care he’d been trained to deliver. “Every day, you deal with somebody who couldn’t get some test or some treatment they needed because they didn’t have insurance,” he said. “Every day, you’re reminded how savage the system is.”

Corl was particularly haunted by something that happened in his late 30s, when he was working in the emergency room of a hospital in Pawtucket, R.I. It was a frigid winter night, so cold you could see your breath. The hospital was busy. When Corl arrived for his shift, all of the facility’s E.R. beds were filled. Corl was especially concerned about an elderly woman with pneumonia who he feared might be slipping into sepsis, an extreme, potentially fatal immune response to infection. As Corl was monitoring her, a call came in from an ambulance, informing the E.R. staff that another patient would soon be arriving, a woman with severe mental health problems. The patient was familiar to Corl — she was a frequent presence in the emergency room. He knew that she had bipolar disorder. He also knew that she could be a handful. On a previous visit to the hospital, she detached the bed rails on her stretcher and fell to the floor, injuring a nurse.

In a hospital that was adequately staffed, managing such a situation while keeping tabs on all the other patients might not have been a problem. But Corl was the sole doctor in the emergency room that night; he understood this to be in part a result of cost-cutting measures (the hospital has since closed). After the ambulance arrived, he and a nurse began talking with the incoming patient to gauge whether she was suicidal. They determined she was not. But she was combative, arguing with the nurse in an increasingly aggressive tone. As the argument grew more heated, Corl began to fear that if he and the nurse focused too much of their attention on her, other patients would suffer needlessly and that the woman at risk of septic shock might die.

Corl decided he could not let that happen. Exchanging glances, he and the nurse unplugged the patient from the monitor, wheeled her stretcher down the hall, and pushed it out of the hospital. The blast of cold air when the door swung open caused Corl to shudder. A nurse called the police to come pick the patient up. (It turned out that she had an outstanding warrant and was arrested.) Later, after he returned to the E.R., Corl could not stop thinking about what he’d done, imagining how the medical-school version of himself would have judged his conduct. “He would have been horrified.”

The info is here, paywalled.

Summary: The article explores the moral distress that many doctors are experiencing in the United States healthcare system. Doctors are feeling increasingly pressured to make decisions based on financial considerations rather than what is best for their patients. This is leading to a number of problems, including:

• Decreased quality of care: Doctors are being forced to cut corners on care, which is leading to worse outcomes for patients.
• Increased burnout: Doctors are feeling increasingly stressed and burned out, which is making it difficult for them to provide quality care.
• Loss of moral compass: Doctors are feeling like they are losing their moral compass, as they are being forced to make decisions that they know are not in the best interests of their patients.

The article concludes by calling for a number of reforms to the healthcare system, including:

• Paying doctors based on quality of care, not volume of services: This would incentivize doctors to provide the best possible care, rather than just the most profitable care.
• Giving doctors more control over their practice:This would allow doctors to make decisions based on what is best for their patients, rather than what is best for their employers.
• Supporting doctors' mental health: Doctors need to be supported through the challenges of providing care in the current healthcare system.

Doctors are drowning in paperwork. Some companies claim AI can help

Geoff Brumfiel

NPR.org - Health Shots

Originally posted 5 APR 23

Here are two excerpts:

But Paul kept getting pinged from younger doctors and medical students. They were using ChatGPT, and saying it was pretty good at answering clinical questions. Then the users of his software started asking about it.

In general, doctors should not be using ChatGPT by itself to practice medicine, warns Marc Succi, a doctor at Massachusetts General Hospital who has conducted evaluations of how the chatbot performs at diagnosing patients. When presented with hypothetical cases, he says, ChatGPT could produce a correct diagnosis accurately at close to the level of a third- or fourth-year medical student. Still, he adds, the program can also hallucinate findings and fabricate sources.

"I would express considerable caution using this in a clinical scenario for any reason, at the current stage," he says.

But Paul believed the underlying technology can be turned into a powerful engine for medicine. Paul and his colleagues have created a program called "Glass AI" based off of ChatGPT. A doctor tells the Glass AI chatbot about a patient, and it can suggest a list of possible diagnoses and a treatment plan. Rather than working from the raw ChatGPT information base, the Glass AI system uses a virtual medical textbook written by humans as its main source of facts – something Paul says makes the system safer and more reliable.

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Nabla, which he co-founded, is now testing a system that can, in real time, listen to a conversation between a doctor and a patient and provide a summary of what the two said to one another. Doctors inform their patients that the system is being used in advance, and as a privacy measure, it doesn't actually record the conversation.

"It shows a report, and then the doctor will validate with one click, and 99% of the time it's right and it works," he says.

The summary can be uploaded to a hospital records system, saving the doctor valuable time.

Other companies are pursuing a similar approach. In late March, Nuance Communications, a subsidiary of Microsoft, announced that it would be rolling out its own AI service designed to streamline note-taking using the latest version of ChatGPT, GPT-4. The company says it will showcase its software later this month.

The info is here.

Telehealth is here to stay. Psychologists should equip themselves to offer it.

Hannah Calkins

The Monitor On Psychology

Vol. 53 No. 7, Print version: page 30

Telehealth continues to play a significant role in the health care industry. However, psychologists who offer both in-person and virtual services are poised to meet increased demand for flexible, accessible mental health care.

In 2020, psychologists responded to the onset of the COVID-19 pandemic by making a nearly universal pivot to telehealth. This rapid and widespread adoption was largely enabled by the federal government’s declaration of a public health emergency (PHE), which prompted several significant policy changes that made telehealth more feasible for both patients and providers.

Yet in the following year, an APA survey found that 50% of psychologists had moved to offering both in-person and virtual services to their patients, up from 30% in 2020. Additionally, Pew Research Center data showed that 25% of adults with ­low incomes do not own smartphones, and 40% of this group do not have broadband internet or computers at home, signaling significant concerns about telehealth equity.

This means that psychologists should prepare for a hybrid future in which they deliver services via both modalities.

“Telehealth is here to stay. In-person isn’t going away,” said Robin McLeod, PhD, a licensed psychologist and president and chief business development officer at Natalis Psychology in St. Paul, Minnesota. “I believe it is vital for most psychologists to be able and willing to provide both options for patients. It just makes good business sense.”

Meeting demand for telehealth

Like many other providers, those at McLeod’s large practice made a quick pivot to virtual care during the pandemic and now offer hybrid options.

“[Our] providers have returned to providing in-person care, which many of our patients welcomed,” said McLeod. “However, most every provider in our organization continues to provide telehealth services for those clients who prefer that.”

Similarly, Zixuan Wang, PsyD, of Encounter Psychotherapy in Gaithersburg, Maryland, also has a robust hybrid practice. However, prior to spring 2020, she had never seriously considered offering telehealth.

“I am so appreciative that technology has enabled us to provide telehealth services, as they have been proven to be effective and beneficial for so many people who need care,” she said.

Wang and McLeod’s stories are scaled-down versions of the broader narrative of telehealth during the pandemic: Rapid and sustained implementation out of necessity has led to a permanent change.

The info is here.

When Patients Become Colleagues

Charles C. Dike

Psychiatric News

Published Online:27 Oct 2022

Dr. Jones, a psychiatrist in private practice, described to me a conundrum she was trying to resolve. A patient she has been treating for eight years with psychotherapy and medication was recently certified as a therapist. The patient intends to terminate treatment with her and set up a private practice in the same district as the psychiatrist. The new therapist is asking for a collaborative relationship with the psychiatrist in which he would refer patients to the psychiatrist for medication management. The psychiatrist is not comfortable with the proposal and worries that her deep knowledge of her ex-patient’s flaws would negatively influence her view of the patient as a therapist. Most importantly, however, she is concerned about the risks of boundary violations and a breach in confidentiality, for example, when patients ask about the relationship between the psychiatrist and their referring therapist, as often happens.

The APA Ethics Committee has received questions about similar situations. One such question involved a patient who had received psychiatric treatment at an institution for years and was now applying to work as a clinician at the same institution a decade later. In this case, the Ethics Committee affirmed the need for psychiatrists “to support the concept that treatment matters and that people can recover and live full lives by addressing the challenges of mental illness. Psychiatrists should model that seeking treatment is a healthful and positive behavior and not a stigmatized act that will forever preclude a person, once a patient, from joining a team of respected mental health professionals. A history of mental health treatment should not be used to ban employment; a history of appropriate qualifications and pursuit of necessary medical treatment should be positive indicators for employment.”

Nonetheless, every such situation requires deep reflection to avoid potential ethics breaches. In some cases, the guidance is clear. For example, it is unethical for a psychiatrist in a solo private practice to employ a former patient because the pre-existing doctor-patient relationship is likely to influence the working relationship on both sides with potential negative consequences. In Dr. Jones’s case, however, the situation has ethics considerations that need to be addressed. Here is the advice that I gave to Dr. Jones: After celebrating her patient’s success, she should schedule a private meeting to discuss the contours of their new professional relationship. She should clarify that it would be a challenge to be his psychiatrist in the future should he suffer a relapse and need care. Further, Dr. Jones should point out that a personal relationship with a former patient could be unethical, especially if intimate, and therefore, all social interactions should be avoided as much as possible. When it is not possible to avoid them, they should carefully manage their interactions, social or professional, making sure boundaries are not breached. Dr. Jones should also discuss possible circumstances that could insinuate to others that she and the therapist had a prior treatment relationship as any such acknowledgment on her part would be a breach of her patient’s confidentiality. The fact that her former patient discloses their relationship to others does not absolve the psychiatrist of this ethical injunction. Such a discussion would prevent future problems and set the stage for the next chapter of their relationship.

The info is here.

7 tell-tale red flags of medical gaslighting

Ashley Laderer

Insider.com

Originally published 29 AUG 2022

Here is an except:

"Medical gaslighting is a term recently used to describe when health care providers dismiss a patient's concerns, feelings, or complaints," says Faith Fletcher, an assistant professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine and a senior advisor to the Hastings Center, a bioethics research institute. 

Numerous studies over the years have found examples of medical gaslighting, whether it's interrupting a patient or misdiagnosing them based on unconscious biases about race or gender. Gaslighting in the medical field tends to affect marginalized groups the most.

"These interactions don't take place in a vacuum and are rooted in long-standing structural and social injustices such as racism, sexism, and class oppression in the US healthcare system," Fletcher says. 

Here are seven signs your doctor may be gaslighting you and the consequences it can have on your health.

1. They interrupt you

2. They rush you 

3. They won't discuss your symptoms with you

4. They let underlying biases affect diagnosis 

5. They say it's all in your head

6. They question the legitimacy of your medical history 

7. They're uncollaborative on treatment options

The information is here.

Defining Their Own Ethics, Online Creators Are De Facto Therapists for Millions—Explosive Demand & Few Safeguards

Tantum Hunter

The Washington Post

Originally posted 29 AUG 22

Here are two excerpts:

In real life, mental health information and care are sparse. In the United States, 1 in 3 counties do not have a single licensed psychologist, according to the American Psychological Association, and Americans say cost is a top barrier to seeking mental health help. On the internet, however, mental health tips are everywhere: TikTok videos with #mentalhealth in the caption have earned more than 43.9 billion views, according to the analytics company Sprout Social, and mentions of mental health on social media are increasing year by year.

The growing popularity of the subject means that creators of mental health content are filling a health-care gap. But social media apps are not designed to prioritize accurate, helpful information, critics say, just whatever content draws the biggest reaction. Young people could see their deepest struggles become fodder for advertisers and self-promoters. With no road map even for licensed professionals, mental health creators are defining their own ethics.

“I don’t want to give anyone the wrong advice,” Moloney says. “I’ve met some [followers] who’ve just started crying and saying ‘thank you’ and stuff like that. Even though it seems small, to someone else, it can have a really big impact.”

As rates of depression and anxiety spiked during the pandemic and options for accessible care dwindled, creators shared an array of content including first-person accounts of life with mental illness and videos listing symptoms of bipolar disorder. In many cases, their follower counts ballooned.

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Ideally, social media apps should be one item in a collection of mental health resources, said Jodi Miller, a researcher at Johns Hopkins University School of Education who studies the relationships among young people, technology and stress.

“Young people need evidence-based sources of information outside the internet, from parents and schools,” Miller said.

Often, those resources are unavailable. So it’s up to consumers to decide what mental health advice they put stock in, Fisher-Quann said. For her, condescending health-care providers and the warped incentives of social media platforms haven’t made that easy. But she thinks she can get better — and that her followers can, too.

“It all has to come from a place of self-awareness and desire to get better. Communities can be extremely helpful for that, but they can also be extremely harmful for that,” she said.

The article is here.

Making psychiatry moral again: the role of psychiatry in patient moral development

McConnell D, Broome M, Savulescu, J.

Journal of Medical Ethics 

Published Online First: 19 August 2022.

doi: 10.1136/jme-2022-108442

Abstract

Psychiatric involvement in patient morality is controversial. If psychiatrists are tasked with shaping patient morality, the coercive potential of psychiatry is increased, treatment may be unfairly administered on the basis of patients’ moral beliefs rather than medical need, moral disputes could damage the therapeutic relationship and, in any case, we are often uncertain or conflicted about what is morally right. Yet, there is also a strong case for the view that psychiatry often works through improving patient morality and, therefore, should aim to do so. Our goal is to offer a practical and ethical path through this conflict. We argue that the default psychiatric approach to patient morality should be procedural, whereby patients are helped to express their own moral beliefs. Such a procedural approach avoids the brunt of objections to psychiatric involvement in patient morality. However, in a small subset of cases where patients’ moral beliefs are sufficiently distorted or underdeveloped, we claim that psychiatrists should move to a substantive approach and shape the content of those beliefs when they are relevant to psychiatric outcomes. The substantive approach is prone to the above objections but we argue it is nevertheless justified in this subset of cases.

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Helping people elaborate a conception of morality has little risk of coercion and damage to the therapeutic relationship because the patient is requesting that content and is not committed to a conflicting moral position. Of course, it would be wrong to simply indoctrinate the patient so, to avoid that, the process of moral development should be patient-led as much as possible. However, if the moral views the patient gravitates towards in this process are clearly unreasonable, then the psychiatrist has an obligation to guide the patient’s views back within the bounds of reasonableness.

Psychiatrists are well placed to affect substantive moral growth. Their skill for helping people understand and elaborate their subjective worlds can reveal where the moral growth required to treat mental illness and support flourishing might be most easily achieved. We suggest a pluralist approach where the psychiatrist draws on any moral reasons, arguments or insights that help the patient achieve moral growth. In order to tailor moral reasons to the patient, psychiatrists would benefit not only from training in normative moral theories (eg, contractualism, deontology, consequentialism) but also from familiarity with a diverse range of autobiographical or fictional narratives that illustrate how different moral views are experienced and put into practice. The latter would also provide material that the psychiatrist could draw on to help the patient develop moral aspects of their own self-narrative. In the near future, the substantive approach could also benefit from pharmacotherapies, such as psychedelics, which might help patients who consent to such treatment become more receptive to new moral reasons, beliefs and emotions.

The info is here.

Ernst & Young to Pay $100 Million Penalty for Employees Cheating on CPA Ethics Exams and Misleading Investigation

Largest Penalty Ever Imposed by SEC Against an Audit Firm

FOR IMMEDIATE RELEASE

2022-114

Washington D.C., June 28, 2022 —

The Securities and Exchange Commission today charged Ernst & Young LLP (EY) for cheating by its audit professionals on exams required to obtain and maintain Certified Public Accountant (CPA) licenses, and for withholding evidence of this misconduct from the SEC’s Enforcement Division during the Division’s investigation of the matter. EY admits the facts underlying the SEC’s charges and agrees to pay a $100 million penalty and undertake extensive remedial measures to fix the firm’s ethical issues.

“This action involves breaches of trust by gatekeepers within the gatekeeper entrusted to audit many of our Nation’s public companies. It’s simply outrageous that the very professionals responsible for catching cheating by clients cheated on ethics exams of all things,” said Gurbir S. Grewal, Director of the SEC’s Enforcement Division. “And it’s equally shocking that Ernst & Young hindered our investigation of this misconduct. This action should serve as a clear message that the SEC will not tolerate integrity failures by independent auditors who choose the easier wrong over the harder right.”

EY admits that, over multiple years, a significant number of EY audit professionals cheated on the ethics component of CPA exams and various continuing professional education courses required to maintain CPA licenses, including ones designed to ensure that accountants can properly evaluate whether clients’ financial statements comply with Generally Accepted Accounting Principles.

EY further admits that during the Enforcement Division’s investigation of potential cheating at the firm, EY made a submission conveying to the Division that EY did not have current issues with cheating when, in fact, the firm had been informed of potential cheating on a CPA ethics exam. EY also admits that it did not correct its submission even after it launched an internal investigation into cheating on CPA ethics and other exams and confirmed there had been cheating, and even after its senior lawyers discussed the matter with members of the firm’s senior management. And as the Order finds, EY did not cooperate in the SEC’s investigation regarding its materially misleading submission.

The entire press release is here.