Do Physicians Have an Ethical Duty to Repair Relationships with So-Called “Difficult” Patients?

Micah Johnson
AMA Journal of Ethics. April 2017, Volume 19, Number 4: 323-331.
doi: 10.1001/journalofethics.2017.19.04.ecas1-1704.

Abstract

This essay argues that physicians hold primary ethical responsibility for repairing damaged patient-physician relationships. The first section establishes that the patient-physician relationship has an important influence on patient health and argues that physicians’ duty to treat should be understood as including a responsibility to repair broken relationships, regardless of which party was “responsible” for the initial tension. The second section argues that the person with more power to repair the relationship also has more responsibility to do so and considers the moral psychology of pain as foundational to conceiving the patient in this case as especially vulnerable and disempowered. The essay concludes with suggestions for clinicians to act on the idea that a healthy patient-physician relationship ought to lie at the center of medicine’s moral mission.

The article is here.

The Real Problem With Hypocrisy

By Jillian Jordan, Roseanna Sommers, and David Rand
The New York Times - Gray Matters
Originally posted January 13, 2017

What, exactly, is the problem with hypocrisy? When someone condemns the behavior of others, why do we find it so objectionable if we learn he engages in the same behavior himself?

The answer may seem self-evident. Not practicing what you preach; lacking the willpower to live up to your own ideals; behaving in ways you obviously know are wrong — these are clear moral failings.

Perhaps. But new research of ours, forthcoming in the journal Psychological Science (and in collaboration with our colleague Paul Bloom), suggests a different explanation. We contend that the reason people dislike hypocrites is that their outspoken moralizing falsely signals their own virtue. People object, in other words, to the misleading implication — not to a failure of will or a weakness of character.

The article is here.

Medical students need to learn the potent medicine of empathy

By Wolfgang Gilliar
STAT News
Originally published September 29, 2016

Here is an excerpt:

How does empathy do this? A patient who feels emotionally connected to his or her doctor is more likely to disclose important medical information and to follow the doctor’s advice. That connection can serve as the basis for true teamwork, with the patient working proactively with the medical team to improve health. Simply put, patients who feel cared about feel better and do better.

There’s also great promise in osteopathic medicine, which couples traditional medical interventions with skilled, specialized, hands-on treatments for the body’s complex system of nerves, muscles, and bones. “Healing touch” isn’t just a metaphor. This simple physical action evokes trust in patients.

Without empathy, doctors run the risk of alienating their patients. The relationship can become one-sided, with the physician simply dictating treatments and the patient following orders. Core emotional needs can be ignored, leading patients to feel lonely and downtrodden. And that deterioration of mood can make it less likely that they will experience positive outcomes from treatment.

The article is here.

Bad News Delivered Badly

By Susan Gubar
The New York Times - Well
Originally posted May 19, 2016

Here is an excerpt:

None of us were eased by communication strategies that have evolved since 2000 when Dr. Walter F. Baile and his associates published their paradigm for delivering bad news in The Oncologist. This article advocates a program called Spikes: S stands for finding the appropriate setting; P for gauging the perceptions of the patient; I for obtaining the patient’s invitation to hear bad news; K for providing the knowledge that the patient needs to receive; E for dealing with the emotional reactions of the patient with empathy; S for concluding with a needed summary.

Despite such a thoughtful template, miscommunication does not taint only diagnosis, as I.M. realized when she went on to confide about a more recent exchange. At her last meeting with her oncologist, they had discussed the sorry fact that the current cycle of chemotherapy had not inhibited tumor growth. The doctor gave her three choices: returning to the drug used in her first cycle, trying a clinical trial or “opting to do nothing.” Alarmed and shaken by this last proposal, she felt as if he were throwing up his hands or she had somehow been fired.

The article is here.

Ghosting on Freud: why breaking up with a therapist is so tricky

Alana Massey
The Guardian
Originally posted May 2, 2016

Here is an excerpt:

Carole Lieberman, a psychiatrist in California, said that patients need to take on some responsibility in letting therapists know when things aren’t working out. “Patients need to come for at least one more session when they are thinking of breaking up with their therapist. Oftentimes, the therapist can resolve a misunderstanding that occurred, or help them to understand why it’s important for them to delve into their past. Even if the patient still decides to leave, they will do so with more insight into themselves and with an open door to return.”

But this expectation demands a great deal, too. Is it really the job of the patient to offer tips and tricks on how the therapist can improve their approach, particularly if the patient is already in a vulnerable or wounded state? Therapists who expect everyone to be experts at the therapeutic process are going to miss or dismiss the patients who need therapy the most.

The article is here.

Engaging Patients Through OpenNotes: An Evaluation Using Mixed Methods

Tobias Esch, Roanne Mejilla1, M. Anselmo1, B. Podtschaske, T. Delbanco, J. Walker
BMJ Open, published online Jan. 29, 2016.

Abstract

Objectives 

(A) To gain insights into the experiences of patients invited to view their doctors’ visit notes, with a focus on those who review multiple notes;

(B) to examine the relationships among fully transparent electronic medical records and quality of care, the patient-doctor relationship, patient engagement, self-care, self-management skills and clinical outcomes.

(cut)

Results 

Patient experiences indicate improved understanding (of health information), better relationships (with doctors), better quality (adherence and compliance; keeping track) and improved self-care (patient-centredness, empowerment). Patients want more doctors to offer access to their notes, and some wish to contribute to their generation. Those patients with repeated experience reviewing notes express fewer concerns and more perceived benefits.

Conclusions 

As the use of fully transparent medical records spreads, it is important to gain a deeper understanding of possible benefits or harms, and to characterise target populations that may require varying modes of delivery. Patient desires for expansion of this practice extend to specialty care and settings beyond the physician's office. Patients are also interested in becoming involved actively in the generation of their medical records. The OpenNotes movement may increase patient activation and engagement in important ways.

The article is here.

Reconceptualizing Autonomy: A Relational Turn in Bioethics

Bruce Jennings
The Hastings Center Report
Article first published online: 5 FEB 2016
DOI: 10.1002/hast.544

Abstract
History's judgment on the success of bioethics will not depend solely on the conceptual creativity and innovation in the field at the level of ethical and political theory, but this intellectual work is not insignificant. One important new development is what I shall refer to as the relational turn in bioethics. This development represents a renewed emphasis on the ideographic approach, which interprets the meaning of right and wrong in human actions as they are inscribed in social and cultural practices and in structures of lived meaning and interdependence; in an ideographic approach, the task of bioethics is to bring practice into theory, not the other way around.

The relational turn in bioethics may profoundly affect the critical questions that the field asks and the ethical guidance it offers society, politics, and policy. The relational turn provides a way of correcting the excessive atomism of many individualistic perspectives that have been, and continue to be, influential in bioethics. Nonetheless, I would argue that most of the work reflecting the relational turn remains distinctively liberal in its respect for the ethical significance of the human individual. It moves away from individualism, but not from the value of individuality.In this review essay, I shall focus on how the relational turn has manifested itself in work on core concepts in bioethics, especially liberty and autonomy. Following a general review, I conclude with a brief consideration of two important recent books in this area: Jennifer Nedelsky's Law's Relations and Rachel Haliburton's Autonomy and the Situated Self.

The article is here.

Reputation, a universal currency for human social interactions

Manfred Milinski
Philosophical Transactions B
Published 4 January 2016.
DOI: 10.1098/rstb.2015.0100

Abstract

Decision rules of reciprocity include ‘I help those who helped me’ (direct reciprocity) and ‘I help those who have helped others’ (indirect reciprocity), i.e. I help those who have a reputation to care for others. A person's reputation is a score that members of a social group update whenever they see the person interacting or hear at best multiple gossip about the person's social interactions. Reputation is the current standing the person has gained from previous investments or refusal of investments in helping others. Is he a good guy, can I trust him or should I better avoid him as a social partner? A good reputation pays off by attracting help from others, even from strangers or members from another group, if the recipient's reputation is known. Any costly investment in others, i.e. direct help, donations to charity, investment in averting climate change, etc. increases a person's reputation. I shall argue and illustrate with examples that a person's known reputation functions like money that can be used whenever the person needs help. Whenever possible I will present tests of predictions of evolutionary theory, i.e. fitness maximizing strategies, mostly by economic experiments with humans.

The article is here.

Microaggression, macro harm

By Regina Rini
The Los Angeles Times
Originally published on October 15, 2015

Here is an excerpt:

There is a serious problem with Campbell and Manning's moral history, and exposing it helps us see that the culture of victimhood label is misleading. Their history is a history of the dominant moral culture: It describes the mores of those social groups with the greatest access to power. Think about the culture of honor and notice how limited it must have been. If you were a woman in medieval Europe, you were not expected or permitted to respond to insults with aggression. Even if you were a lower-class man, you certainly would not have drawn your sword in response to an insult from a superior.

Now think about the culture of dignity, which Campbell and Manning claim “existed perhaps in its purest form among respectable people in the homogenous towns of mid-20th century America.” Another thing that existed among the “respectable people” in those towns was approval of racial segregation; “homogenous towns” did not arise by accident.

People of color, women, gay people, immigrants: none could rely on the authorities to respond fairly to reports of mistreatment.

The cultures of honor and dignity left many types of people with no recognized way of responding to moral mistreatment.

The entire article is here.

Memory and Morality: What Determines How Others See Us?

By Kathleen Lees
Science World Report
Originally published August 17, 2015

Here is an excerpt:

Statistical models also showed that perceived identity change was strongly linked with change in moral traits, with close to no other symptom, including depression, amnesia, and changes in personality traits, holding observable impact on perceived identity change.

Furthermore, the researchers based the degree of perceived identity change on how much they felt their relationship with the patient had deteriorated, as well as the association that was driven by the degree of change in the patient's moral traits.

Researchers also found that the degree of perceived identity change was associated with how much the participants thought their relationship with the patient had deteriorated, and this association was driven by the degree of change in the patient's moral traits.

The entire article is here.

Is Consciousness an Engineering Problem?

We could build an artificial brain that believes itself to be conscious. Does that mean we have solved the hard problem?

By Michael Graziano
Aeon Magazine
Originally published July 10, 2015

Here is an excerpt:

As long as scholars think of consciousness as a magic essence floating inside the brain, it won’t be very interesting to engineers. But if it’s a crucial set of information, a kind of map that allows the brain to function correctly, then engineers may want to know about it. And that brings us back to artificial intelligence. Gone are the days of waiting for computers to get so complicated that they spontaneously become conscious. And gone are the days of dismissing consciousness as an airy-fairy essence that would bring no obvious practical benefit to a computer anyway. Suddenly it becomes an incredibly useful tool for the machine.

The entire article is here.

Instilling empathy among doctors pays off for patient care

By Sandra G. Boodman via Kaiser Health News
CNN website
Originally posted March 26, 2015

Here is an excerpt:

Clinical empathy was once dismissively known as "good bedside manner" and traditionally regarded as far less important than technical acumen. But a spate of studies in the past decade has found that it is no mere frill. Increasingly, empathy is considered essential to establishing trust, the foundation of a good doctor-patient relationship.

Studies have linked empathy to greater patient satisfaction, better outcomes, decreased physician burnout and a lower risk of malpractice suits and errors. Beginning this year, the Medical College Admission Test will contain questions involving human behavior and psychology, a recognition that being a good doctor "requires an understanding of people," not just science, according to the American Association of Medical Colleges. Patient satisfaction scores are now being used to calculate Medicare reimbursement under the Affordable Care Act. And more than 70 percent of hospitals and health networks are using patient satisfaction scores in physician compensation decisions.

The entire article is here.

The Ethics of Physicians’ Web Searches for Patients’ Information

Nicholas Genes and Jacob Appel
The Journal of Clinical Ethics
Volume 26, Number 1, Spring 2015

When physicians search the web for personal information about their patients, others have argued that this undermines  patients’ trust, and the physician-patient relationship in general. We add that this practice also places other relationships at risk, and could jeopardize a physician’s career.

Yet there are also reports of web searches that have unambiguously helped in the care of patients, suggesting circumstances in which a routine search of the web could be beneficial. We advance the notion that, just as nonverbal cues and unsolicited information can be useful in clinical decision making, so too can online information from patients. As electronic records grow more voluminous and span more types of data, searching these resources will become a clinical skill, to be used judiciously and with care—just as evaluating the literature is, today.

But to proscribe web searches of patients’ information altogether is as nonsensical as disregarding findings from physical exams—instead, what’s needed are guidelines for when to look and how to evaluate what’s uncovered, online.

The entire article is here.

Physician guidelines for Googling patients need revision

By Jennifer Abbasi
Penn State News
Originally posted February 2, 2015

With the Internet and social media becoming woven into the modern medical practice, Penn State College of Medicine researchers contend that professional medical societies must update or amend their Internet guidelines to address when it is ethical to "Google" a patient.

"As time goes on, Googling patients is going to become more and more common, especially with doctors who grew up with the Internet," says Maria J. Baker, associate professor of medicine.

Baker has dealt with the question first hand in her role as a genetic counselor and medical geneticist. In a case that inspired her recent paper in the Journal of General Internal Medicine, a patient consulted her regarding prophylactic mastectomies. The patient's family history of cancer could not be verified and then a pathology report revealed that a melanoma the patient listed had actually been a non-cancerous, shape-changing mole.

The entire article is here.

Clinical supervision of psychotherapy: essential ethics issues for supervisors and supervisees

By Jeffrey E. Barnett and Corey H. Molzon
J Clin Psychol 2014 Nov 14;70(11):1051-61. Epub 2014 Sep 14.

Abstract

Clinical supervision is an essential aspect of every mental health professional's training. The importance of ensuring that supervision is provided competently, ethically, and legally is explained. The elements of the ethical practice of supervision are described and explained. Specific issues addressed include informed consent and the supervision contract, supervisor and supervisee competence, attention to issues of diversity and multicultural competence, boundaries and multiple relationships in the supervision relationship, documentation and record keeping by both supervisor and supervisee, evaluation and feedback, self-care and the ongoing promotion of wellness, emergency coverage, and the ending of the supervision relationship. Additionally, the role of clinical supervisor as mentor, professional role model, and gatekeeper for the profession are discussed. Specific recommendations are provided for ethically and effectively conducting the supervision relationship and for addressing commonly arising dilemmas that supervisors and supervisees may confront.

The entire article is here.

Robert Wright: The evolution of compassion

TED Talk Video
Originally published October 2009

Robert Wright uses evolutionary biology and game theory to explain why we appreciate the Golden Rule ("Do unto others..."), why we sometimes ignore it and why there’s hope that, in the near future, we might all have the compassion to follow it.

The Philosophy of ‘Her’

By Susan Schneider
The New York Times
Originally published March 2, 2014

Here is an excerpt:

“Her” raises two questions that have long preoccupied philosophers. Are nonbiological creatures like Samantha capable of consciousness — at least in theory, if not yet in practice? And if so, does that mean that we humans might one day be able to upload our own minds to computers, perhaps to join Samantha in being untethered from “a body that’s inevitably going to die”?

(cut)

Some people argue that the capacity to be conscious is unique to biological organisms, so that even superintelligent A.I. programs would be devoid of conscious experience. If this view is correct, then a relationship between a human being and a program like Samantha, however intelligent she might be, would be hopelessly one-sided. Moreover, few humans would want to join Samantha, for to upload your brain to a computer would be to forfeit your consciousness.

The entire article is here.

Online Medical Professionalism: Patient and Public Relationships

Policy Statement From the American College of Physicians and the Federation of State Medical Boards

By Jeanne M. Farnan, Lois Snyder Sulmasy, and others
Ann Intern Med. 2013;158(8):620-627. doi:10.7326/0003-4819-158-8-201304160-00100

Abstract

User-created content and communications on Web-based applications, such as networking sites, media sharing sites, or blog platforms, have dramatically increased in popularity over the past several years, but there has been little policy or guidance on the best practices to inform standards for the professional conduct of physicians in the digital environment. Areas of specific concern include the use of such media for nonclinical purposes, implications for confidentiality, the use of social media in patient education, and how all of this affects the public's trust in physicians as patient–physician interactions extend into the digital environment. Opportunities afforded by online applications represent a new frontier in medicine as physicians and patients become more connected. This position paper from the American College of Physicians and the Federation of State Medical Boards examines and provides recommendations about the influence of social media on the patient–physician relationship, the role of these media in public perception of physician behaviors, and strategies for physician–physician communication that preserve confidentiality while best using these technologies.

The entire policy statement is here.