Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Treatment Relationship. Show all posts
Showing posts with label Treatment Relationship. Show all posts

Tuesday, April 20, 2021

State Medical Board Recommendations for Stronger Approaches to Sexual Misconduct by Physicians

King PA, Chaudhry HJ, Staz ML. 
Published online March 29, 2021. 

The Federation of State Medical Boards (FSMB) recently engaged with its member boards and investigators, trauma experts, physicians, resident physicians, medical students, survivors of physician abuse, and the public to critically review practices related to the handling of reports of sexual misconduct (including harassment and abuse) toward patients by physicians. The review was undertaken as part of a core responsibility of boards to protect the public and motivated by concerning reports of unacceptable behavior by physicians. Specific recommendations from the review were adopted by the FSMB’s House of Delegates on May 2, 2020, and are highlighted in this Viewpoint.

Sexual misconduct by physicians exists along a spectrum of severity that may begin with “grooming” behaviors and end with sexual assault. Behaviors at any point on this spectrum should be of concern because unreported minor violations (including sexually suggestive comments or inappropriate physical contact) may lead to greater misconduct. In 2018, the National Academies of Science, Engineering, and Medicine identified sexual harassment as an important problem in scientific communities and medicine, finding that greater than 50% of women faculty and staff and 20% to 50% of women students reportedly have encountered or experienced sexually harassing conduct in academia. Data from state medical boards indicate that 251 disciplinary actions were taken against physicians in 2019 for “sexual misconduct” violations (Table). The actual number may be higher because boards often use a variety of terms, including unprofessional conduct, physician-patient boundary issues, or moral unfitness, to describe such actions. The FSMB has begun a project to encourage boards to align their categorization of all disciplinary actions to better understand the scope of misconduct.

Friday, June 19, 2020

My Bedside Manner Got Worse During The Pandemic. Here's How I Improved

Shahdabul Faraz
Health Shots
Originally published 16 May 20

Here is an excerpt:

These gestures can be as simple as sitting in a veteran's room for an extra five minutes to listen to World War II stories. Or listening with a young cancer patient to a song by our shared favorite band. Or clutching a sick patient's shoulder and reassuring him that he will see his three daughters again.

These gestures acknowledge a patient's humanity. It gives them some semblance of normalcy in an otherwise difficult period in their lives. Selfishly, that human connection also helps us — the doctors, nurses and other health care providers — deal with the often frustrating nature of our stressful jobs.

Since the start of the pandemic, our bedside interactions have had to be radically different. Against our instincts, and in order to protect our patients and colleagues, we tend to spend only the necessary amount of time in our patients' rooms. And once inside, we try to keep some distance. I have stopped holding my patients' hands. I now try to minimize small talk. No more whimsical conversational detours.

Our interactions now are more direct and short. I have, more than once, felt guilty for how quickly I've left a patient's room. This guilt is worsened, knowing that patients in hospitals don't have family and friends with them now either. Doctors are supposed to be there for our patients, but it's become harder than ever in recent months.

I understand why these changes are needed. As I move through several hospital floors, I could unwittingly transmit the virus if I'm infected and don't know it. I'm relatively young and healthy, so if I get the disease, I will likely recover. But what about my patients? Some have compromised immune systems. Most are elderly and have more than one high-risk medical condition. I could never forgive myself if I gave one of my patients COVID-19.

The info is here.

Monday, April 20, 2020

How Becoming a Doctor Made Me a Worse Listener

Adeline Goss
JAMA. 2020;323(11):1041-1042.

Here is an excerpt:

And I hadn’t noticed. Maybe that was because I was still connecting to patients. I still choked up when they cried, felt joy when they rejoiced, felt moved by and grateful for my work, and generally felt good about the care I was providing.

But as I moved through my next days in clinic, I began to notice the unconscious tricks I had developed to maintain a connection under time pressure. A whole set of expressions played out across my face during history taking—nonverbal concern, nonverbal gentleness, nonverbal apology—a time-efficient method of conveying empathy even when I was asking directed questions, controlling the type and volume of information I received, and, at times, interrupting. Sometimes I apologized to patients for my style of interviewing, explaining that I wanted to make sure I understood things clearly so that I could treat them. I apologized because I didn’t like communicating this way. I can’t imagine it felt good to them.

What’s strange is that, at the end of these visits, patients often thanked me for my concern and detail-orientedness. They may have interpreted my questioning as a sign that I was interested. But was I?

Interest is a multilayered concept in medicine. I care about patients, and I am interested in their stories in the sense that they contain the information I need to make the best possible decisions for their care. Interest motivates doctors to take a detailed history, review the chart, and analyze the literature. Interest leads to the correct diagnosis and treatment. Residency rewards this kind of interest. Perhaps as a result, looking around at my co-residents, it’s in abundant supply, even when time is tight.

The info is here.

Thursday, October 3, 2019

Empathy in the Age of the EMR

Danielle Ofri
The Lancet

Here is an excerpt:

Keeping the doctor-patient connection from eroding in the age of the EMR is an uphill battle. We all know that the eye contact that Fildes depicts is a critical ingredient for communication and connection, but when the computer screen is so demanding of focus that the patient becomes a distraction, even an impediment—this is hopelessly elusive.

Recently, I was battling the EMR during a visit with a patient who had particularly complicated medical conditions. We hadn’t seen each other in more than a year, so there was much to catch up on. Each time she raised an issue, I turned to the computer to complete the requisite documentation for that concern. In that pause, however, my patient intuited a natural turn of conversation. Thinking that it was now her turn to talk, she would bring up the next thing on her mind. But of course I wasn’t finished with the last thing, so I would say, “Would you mind holding that thought for a second? I just need to finish this one thing…”

I’d turn back to the computer and fall silent to finish documenting. After a polite minute, she would apparently sense that it was again her turn in the conversation and thus begin her next thought. I was torn because I didn’t want to stop her in her tracks, but we’ve been so admonished about the risks inherent in distracted multitasking that I wanted to focus fully on the thought I was entering into the computer. I know it’s rude to cut someone off, but preserving a clinical train of thought is crucial for avoiding medical error.

The info is here.

Monday, May 6, 2019

Ethical Considerations Regarding Internet Searches for Patient Information.

Charles C. Dike, Philip Candilis, Barbara Kocsis  and others
Psychiatric Services
Published Online:17 Jan 2019


In 2010, the American Medical Association developed policies regarding professionalism in the use of social media, but it did not present specific ethical guidelines on targeted Internet searches for information about a patient or the patient’s family members. The American Psychiatric Association (APA) provided some guidance in 2016 through the Opinions of the Ethics Committee, but published opinions are limited. On behalf of the APA Ethics Committee, the authors developed a resource document describing ethical considerations regarding Internet and social media searches for patient information, from which this article has been adapted. Recommendations include the following. Except in emergencies, it is advisable to obtain a patient’s informed consent before performing such a search. The psychiatrist should be aware of his or her motivations for performing a search and should avoid doing so unless it serves the patient’s best interests. Information obtained through such searches should be handled with sensitivity regarding the patient’s privacy. The psychiatrist should consider how the search might influence the clinician-patient relationship. When interpreted with caution, Internet- and social media–based information may be appropriate to consider in forensic evaluations.

The info is here.

Saturday, April 20, 2019

Cardiologist Eric Topol on How AI Can Bring Humanity Back to Medicine

Alice Park
Originally published March 14, 2019

Here is an excerpt:

What are the best examples of how AI can work in medicine?

We’re seeing rapid uptake of algorithms that make radiologists more accurate. The other group already deriving benefit is ophthalmologists. Diabetic retinopathy, which is a terribly underdiagnosed cause of blindness and a complication of diabetes, is now diagnosed by a machine with an algorithm that is approved by the Food and Drug Administration. And we’re seeing it hit at the consumer level with a smart-watch app with a deep learning algorithm to detect atrial fibrillation.

Is that really artificial intelligence, in the sense that the machine has learned about medicine like doctors?

Artificial intelligence is different from human intelligence. It’s really about using machines with software and algorithms to ingest data and come up with the answer, whether that data is what someone says in speech, or reading patterns and classifying or triaging things.

What worries you the most about AI in medicine?

I have lots of worries. First, there’s the issue of privacy and security of the data. And I’m worried about whether the AI algorithms are always proved out with real patients. Finally, I’m worried about how AI might worsen some inequities. Algorithms are not biased, but the data we put into those algorithms, because they are chosen by humans, often are. But I don’t think these are insoluble problems.

The info is here.

Saturday, December 8, 2018

Psychological health profiles of Canadian psychotherapists: A wake up call on psychotherapists’ mental health

Laverdière, O., Kealy, D., Ogrodniczuk, J. S., & Morin, A. J. S.
(2018) Canadian Psychology/Psychologie canadienne, 59(4), 315-322.


The mental health of psychotherapists represents a key determinant of their ability to deliver optimal psychological services. However, this important topic is seldom the focus of empirical investigations. The objectives of the current study were twofold. First, the study aimed to assess subjective ratings of mental health in a broad sample of Canadian psychotherapists. Second, this study aimed to identify profiles of psychotherapists according to their scores on a series of mental health indicators. A total of 240 psychotherapists participated in the survey. Results indicated that 20% of psychotherapists were emotionally exhausted and 10% were in a state of significant psychological distress. Latent profile analyses revealed 4 profiles of psychotherapists that differed on their level of mental health: highly symptomatic (12%), at risk (35%), well adapted (40%), and high functioning (12%). Characteristics of the profiles are discussed, as well as potential implications of our findings for practice, trainee selection, and future research on psychotherapists’ mental health.

Here is part of the Discussion:

Considering that 12% of the psychotherapists were highly symptomatic and that an additional 35% could be considered at risk for significant mental health problems, the present findings raise troubling questions. Were these psychotherapists adequately prepared to help clients? From the perspective of attachment theory, the psychotherapist functions as an attachment figure for the client (Mallinckrodt, 2010); clients require their psychotherapists to provide a secure attachment base that allows for the exploration of negative thoughts and feelings, as well as for the alleviation of distress (Slade, 2016). A psychotherapist who is preoccupied with his or her own personal distress may find it very difficult to play this role efficiently and may at least implicitly bring some maladaptive features to the clinical encounter, thus depriving the client of the possibility of experiencing a secure attachment in the context of the therapeutic relationship. Moreover, regardless of the potential attachment implications, clients prefer experiencing a secure relationship with an emotionally responsive psychotherapist (Swift & Callahan, 2010). More precisely, Swift and Callahan (2010) found that clients were, to some extent, willing to forego empirically supported interventions in favour of a satisfactory relationship with the therapist, empathy from the therapist, and greater level of therapist experience. The present results cast a reasonable doubt on the ability of extenuated psychotherapists, and more so psychologically ill therapists, to present themselves in a positive light to the client in order to build strong therapeutic relationships with them.

Monday, October 29, 2018

The dismantling of informed consent is a disaster

David Penner
Originally posted September 26, 2018

Informed consent is the cornerstone of medical ethics. And every physician must defend this sacred principle from every form of evil that would seek to dismantle, degrade and debase it. If informed consent is the sun, then privacy, confidentiality, dignity, and trust are planets that go around it. For without informed consent, the descent of health care into amorality is inevitable, and the doctor-patient relationship is doomed to ruination, oblivion, and despair. It is also important to acknowledge the fact that a lack of informed consent has become endemic to our health care system.

This betrayal of patient trust is inextricably linked to three violations: a rape of the body, a rape of the mind and a rape of the soul. The rape of the mind is anchored in a willful nondisclosure of common long-term side effects associated with powerful drugs, such as opioids and certain types of chemotherapy. When a patient starts a chemotherapy regimen, they are typically briefed by a nurse, who proceeds to educate them regarding common short-term side effects such as mouth sores, constipation, and nausea, while failing to mention any of the typical long-term side effects, such as cognitive difficulties and early menopause. It is the long-term side effects that underscore the tragedy of having to resort to chemotherapy, as they can have a devastating impact on a patient’s quality of life, even long after remission has been attained.

The info is here.

Tuesday, September 18, 2018

Changing the way we communicate about patients

Abraar Karan
BMJ Blog
Originally posted August 29, 2018

Here is an excerpt:

There are many changes that we can make to improve how we communicate about patients. One of the easiest and most critical transformations is how we write our medical notes. One of the best doctors I ever worked with did exactly this, and is famous at the Brigham (our hospital) for doing it. He systematically starts every single note with the person’s social history. Who is this patient? It is not just a lady with abdominal pain. It is a mother of three, a retired teacher, and an active cyclist. That is the first thing we read about her, and so when I enter her room, I can’t help but see her this way rather than as a case of appendicitis.

This matters because patients deserve to be treated as people—a statement that’s so obvious it shouldn’t need to be said, but which physician behaviour doesn’t always reflect. You wouldn’t expect to know the most sensitive and vulnerable aspects of someone before even knowing their most basic background, yet we do this in medicine all the time. This is also important because in many clinical presentations, it provides critical information that helps deduce how they got sick, and why they may get sick again in the same way if we don’t restructure something essential in their life. For instance, if I didn’t know that the 22 year old opioid addict had just been kicked out of his house and is on the street without transportation to get to his suboxone clinic, I will not have truly solved what brought him to the hospital in the first place.

The info is here.

Monday, April 23, 2018

Shared Decision-making for PTSD

Juliette Harik, PhD
PTSD Research Quarterly (2018) Volume 29 (1)

Here is an excerpt:

Although several different shared decision-making models exist (for a review see Lin & Fagerlin, 2014), one useful approach conceptualizes shared decision-making as consisting of three phases
(Elwyn et al., 2012): choice talk, option talk, and decision talk. Choice talk involves communicating
to patients that there is a decision to make and that they can be involved in this decision to the extent
that they are comfortable. Option talk consists of sharing accurate and comprehensive information
about treatment options. Ideally, this involves the use of a decision aid, which is an educational tool
such as a website, brochure, or video designed to help patients understand and compare various
options (for a review, see Stacey et al., 2017). The third and final step, decision talk, consists of an
exploration of the patient’s preferences and what matters most to him or her. The process of shared
decision-making is intended to help the patient develop informed preferences, and ultimately arrive
at the decision that is best for him or her. Importantly, patients with the same clinical condition may arrive at very different treatment decisions on the basis of unique values and preferences.

Shared decision-making has been evaluated most often among patients facing care decisions for chronic medical conditions, especially cancer. In medical patients, shared decision-making has been linked with greater confidence in the treatment decision, improved satisfaction with decision-making and with treatment, greater self-efficacy, and increased trust in the provider (Joosten et al., 2008; Shay & Lafata, 2015). In mental health, shared decision-making has been most often evaluated in the context of depression, yielding mixed results on both satisfaction and treatment outcomes (Duncan, Best, & Hagen, 2010). Fewer studies have evaluated the effectiveness of shared decision-making for other mental health conditions such as PTSD.

The information is here.

Friday, February 16, 2018

Health Care Workers & Moral Objections I: Procedures

Mike LaBossiere
Talking Philosophy
Originally published on January 18, 2018

Here is an excerpt:

But, this moral coin has another side—entering a profession, especially in the field of health, also comes with moral and professional responsibilities. These responsibilities can, like all responsibilities, can justly impose burdens. For example, doctors are not permitted to instantly abandon patients they dislike or because they want to move to a better paying position. As such, ethics of a health worker refusing to perform a procedure based on their moral or religious views requires that each procedure be reviewed to determine whether it is one that a health care worker can justly refuse or one that is a justly imposed burden.

To illustrate, consider a doctor who is asked to keep prisoners conscious and alive during torture performed by agents of the state. Most doctors, like most people, would have moral objections to being involved in torture. However, there is the question of whether this would be something they should be morally expected to do as part of their profession. On the face of it, since the purpose of the medical profession is to heal and alleviate suffering (a professional ethics that goes back to the origin of western medicine) this is not something that a doctor is obligated to do even in the face of moral objections. In fact, the ethics of the profession would dictate against engaging in this behavior.

Now, imagine a health care worker who has sincere religious or moral beliefs that when a person can no longer sustain their life on their own, they must be released to God. As such, the worker refuses to engage in procedures that violate their principles, such as keeping a patient on life support. While this could be a sincerely held belief, it seems to run counter to the ethics of the profession. As such, such a health care worker would seem to not have the right to refuse such services.

The article is here.

Tuesday, November 21, 2017

Harnessing the Placebo Effect: Exploring the Influence of Physician Characteristics on Placebo Response

Lauren C. Howe, J. Parker Goyer, and Alia J. Crum
Health Psychology, 36(11), 1074-1082.


Objective: Research on placebo/nocebo effects suggests that expectations can influence treatment outcomes, but placebo/nocebo effects are not always evident. This research demonstrates that a provider’s social behavior moderates the effect of expectations on physiological outcomes.

Methods: After inducing an allergic reaction in participants through a histamine skin prick test, a health care provider administered a cream with no active ingredients and set either positive expectations (cream will reduce reaction) or negative expectations (cream will increase reaction). The provider demonstrated either high or low warmth, or either high or low competence.

Results: The impact of expectations on allergic response was enhanced when the provider acted both warmer and more competent and negated when the provider acted colder and less competent.

Conclusion: This study suggests that placebo effects should be construed not as a nuisance variable with mysterious impact but instead as a psychological phenomenon that can be understood and harnessed to improve treatment outcomes.

Link to the pdf is here.

Monday, June 6, 2016

Freedom of patient-physician conversations hinges on court case

AMA Wire
Originally posted May 16, 2016

A federal court will be hearing a case about the constitutionality of a state law that represses free discussion between physicians and patients regarding health and safety issues.

In a friend-of-the-court brief filed April 26, the AMA and eight other medical societies urged the Court of Appeals for the 11th Circuit to overturn a Florida law that restricts physicians from discussing firearm safety with patients and their families.

The brief argues that the Firearm Owners’ Privacy Act is unconstitutional and intrudes on the practice of medicine. The law will inevitably affect other aspects of patient care, the brief says.

The press release is here.

Monday, April 25, 2016

Shame and Blame in the Therapeutic Relationship

Ami Schattner
JAMA Intern Med. Published online April 04, 2016.

Here is an excerpt:

[The physician-patient relationship] requires full commitment providing information, empathy, and bonding obligatory for patient-centeredness, patient satisfaction, trust, and adherence which translate into "hard" health outcomes. Because clinical care is strongly dependent on this human interaction, it is also susceptible to inherent biases (mostly unintentional) that are one major cause of variation in care. In this context, providers' reactions to certain patients may involve negative feelings adversely affecting the degree of effort invested in their care, diagnostic accuracy, treatment decisions, and level of communication, empathy and support. Stigmatized patients may get different (less than optimal) care, just as "nice" patients may be preferred and receive better care. Instead of empathy and bonding, which have a positive impact on outcomes, censure, absent compassion, diminished bonding, and poor support toward patients who caused their own wretched state are likely, as well as actual variation in care, all compromising patient outcomes. For example, poor provider's empathy and bonding on the part of the clinician was linked to low patient adherence and may be associated with actual discrimination and rationing.

The article is here.

Wednesday, May 20, 2015

How is the doctor-patient relationship changing? It’s going electronic.

By Suzanne Allard Levingston
The Washington Post
Originally posted April 27, 2015

Here are two excerpts:

Almost three-quarters of American adults use the Internet to search online for health information each year, according to the Pew Research Center. While patients are digging through new information, so are doctors. A “tsunami of knowledge” from hundreds of journals pours over doctors, says Jack Cochran, executive director of the Permanente Federation.

All this information changes the culture. “Doctors say they’re taught to know things that others don’t,” said Dave deBronkart, a cancer survivor and advocate for patient engagement. Today, thanks to online searches and communities, a patient may know about advances before a doctor does.


Not only should you read your electronic health record, you should check for errors. “Most people’s records contain mistakes,” deBronkart said. His 2009 blog about mistakes in his Google Health record led to a front-page story in the Boston Globe and a career as an advocate known as e-Patient Dave. (Google Health, a free service intended to help consumers pull together medical and wellness information, was discontinued in 2013 because it failed to generate broad interest.)

The entire article is here.

Sunday, May 17, 2015

Deceased clients and their wills

When a treating psychologist receives a bequest, what ethical considerations come into play?

By Stephen Behnke, JD, PhD, MDiv
The Monitor on Psychology
May 2015, Vol 46, No. 5
Print version: page 72

Here is an excerpt:

Most risk managers — people who work for insurance carriers, for example, whose primary goal is to lower a psychologist's exposure to risk — will advise the psychologist to decline the property. This advice makes good sense. The situation invites a claim that the psychologist exercised undue influence over the client, which is a relevant legal standard for overturning the bequest. The likelihood that a claim of undue influence will be made against the psychologist rises exponentially if the client had heirs, or potential beneficiaries of the estate who are found. If a complaint is made to an ethics committee or licensing board, the psychologist will bear the burden of demonstrating that there has been no exploitation:

The entire article is here.

Friday, May 15, 2015

Navigating the Google Blind Spot

An Emerging Need for Professional Guidelines to Address Patient-Targeted Googling

By Maria J. Baker, Daniel R. George and Gordon L. Kauffman
Journal of General Internal Medicine
Originally published September 17, 2014

Many physicians would agree that seeking information about their patients via Google seems to be an invasion of privacy, violating trust between patients and their healthcare providers. However, it may be viewed as ethically valid, and even warranted under certain circumstances. Although guidelines developed by the American Medical Association and the Federation of State Medical Boards (FSMB) provide general guidance on the appropriate use of the Internet, they do not specifically address the crucial issue of whether physicians should ‘google’ their patients, and, if so, under what circumstances. As a result, physicians are left to navigate this “google blind spot” independently, and to decipher on a case-by-case basis where the boundary of professionalism lies with regard to patient-targeted googling.

Two case scenarios illustrate the moral ambiguity present within this “blind spot.”

The entire article is here.

Saturday, April 4, 2015

Teaching doctors how to engage more and lecture less

By Sandra G. Boodman
The Washington Post
Originally posted March 9, 2015

Here is an excerpt:

“Doctors are explainaholics,” Tulsky said. “Our answer to distress is more information, that if a patient just understood it better, they would come around.” In reality, bombarding a patient with information does little to alleviate the underlying worry.

The “Empathetics” program teaches doctors “how to show up, not what to say,” said Riess. “We do a lot of training in emotional recognition and self-monitoring.” That includes learning to identify seven universal facial expressions — using research pioneered by psychologist Paul Ekman — and to take stock of one’s own emotional responses to patients or situations.

The entire article is here.

Sunday, March 29, 2015

Ethics, self-disclosure and our everyday multiple identities

APA’s Ethics Code speaks to our psychologies — and our clients’ psychologies — on many levels.

By Stephen Behnke, JD, PhD, MDiv
March 2015, Vol 46, No. 3
Print version: page 70

Here is an excerpt:

Here our profession's rather rigid history with multiple relationships may get in the way of good ethical thinking. The belief that all multiple relationships are unethical may lead a student to conclude that a rigid demarcation among identities is preferable or necessary. Of course, such demarcations are not possible and attempting to behave as though they are is futile, counterproductive and painfully distracting. Although a psychologist who is a parent is not parenting during psychotherapy, such a psychologist nonetheless remains a parent during the session. Standard 3.05 offers a way to think about this intra-psychic conundrum.

The entire article is here.

Wednesday, March 11, 2015

Impact of Burnout: Clinicians Speak Out

Deborah Brauser
Originally posted February 10, 2015

Professional burnout has serious negative consequences not only for affected clinicians but potentially for patient care and outcomes as well, new research suggests.


In addition, those who reported higher levels of depersonalization were significantly more likely to report that burnout affected their interaction with patients.

Interestingly, emotionally exhausted clinicians were significantly less likely to report an impact on patient outcomes.

The entire article is here.