Recently in Ethical Category

Sometimes I look inside my head and see a violent, stormy ocean of ideas such that I need a life jacket in order to stay afloat and to make some kind of sense of things so as not to unleash fragmented bits of unfettered emotion onto the world. Other times, there are nothing but sand dunes as far as the eye can see; even the rare oasis quickly drained before it can quench anyone's intellectual thirst. After staring off into space for about 10 minutes, realizing that I am clearly in a state of mind more closely resembling the latter, I came upon this article: Mary-Kate Olsen Wants Immunity in Heath Ledger Case. What was more interesting to me than whether or not Mary-Kate is going to cooperate was the following quote, "Investigators have interviewed Ledger's doctors and found prescriptions for every drug so far except Oxycodone and Vicodin, two powerful and often-abused painkillers..." So, is it malpractice if a patient overdoses on a drug that I prescribe? Any real attempt to answer this question would require far more brainpower than the wasteland inside my head is going to provide me with. What's your answer?

Does race make a difference or does it not make a difference?
I remember a time, a simpler time, long ago, when the common wisdom was that the solution to the problem of racism was to achieve a color-blind society - a society in which a person's skin color made no more difference to anyone than the color of his eyes. We seem to have lost our way at some point, deciding that we, as a society, believe that race does make a difference. As another example of this fact, the AMA has recently apologized for racial disparities in the provision of health care in this country.

I have to wonder, do they really understand what they've done? A perfectly analogous situation would be if the justice department were to apologize for the disparity between the number of blacks and whites on death row. Can you imagine the public outcry if that happened? I mean, we already knew that there way more blacks were convicted of murder but we didn't realize that you guys were preferentially convicting them on purpose! Why were you doing that? And if that's what you're doing, don't apologize, just stop doing it!

Likewise, the AMA's apology amounts to an admission of racism. They have apparently been intentionally giving inferior care to their African American patients. Again, rather than apologize, why not simply stop doing it? The answer, of course, is that they really aren't responsible. With rare exceptions (the Tuskegee experiment, comes to mind) you won't find any doctor who makes it part of his practice to provide one level of care to members of one race and another level of care to another race. Nor are any such health care policies in place, nor has the AMA issued any such guidelines. Are there disparities in the levels of care that blacks and whites receive in this country? Absolutely, there are! Just as there are huge disparities in income, level of education, crime etc. But for the AMA to say, "Yeah, sorry. These disparities exist because we fucked up. We've been giving shitty care to blacks while giving excellent care to whites, " is obviously ludicrous. If this were the case then the solution, as I have said, would be simple - STOP DOING IT! But, even though the AMA has apologized for these disparities, I'm pretty confident they will persist - at least for the short term. Which means that either a) the AMA was never responsible for these disparities in health care to begin with or b) they were responsible, but are going to choose to go on providing disparate care based on their patient's race.

We need to put aside this issue once and for all. The simple existence of racial disparity would not be a problem if race made no more difference to people than hair or eye color. Can you imagine anyone studying whether blue-eyed people received the same level of health care as brown-eyed people? If there are systematic ways in which our society is treating whites differently from blacks the solution is to seek out these injustices and to fight them. But the simple existence of these disparities does not necessarily point to any such injustice. And, if we are serious about achieving a color-blind society, the question of racial disparity is one that we need to stop asking.

The fact that I'm now a doctor somehow causes everyone around me to assume that, if they have a problem and there is no other specific person who has the solution, I am the one to turn to. "Doctor, I've noticed my dog's farts smell a lot worse lately." "Doctor, I think my son might be gay. Can they do hypnosis for that?" "Doctor, I have a nearly uncontrollable urge to shout obscenities when I go to church." This is a priniciple I have been familiar with since childhood. The reason this knowledge did not deter me from going to medical school is that I believed, naively as it turns out, that medical school would actually prepare me to answer these questions. After all, there must be some reason people feel their doctor should have an opinion on whether or not they should let their child play violent video games. I figured, as many others do, that doctors must have access to some secret, ancient knowledge to which only a chosen few are allowed access. In fact, somewhere deep in my subconscious, I'm still hoping my program director will turn a wall-mounted oxygen dial in a particular sequence opening a hidden passage leading to a dark room deep below the hospital where he will gather all the interns, tell us to forget everything we learned in medical school as it was just to keep up appearances for the general public, and unlock a dusty, leather-bound book containing the real answers.

Clem Bronson, a 70 year old army vet from Oklahoma who wears cowboy boots, gray hair down to the shoulders, a thick bushy mustache and a face that appears to have been left out in the sun too long had been admitted two days earlier with a COPD exaccerbation. On the way to his room this morning, I was confronted by the respiratory therapist. "Mr. Bronson really made upset Rachel this morning." Tall, blond, 25 year-old Rachel was his nurse today.
"How so?"
"He was making comments about her legs and her butt. Rachel told him to stop, but he didn't. She was really upset."
And, the fact that I went to medical school and wear a white coat makes me qualified to deal with this situation how?

That morning on rounds, we decided to have a little chat with Mr. Bronson about his behavior. His response, "Yeah, I know she's upset. She'll git over it." Great. And in regal fashion, the men in white coats come charging forth in order to...have virtually no impact on the situation. If it happens again, plan B is to recruit the second large category of professionals one goes to when there's nobody else who is specifically qualified to deal with their problem - the police.

I missed the season finale of Law and Order SVU because I was watching the Frontline documentary: Storm Over Everest. But I quite enjoyed the previous episode called "Authority," in which Robin Williams plays a disgruntled sound engineer who expresses his years of stored guilt and rage by tricking gullable people into doing things that they wouldn't otherwise do. He does so under the guise of a fictional character named, Miilgram; the name is a reference to the famous "Milgram Experiment" (footage below) in which subjects were asked to administer what they believed to be real electric shocks of increasing voltage to paid volunteers. The shocks, of course, were not real; the subjects who were allegedly being shocked were confederates. The purpose of the experiment was to study the degree to which individuals would blindly follow authority.

Though it produced some very interesting results, today the expirement is widely considered to have been unethical. I, personally, am a strong beliver in informed consent and I don't necessarily think such an experiment is unethical so long as adequate informed consent is obtained (though, this very issue often presents a problem for psychological experiments, in general).
For fun, I included some actual footage from the Milgram experiemnt:

This footage was also included in the Enron documentary, The Smartest Guys in the Room - which I highly recommend.

I'm not sure how much I've related in previous posts, but here's the scoop. I left my previous job as an OB resident back in mid-February. My decision had as much to do with subjecting myself to another two and a half years of OB residency as it did with needing a change in career path. I think both reasons were equally vaild. It was around the beginning of November that plans began to coalesce. My girlfriend was subletting a place on the west coast. I would go live with her while I continued interviewing for family medicine spots and studying for Step III of the medical licensing exam. I'd have a nice little vacation coming up because residency programs universally start at the end of June. By the end of November I had my plans in order and I went to inform my program that my last day of work would be January 1st. They, of course, had been gracious enough to provide letters of recommendation so they knew I was leaving. It was certainly no suprise to them.

They went BALLISTIC. The department chair actually accused me of being "unethical" for leaving with such short notice (i.e. 30 days). I'm not sure how much notice I was required to give. My contract specified 30 days. On what day would it have become ethical for me to leave? We had a long argument about it. In the end, not wanting to leave on bad tems, I gave them another 6 weeks and left in mid-February.

And now I'm enjoying myself on the beautiful, sunny west coast in anticipation of starting over again as a family medicine resident. We start June 16th.

Last thing - until I figure out where to put my contact info on this blog, you can email me here: jamesNOSPAM AT jamesloganmd DOT com. Make sure to get rid of the 'NOSPAM' part :)

There's a flyer up. It's posted on the walls of the more discreete areas of the labor and delivery floor at our hospital - the conference room, the physician lounge, the little cubicle in triage where the intern (i.e. me) writes his notes. The flyer reads as follows:

Wanted

Jasmine Ramirez (pictured) and Matthew Orton are wanted by the FBI in connection with drug trafficking charges. There is a $5,000 reward for information leading the the arrest of these individuals. Jasmine Ramirez is pregnant with a due date of 12/16/06. If she presents for care at your facility, please report her to your local police department immediately.

That was the jist of it anyway.
Is this a problem for anyone else? I looked up Ms. Ramirez's chart (not her real name, incidentally) in our system. She did present twice to our hospital for care - once to triage and once for a clinic visit. Her alleged due date of 12/16/06 by last menstrual period comes from our records. I thought about what I would do if she came in:
Thought #1 - how much of the money do I have to give to my program in order to pay for lunch at our weekly conference and how much can I keep for myself without appering a greedy asshole?
Thought #2 - when a patient presents for care, aren't they reasonably entitled to the expectation that whatever information they provide - including their name and what they are being treated for - will be held in the strictest confidence?
"Well Ms. Ramirez, I can see on the monitor that your contractins are coming every 3-5 minutes now. Your cervix is almost four centimeters dilated and very thinned out. I think you're going to have this baby pretty soon! We'll move you over to a labor room. First we'll just have the nurse start your IV while I let the FBI know you're here."
I contacted the head of our hospital ethics consult service regarding the matter. She bumped the question on up to risk management. The reply I received:

Hi James. Great question! I went to the OB unit and saw the posting. Tom McDougal in risk did state that exceptions to HIPAA rules would include folks wanted by the FBI. If this is a legitimate FBI posting (nurses did say that an FBI agent escorted by hospital security posted the paper on the unit) then employees should comply.

The woman in question has yet to reappear. She was only about 8 weeks pregnant when we saw her; who knows whether or not she's even still pregnant? i will repost regarding the outcome if she does decide to deliver at our hospital. I personally have decided that I'm not ethically comfortable reporting her to the FBI if she were to come in. But, there are plenty of other staff members here. Undoubtedly there will be at least one for whom the urge to see justice served, evil punished and $5,000 in his pocket will be too overpowering.

I turned on the saline and advanced the hysteroscope slowly. As the uterus distended, my camera was able to pick up the image of a long and narrow uterine cavity - very unusually shaped. The small black-hole passageways leading to the fallopian tubes which should have been visible on both the right and left side were conspicuously absent.
"Here, let me take over." I handed the scope over to my attending. She advanced the scope slowly, gently, revealing the same oblong cavity that was rapidly growing shorter as the camera advanced ever inward. The fluffy surface of uterine lining was then suddenly gone and our monitor screen revealed long loops of bowel. "And, we've perforated the uterus. We cannont continue," my attending announced as she calmly removed the hysteroscope. "Get a CBC now, and again in 3 hours," she instructed while checking for blood at the cervix. "Have her follow up with me in clinic on Friday."

The guiding philosophy behind residency training is that we learn to manage various medical conditions by being exposed to patients with that condition and participating in their care. As OBGYN residents, we compete for deliveries, c-sections and hysterectomies so that we will become proficient at them. You're not considered competent to do a hysterectomy on your own in the community until you've done a certain number under supervision. But there is no set number of complications you are required to deal with before you are allowed to practice on your own. Complications happen. Uteri get perforated, major arteries get transected, umbilical cords get prolapsed. How do we learn to cope with these events if we're never exposed to them? There is a conflict of interest here between being responsible for my own education and providing good patient care that I never anticipated would exist when I started med school. Certainly we don't try to cause complications. Hopefully they happen often enough on their own without any help from us. But we are still in the unenviable position of hoping that they happen. Doctors aren't suppose to hope that bad things happen to their patients. And, in actuality, medical and surgical residents don't hope that anything terrible happen to any particular patient; we only hope for complications in the global sense.

The patient did fine. "Perforations at the funuds usually seal themselves and don't bleed," my attending had said. "We just have to watch her closely for awhile." I brought the issue up with my senior resident, who had had a perforation of her own the very next day - coincidently enough, with the same attending. Her opinion:
"Don't try to cause complications. Just be grateful when they happen."