Informal medicine: ethical analysis

Medicine and the media: the ethics of virtual medical encounters

The expansion of new forms of public media, including social media, exposes clinicians to more illness experiences/narratives than ever before and increases the range of ways to interact with the people depicted. Existing professional regulations and ethics codes offer very limited guidance for such situations. We discuss the ethics of responding to such scenarios through presenting three cases of clinicians encountering television or social media stories involving potential unmet healthcare needs. We offer a structured framework for health workers to think through their responses to such situations, based around four key questions for the clinician to deliberate upon: who is vulnerable to harm; what can be done; who is best placed to do it; and what could go wrong? We illustrate the application of this framework to our three cases.

Informal (Hallway) medical consultation in orthopedics-is it as common as it seems?

INTRODUCTION

Informal (hallway) medical consultation is an integral part of the physician's work. As musculoskeletal complaints are very common, orthopedic surgeons stand in the frontline of this practice. Many of these consultations are poorly, if at all, documented, thus imposing a potential medical danger to the patient and a medicolegal danger to the surgeon. We conducted this first study to examine whether this practice is common among the orthopedic surgeons in university hospital.

METHODS

In this prospective study, a 2-month record of informal consultations was kept. Six orthopedic surgeons-two joint reconstruction surgeons, one spine surgeon, two arthroscopy and sports medicine surgeons, and a shoulder surgeon participated. They recorded the details of the consulter, whether the consultation was for himself or somebody else, the major complaint, and whether it was a second opinion. All patients were advised to go to the formal orthopedic consultation and no advice or treatment was given. At the end of 2 months, each surgeon was asked to evaluate the percentage of cases he had failed to report.

RESULTS

During the 2-month period, 158 people asked for informal (hallway) consultations. 11 of them (7%) were physicians, 114 (72%) were other hospital personnel, 26 (17%) were unrelated to hospital, and 6 (4%) were treated patients' relatives. 93 (59%) of consultations were about the consulter himself and the rest were about a relative or a friend. 41 (26%) were requests for a second opinion. The estimated percentage of not reported cases was 10-40%; when the number of consultations was corrected for these figures, it reached 208 consultations in 2 months.

DISCUSSION

In this prospective study, six participating surgeons recorded 158 informal consultation requests in 2 months. If a correction is performed, it averages 0.6 consultations a day for a surgeon (or, if only workdays are counted-0.8 consultations a day). Orthopedic surgeons should be aware of this frequent habit and send these patients to a formal consultation.

Diagnosis by Documentary: Professional Responsibilities in Informal Encounters

Most work addressing clinical workers' professional responsibilities concerns the norms of conduct within established professional-patient relationships, but such responsibilities may extend beyond the clinical context. We explore health workers' professional responsibilities in such "informal" encounters through the example of a doctor witnessing the misdiagnosis and mistreatment of a serious long-term condition in a television documentary, arguing that neither internalist approaches to professional responsibility (such as virtue ethics or care ethics) nor externalist ones (such as the "social contract" model) provide sufficiently clear guidance in such situations. We propose that a mix of both approaches, emphasizing the noncomplacency and practical wisdom of virtue ethics, but grounding the normative authority of virtue in an external source, is able to engage with the health worker's responsibilities in such situations to the individual, the health care system, and the population at large.

Young physicians' recall about pediatric training in ethics and professionalism and its practical utility

OBJECTIVE

To assess the adequacy of ethics and professionalism education in residency by examining the recollections of young pediatricians in practice.

STUDY DESIGN

We surveyed a random sample of members of the American Academy of Pediatrics Section on Young Physicians between February and June 2012.

RESULTS

The majority of young pediatricians reported that ethics and professionalism were taught ad hoc in their training programs. Compared with physicians in practice for >5 years, those in practice for ≤ 5 years were significantly more likely to report having had an organized curriculum (72 of 181 [40%] vs 27 of 113 [24%]; P < .01) and that the ethics and professionalism training in their program was adequate (124 of 180 [69%] vs 62 of 113 [55%]). Of the topics encountered in practice by at least two-thirds of pediatricians, more than two-thirds of the respondents stated that residency training adequately prepared them to address issues of consent, privacy, truth-telling, and child abuse/neglect, but less than one-third felt adequately prepared to address conduct on social media and requests for prescriptions by family, friends, and colleagues outside of clinical encounters.

CONCLUSION

The majority of recent graduates from pediatric training programs described themselves as competent to address the ethical and professionalism issues faced in practice, but nonetheless reported gaps in their education. As pediatric residency programs adopt more structured curricula for ethics and professionalism education, issues commonly faced by practitioners should be incorporated.

Medical misconduct in Hong Kong: implications for medical education around the world

CONTEXT

Medical educators emphasise responses to medical misconduct, but little is known about medical misconduct and its implications for medical education. This article investigates the nature of medical malpractice in Hong Kong and offers guidance for the inclusion of a curriculum to prevent the occurrence of medical misconduct in medical education around the world.

METHODS

A comprehensive review of judgements made by the Medical Council of Hong Kong during the period from July 2008 to December 2010 was conducted. Each of the 40 cases of inquiry related to medical misconduct were summarised and analysed according to 14 factors.

RESULTS

Of the 40 cases, nearly half involved only one or two charges. The Council found the defendants guilty of professional misconduct on 148 of 169 charges, and ordered the following four types of penalty: removal order, suspension, warning letter, and reprimand. Cases are grouped into three categories involving: improper documentation, inappropriate management or prescription of drugs, and failure to interact appropriately with patients. The relevant ethical codes or legislation for each category are illustrated.

CONCLUSIONS

Various types of medical misconduct unquestionably caused suffering to the patients involved, their families and society. Hence, it is crucial for medical educators to teach students about the importance of medical ethics and the prevention of misconduct.

Providing cell phone numbers and e-mail addresses to patients: The patient's perspective, a cross sectional study

Background

Today patients can consult with their treating physician by cell phone or e-mail. These means of communication enhance the quality of medical care and increase patient satisfaction, but they can also impinge on physicians’ free time and their patient schedule while at work. The objective of this study is to assess the attitudes and practice of patients on obtaining the cell phone number or e-mail address of their physician for the purpose of medical consultation.

Methods

Personal interviews with patients, 18 years of age or above, selected by random sampling from the roster of adults insured by Clalit Health Services, Southern Division. The total response rate was 41%. The questionnaire included questions on the attitude and practice of patients towards obtaining their physician’s cell phone number or e-mail address. Comparisons were performed using Chi-square tests to analyze statistically significant differences of categorical variables. Two-tailed p values less than 0.05 were considered statistically significant, with a power of 0.8.

Results

The study sample included 200 patients with a mean age of 46.6 ± 17.1, of whom 110 were women (55%). Ninety-three (46.5%) responded that they would be very interested in obtaining their physician’s cell phone number, and an additional 83 (41.5%) would not object to obtaining it. Of the 171 patients (85.5%) who had e-mail addresses, 25 (14.6%) said they would be very interested in obtaining their physician’s e-mail address, 85 (49.7%) said they would not object to getting it, and 61 (35.7%) were not interested. In practice only one patient had requested the physician’s e-mail address and none actually had it.

Conclusions

Patients favored cell phones over e-mail for consulting with their treating physicians. With new technologies such as cell phones and e-mail in common use, it is important to determine how they can be best used and how they should be integrated into the flow of clinical practice.

Providing cell phone numbers and email addresses to Patients: the physician's perspective

Background

The provision of cell phone numbers and email addresses enhances the accessibility of medical consultations, but can add to the burden of physicians' routine clinical practice and affect their free time. The objective was to assess the attitudes of physicians to providing their telephone number or email address to patients.

Methods

Primary care physicians in the southern region of Israel completed a structured questionnaire that related to the study objective.

Results

The study population included 120 primary care physicians with a mean age of 41.2 ± 8.5, 88 of them women (73.3%). Physicians preferred to provide their cell phone number rather than their email address (P = 0.0007). They preferred to answer their cell phones only during the daytime and at predetermined times, but would answer email most hours of the day, including weekends and holidays (P = 0.001). More physicians (79.7%) would have preferred allotted time for email communication than allotted time for cell phone communication (50%). However, they felt that email communication was more likely to lead to miscommunication than telephone calls (P = 0.0001). There were no differences between male and female physicians on the provision of cell phone numbers or email addresses to patients. Older physicians were more prepared to provide cell phone numbers that younger ones (P = 0.039).

Conclusions

The attitude of participating physicians was to provide their cell phone number or email address to some of their patients, but most of them preferred to give out their cell phone number.