"Breaking" the Emergency Department: Does the Culture of Emergency Medicine Present a Barrier to Self-Care?

INTRODUCTION: Our goal was to critically examine emergency physician's (EP) beliefs about taking breaks for self-care on shift. Our operational definition of a break for self-care included time not engaging in direct patient care, eating, drinking, using the bathroom, or leaving a clinical area for a mental break. Using focus groups, the study aimed to accomplish the following: 1) identify barriers to why residents and faculty at our academic center may not take breaks in the emergency department; 2) generate hypotheses for empirical testing; and 3) generate solutions to include in a departmental breaks initiative. METHODS: We convened eight focus groups comprised separately of resident and faculty physicians. Group discussion was guided by eight questions representing a priori themes. The groups were recorded for transcription and subjected to a "cut-and-sort" process. Six themes were identified by consensus after independent review by three of the co-authors, which were confirmed by participant validation. RESULTS: We identified six themes that represented the pooled outcomes of both resident and faculty focus groups: 1) Physiological needs affect clinical performance, 2) EPs share beliefs around taking breaks that center on productivity, patient safety and the dichotomy of strength/weakness, 3) when taking breaks EPs fear worst-case scenarios, 4) breaking is a learned skill, 5) culture change is needed to allow EPs to engage in self-care; and 6) a flexible, individualized approach to breaking is necessary. Our central finding was that productivity and patient safety are of key importance to EPs when considering whether to take a break for self-care. We identified a dichotomy with the concept of strength related to productivity/patient safety, and the concept of weakness related to self-care. CONCLUSION: The current practice culture of emergency medicine and the organization of our unique work environment may present barriers to physicians attempting to engage in self-care.

Forensic patients, treating psychiatrist and the Mental Health Review Tribunal - An ethical question?

OBJECTIVE: In inpatient forensic settings, a psychiatrist is expected to wear 'Two Hats', as a treating physician and as an expert to provide risk assessments and expert advice to the judicial authorities for leave and release decisions. Although dual roles have long been accepted as an inevitable part of independent forensic practice, there are additional ethical challenges for the treating psychiatrist to provide an expert opinion. This paper examines the specific ethical ambiguities for a treating psychiatrist at the interface of legal process related to leave and release decisions in the treatment of forensic patients. CONCLUSIONS: While respect for justice is the prevailing ethical paradigm for court-related forensic work, the medical paradigm should remain the key ethical framework for psychiatrists in treatment settings. Thus, psychiatrist should be aware of possible adverse consequences in acting as forensic experts for their patients. A conscientious adherence to clinical facts and awareness of the 'Two Hats' ethical pitfall can serve as important reference points in framing the psychiatric evidence in the decision-making process and safeguard treating psychiatrist's role.

Debating Medical Utility, Not Futility: Ethical Dilemmas in Treating Critically Ill People Who Use Injection Drugs.

Physicians who care for critically ill people with opioid use disorder frequently face medical, legal, and ethical questions related to the provision of life-saving medical care. We examine a complex medical case that illustrates these challenges in a person with relapsing injection drug use. We focus on a specific question: Is futility an appropriate and useful standard by which to determine provision of life-saving care to such individuals? If so, how should such determinations be made? If not, what alternative decisionmaking framework exists? We determine that although futility has been historically utilized as a justification for withholding care in certain settings, it is not a useful standard to apply in cases involving people who use injection drugs for non-medical purposes. Instead, we are welladvised to explore each patient's situation in a holistic approach that includes the patient, family members, and care providers in the decision-making process. The scope of the problem illustrated demonstrates the urgent need to definitively improve outcomes in people who use injection drugs. Increasing access to high quality medication-assisted treatment and psychiatric care for individuals with opioid use disorder will help our patients achieve a sustained remission and allow us to reach this goal.

¿Qué hacer cuando un médico tiene problemas de salud que afectan su desempeño clínico? / What to do when a doctor presents health problems affecting his/her clinical function?

Al igual que cualquier persona, los médicos sufren de depresión que puede afectar su desempeño clínico y la seguridad de los pacientes. Para las autoridades institucionales estos problemas se traducen en un dilema entre los principios de no-discriminación y justicia hacia estos médicos y los de protección y no-maleficencia hacia los enfermos. A raíz de dos casos, los docentes de un hospital pediátrico se plantearon una serie de preguntas sobre la responsabilidad médica en esta situación, su posibilidad de estudiar medicina y las medidas a tomar; así como sobre la responsabilidad de los docentes y de los psiquiatras frente a estos médicos (confidencialidad) y a los pacientes representados por la institución. Se presentan los resultados de las entrevistas semiabiertas realizadas con estos docentes. El protocolo fue aprobado por el Comité de Bioética de Investigación de la institución

Like any person, doctors suffer from depression that may affect their clinical performance and patients’ security. For institutional authorities these problems represent a dilemma between principles of non-discrimination and justice for them, and those of protection and nonmaleficence for the patients. The first two cases in a pediatric hospital provoked the reflection of the clinical docents about medical responsibility in this situation, possibility to study medicine and measures to be taken; as well as docent and psychiatrics responsibility. The results of interview of these docents are presented. The research was approved by the Bioethics Research Committee of the institution

Placebo Trends across the Border: US versus Canada.

BACKGROUND: Physicians around the world report to using placebos in a variety of situations and with varying degrees of frequency. Inconsistent methodologies, however, complicate interpretation and prevent direct comparisons across studies. While US- and Canada-based physicians share similar professional standards, Canada harbours a less-litigious universal healthcare model with no formal placebo-related policy-factors that may impact how physicians view and use placebos. METHODS: To compare American and Canadian data, we circulated an online survey to academic physicians practicing in Canada, collected anonymous responses, and extracted those of internists and rheumatologists for comparison to US data obtained through parallel methodologies. RESULTS: Whereas our data show overall concordance across the border-from definitions to ethical limitations and therapeutic potential-differences between American- and Canadian-based placebo practices merit acknowledgement. For example, compared to 45%-80% among US-based respondents, only 23±7% of Canada-based respondents reported using placebos in clinical practice. However, 79±7% of Canada-respondents-a figure comparable to US data-professed to prescribing at least one form of treatment without proven or expected efficacy. Placebo interventions including unwarranted vitamins and herbal supplements (impure placebos) as well as sugar pills and saline injections (pure placebos) appear more common in Canada, where more doctors described placebos as "placebos" (rather than "medications") and used them as a "diagnostic" tool (rather than a means of placating patient demands for treatment). INTERPRETATION: Cross-border variation in the use of clinical placebos appears minor despite substantial differences in health care delivery system, malpractice climate, and placebo-related policy. The prevalence of impure placebos in both Canadian and US clinics raises ethical and practical questions currently unaddressed by policy and warranting investigation.

Unproven stem cell-based interventions & physicians' professional obligations; a qualitative study with medical regulatory authorities in Canada.

BACKGROUND: The pursuit of unproven stem cell-based interventions ("stem cell tourism") is an emerging issue that raises various concerns. Physicians play different roles in this market, many of which engage their legal, ethical and professional obligations. In Canada, physicians are members of a self-regulated profession and their professional regulatory bodies are responsible for regulating the practice of medicine and protecting the public interest. They also provide policy guidance to their members and discipline members for unprofessional conduct. METHODS: We conducted semi-structured telephone interviews with representatives from six different provincial Colleges of Physicians and Surgeons in Canada to discuss their experiences and perspectives regarding stem cell tourism. Our focus was on exploring how different types of physician involvement in this market would be viewed by physicians' professional regulatory bodies in Canada. RESULTS: When considering physicians' professional obligations, participants drew analogies between stem cell tourism and other areas of medical tourism as well as with some aspects of complementary alternative medicine where existing policies, codes of ethics and regulations provide some guidance. Canadian physicians are required to act in the best interests of their patients, respect patient autonomy, avoid conflicts of interest and pursue evidence-based practice in accordance with accepted standards of care. Physicians who provide unproven treatments falling outside the standard of care, not in the context of an approved research protocol, could be subject to professional discipline. Other types of problematic conduct include referrals involving financial conflict of interest and failure to provide urgent medically necessary care. Areas of ambiguity include physicians' obligations when asked for information and advice about seeking unproven medical treatments, in terms of providing non-urgent follow-up care, and when asked to support efforts to go abroad by providing tests or procedures in advance that would not otherwise be medically indicated. CONCLUSIONS: Specific policy guidance regarding the identified areas of tension or ambiguity may prove helpful for physicians struggling with these issues. Further consideration of the complex interplay of factors at issue in how physicians may (should) respond to patient demands related to unproven medical interventions while meeting their professional, legal and ethical obligations, is warranted.

Edmund Pellegrino's philosophy and ethics of medicine: an overview.

It might seem ironic that the author in this mini-symposium who knew Edmund Pellegrino the best should be the one whose essay is the least personal,eschewing anecdote and reminiscence and concentrating on the substance of his scholarly contribution. I think, however, that for Ed, an exposition of his ideas would be the most fitting tribute one could offer. Accordingly, I will attempt to outline his main ideas and bring together his disparate writings in a constructive manner. I do this firstly because there really is no other such brief exposition of his main ideas anywhere in the bioethics literature. Moreover, Pellegrino himself made no attempt to provide an explicit synthesis of his various writings on various topics, and so I will attempt to make explicit a number of implicit connections.Lastly, inasmuch as bioethics has developed dramatically as a field over the last 40 years, there may be young scholars who are unfamiliar with Pellegrino's truly seminal work. A brief overview of his body of scholarship might spur them togo to the primary sources. If I succeed in interesting such persons in reading the work of Edmund Pellegrino, or inspire others to look again at that work with fresh eyes, I believe they will be richly rewarded.

Doctors and vampires in sub-Saharan Africa: ethical challenges in clinical trial research.

Collecting blood samples from individuals recruited into clinical research projects in sub-Saharan Africa can be challenging. Strikingly, one of the reasons for participant reticence is the occurrence of local rumors surrounding "blood stealing" or "blood selling." Such fears can potentially have dire effects on the success of research projects--for example, high dropout rates that would invalidate the trial's results--and have ethical implications related to cultural sensitivity and informed consent. Though commonly considered as a manifestation of the local population's ignorance, these rumors represent a social diagnosis and a logical attempt to make sense of sickness and health. Born from historical antecedents, they reflect implicit contemporary structural inequalities and the social distance between communities and public health institutions. We aim at illustrating the underlying logic governing patients' fear and argue that the management of these beliefs should become an intrinsic component of clinical research.

Athlete support personnel and anti-doping: Knowledge, attitudes, and ethical stance.

Athlete support personnel (ASP) failing to meet responsibilities under the World Anti-Doping Code risk sanction. It is unclear whether the poor knowledge of responsibilities seen in sports physicians and coaches applies to other ASP (e.g., administrators, chiropractors, family, nutritionists, physiotherapists, psychologists, and trainers). A purposive sample of Australian ASP (n = 292) responded to a survey on knowledge of anti-doping rules (35 true/false questions), ethical beliefs and practice, and attitudes toward performance enhancement. Some ASP declined to participate, claiming doping was irrelevant to their practice. Physicians were most knowledgeable (30.8/35), with family and trainers the least (26.0/35). ASP reported that improvements were needed to support anti-doping education (e.g., basis for anti-doping) and practice (e.g., rules). ASP also had a slightly negative attitude toward performance enhancement. Linear regression showed that being a sports physician, providing support at the elite level, and 15 years of experience influenced knowledge. The results confirm gaps in knowledge, suggesting that stronger engagement with ASP anti-doping education and practice is needed. Applying the principles of andragogy could help foster active engagement through emphasis on active inquiry, rather than passive reception of content. Future work on the context within which ASP experience anti-doping is needed, exploring acquisition and translation of knowledge into practice.

The duty to be well-informed: the case of depression.

It is now an ethical dictum that patients should be informed by physicians about their diagnosis, prognosis and treatment options. In this paper, I ask: 'How informed are the 'informers' in clinical practice?' Physicians have a duty to be 'well-informed': patient well-being depends not just in conveying adequate information to patients, it also depends on physicians keeping up-to-date about: (1) popular misunderstandings of illnesses and treatments; and (2) the importance of patient psychology in affecting prognosis. Taking the case of depression as an entry point, this paper argues that medical researchers and physicians need to pay serious attention to the explanations given to patients regarding their diagnosis. Studies on lay understanding of depression show that there is a common belief that depression is wholly caused by a 'chemical imbalance' (such as 'low serotonin') that can be restored by chemically restorative antidepresssants, a claim that has entered 'folk wisdom'. However, these beliefs oversimplify and misrepresent the current scientific understanding of the causes of depression: first, there is consensus in the scientific community that the causes of depression include social as well as psychological triggers (and not just biochemical ones); second, there is significant dissensus in the scientific community over exactly what lower level, biological or biochemical processes are involved in causing depression; third, there is no established consensus about how antidepressants work at a biochemical level; fourth, there is evidence that patients are negatively affected if they believe their depression is wholly explained by (the vague descriptor) of 'biochemical imbalance'. I argue that the medical community has a duty, to provide patients with adequate information and to be aware of the negative health impact of prevalent oversimplifications-whatever their origins.

Should doctors strike?

Last year in June, British doctors went on strike for the first time since 1975. Amidst a global economic downturn and with many health systems struggling with reduced finances, around the world the issue of public health workers going on strike is a very real one. Almost all doctors will agree that we should always follow the law, but often the law is unclear or does not cover a particular case. Here we must appeal to ethical discussion. The General Medical Council, in its key guidance document for practising doctors, Good Medical Practice, claims that 'Good doctors make the care of their patients their first concern'. Is this true? And if so, how is this relevant to the issue of striking? One year on since the events, we carefully reflect and argue whether it was right for doctors to pursue strike action, and call for greater discussion of ethical issues such as the recent strikes, particularly among younger members of the profession.

A reconsideration of home birth in the United States.

Home births continue to constitute only a small percentage of all deliveries in the United States, in part because of concerns about their safety. While the literature is decidedly mixed in regard to the degree of risk, there are several studies that report that home birth may at times entail a small absolute increase in perinatal risks in circumstances that cannot always be anticipated prior to the onset of labor. While the definition of "small" will vary between individuals, and publications vary in the level of risk they ascribe to birth at home, studies with the least methodological flaws and with adequate power often cite an excess death rate in the range of one per thousand. Home birth is, in that regard, but one example of patients' choices and plans that sometimes carry increased risk or include alternatives that individual physicians feel uncomfortable supporting or recommending. Our intention in this opinion piece is not to advocate for or against home birth. Rather, we recognize that home birth is but one example of a patient choice that might differ from what a provider feels is in a woman's best interests. In this article we will discuss ethical considerations in such circumstances using home birth as an example. We consider in this article how the ethical principles of respect for autonomy and non-maleficence can be balanced using, among other examples, the choice by some for a home birth. We discuss how absolute rather than relative risk should guide individuals' evaluation of patient choices. We also consider how in some circumstances, the value and safety added by a physician's participation may outweigh a potentially small increment in absolute risk that might result from a patient's decision to deliver at home because of a perceived physician endorsement. We recognize, however, that doctors and midwives participating in choices they have not recommended, or may even believe will lead to or increase risk for adverse outcomes, presents dilemmas and raises important questions. When does respect for patient choice and autonomy become support for poor decision making? When is participation not respectful but enabling? Finally we discuss the role and responsibility of organized medicine in making all births as safe as possible.