Consideraciones bioéticas para la investigación sobre los programas de residencias médicas / Consideracions bioètiques per a la investigació sobre els programes de residències mediques / Bioethical considerations for research on medical residents

El presente artículo argumenta que es necesaria la investigación sobre los programas de residencias médicas para mejorar el entorno laboral y académico que viven los médicos y médicas en su formación como especialistas. Por lo que se proponen algunas consideraciones para garantizar una investigación ética. Para ello, el artículo sigue la estructura de dos premisas y una conclusión, donde cada premisa se fundamenta analíticamente. La primera premisa es que los factores estructurales de los programas de residencias médicas conducen a una condición de vulnerabilidad, se sustenta la primera premisa al explorar los factores estructurales que contribuyen a su vulnerabilidad desde el análisis del contexto mexicano y el marco teórico de la interseccionalidad. Así, se presentan algunas de las características que se entrecruzan y determinan la forma en la que los y las residentes experimentan en sus espacios sociales y ambientes de desarrollo. La segunda premisa es que la investigación de un grupo vulnerable conduce al desarrollo de estrategias para el cambio. El artículo reconoce la necesidad de investigar y desarrollar intervenciones para los grupos sociales vulnerables con el fin de mejorar su situación y proporcionar un entorno más seguro.(AU)

L'article actual argumenta que és necessària la investigació sobre els programes de residències mèdiques per millorar l'entorn laboral i acadèmic que viuen els metges en la seva formació com a especialistes. Per això, es proposen algunes consideracions per garantir una investigació ètica. L'article segueix l'estructura de dues premisses i una conclusió, on cada premissa es fonamenta analíticament. La primera premissa és que els factors estructurals dels programes de residències mèdiques porten a una condició de vulnerabilitat. Aquesta primera premissa es fonamenta explorant els factors estructurals que contribueixen a la seva vulnerabilitat des de l'anàlisi del context mexicà i el marc teòric de la interseccionalitat. Així, es presenten algunes de les característiques que es creuen i determinen la forma en què els residents experimenten en els seus espais socials i entorns de desenvolupament. La segona premissa és que la investigació d'un grup vulnerable condueix al desenvolupament d'estratègies per al canvi. L'article reconeix la necessitat d'investigar i desenvolupar intervencions per als grups socials vulnerables amb l'objectiu de millorar la seva situació i proporcionar un entorn més segur.(AU)

This paper argues that research on medical residency programs is necessary to improve the work and academic environment that physicians experience in their training as specialists. Therefore, some considerations are proposed to ensure ethical research. on medical residents. For this purpose, the paper follows the structure of two premises and a conclusion, where each premise is analytically supported. The first premise is that the structural factors of medical residency programs lead to a condition of vulnerability. The first premise is supported by exploring the structural factors that contribute to their vulnerability from the analysis ofthe Mexican context and the theoretical framework of intersectionality. Thus, some of the characteristics that intersect and determine the way in which residents experience their social spaces and development environments are presented. The second premiseis that researching a vulnerable group leads to the development of strategies for change. The article recognizes the need to research and develop interventions for vulnerable social groups to improve their situation and provide a safer environment.(AU)

La conciencia y la esencia del médico en dos películas / The Physician’s Conscience and Essence through Two Films

Dos películas -una española ambientada en Colombia, la otra belga- que tienen un denominador común, y provocan un cuestionamiento vocacional: ¿Cuál es el sentido de ser médico? ¿Por qué elegir esta profesión? Y, a continuación, la pregunta lógica: ¿Cómo formar médicos hoy en día, cuando parece que el sistema no ayuda? La construcción del profesionalismo médico enfrenta desafíos únicos que ven de dentro del sistema sanitario. La atención está centrada en procesos y resultados, y el paciente es, con mucha frecuencia, olvidado. El enfermo se transforma en un detalle o, peor, en un elemento que problematiza el sistema, diseñado para situaciones teóricas, sin contemplar la necesaria imprevisibilidad del ser humano. La solución posible sugiere la necesidad de formar una cultura en grupo, trabajar en conjunto con profesionales que son felices, y tiene orgullo de ser médicos y dedicarse vocacionalmente a cuidar de los pacientes. El médico es una conciencia frente a una confianza que el paciente le otorga. Por eso, reflexionar sobre la práctica médica es fundamental para el aprendizaje y el despertar de esta conciencia profesional. Sólo cuando pensamos en nuestro desempeño, en cómo aprendemos de cada encuentro con el paciente, podemos mejorar y adquirir nuevas actitudes. Postura que es integridad y al mismo tiempo dedicación y cuidado amoroso, donde se injerta la verdadera competencia y sabiduría, como la demostrada por los médicos ejemplares de todas las épocas. Aprender, que la sabiduría no es sólo saber las cosas, sino también amarlas. (AU)

Two films -one Spanish set in Colombia, the other Belgian- that have a common denominator, and provoke a vocational questioning: What is the meaning of being a doctor? Why we choose this profession? And then, the logical question: how to train doctors today, when it seems that the system does not help? Building medical professionalism faces unique challenges that come from within the healthcare system. Attention is focused on processes and results, and the patient is very often forgotten. The patient becomes a detail or, worse, an element that problematizes the system, designed for theoretical situations, without contemplating the necessary unpredictability of the human being. The possible solution suggests the need to form a culture-group, able to work together with professionals who are happy and proud to be doctors and dedicate themselves to caring for patients. The doctor is a conscience in the face of a trust that the patient gives him. For this reason, reflecting on medical practice is essential for learning and awakening this professional awareness. Only when we think about our performance, about how we learn from each encounter with the patient, we can improve and acquire new attitudes. Posture that is integrity and at the same time dedication and loving care, where true competence and wisdom are grafted, as demonstrated by exemplary doctors of all times. And at the bottom, to learn that wisdom is not only knowing things, but also loving them. (AU)

The Medicare Physician Fee Schedule and Unethical Behavior.

This Viewpoint discusses the Medicare Physician Fee Schedule and its flaws, including how they might be remedied by severing CMS dependence on Relative Value Update Committee estimates of time and intensity.

Assessment of Knowledge Among the Physicians Regarding Dental Screening Prior to Chemotherapy and Radiotherapy

ABSTRACT Objective: To evaluate the physicians' knowledge regarding the referral for dental screening prior to chemotherapy and radiotherapy. Material and Methods: We conducted a cross-sectional study using simple random sampling among 468 physicians from various specialties with diverse experience levels from different regions in Saudi Arabia. A self-reporting questionnaire was distributed among the physicians, which consisted of questions assessing the physicians' knowledge about oral health and complications in patients prior to chemotherapy and radiotherapy. Statistical analysis was done after the data was collected employing SPSS, and p<0.05 was taken as significant. Results: Residents were more as expected (39.3%), followed by specialists (2.31%). The majority had a practice experience for more than five years (67.8%).The scores for the knowledge assessment showed that 51.3%, nearly half of the participants, had lower scores. The scores were statistically significant (p<0.05). Conclusion: General physicians and specialists should be aware of the dental complications and associated diseases in patients with malignancies and those undergoing chemo and radiotherapy. It is proposed that more awareness should be raised among physicians to rectify this lapse.

Legal Risks and Ethical Dilemmas for Clinicians in the Aftermath of Dobbs.

This Viewpoint discusses the ways in which the Supreme Court's ruling in Dobbs v Jackson Women's Health Organization, which triggered abortion bans or restrictions in half of states, presents serious legal risks to clinicians and major ethical dilemmas.

Remember, do no harm?

When the advocacy group America's Frontline Doctors appeared on the steps of the United States Supreme Court in 2020, falsely stating that hydroxychloroquine was a cure for COVID-19, their pronouncement was virally shared by right-wing media and soundly debunked by medical academicians. A year later, one of these frontliners, Joseph Ladapo, became the surgeon general of Florida and a faculty member at the University of Florida College of Medicine. He has continued to spread dangerous misinformation about COVID-19 while his academic colleagues are shamefully silent.

Experimental evidence of physician social preferences.

Physicians' professional ethics require that they put patients' interests ahead of their own and that they should allocate limited medical resources efficiently. Understanding physicians' extent of adherence to these principles requires understanding the social preferences that lie behind them. These social preferences may be divided into two qualitatively different trade-offs: the trade-off between self and other (altruism) and the trade-off between reducing differences in payoffs (equality) and increasing total payoffs (efficiency). We experimentally measure social preferences among a nationwide sample of practicing physicians in the United States. Our design allows us to distinguish empirically between altruism and equality-efficiency orientation and to accurately measure both trade-offs at the level of the individual subject. We further compare the experimentally measured social preferences of physicians with those of a representative sample of Americans, an "elite" subsample of Americans, and a nationwide sample of medical students. We find that physicians' altruism stands out. Although most physicians place a greater weight on self than on other, the share of physicians who place a greater weight on other than on self is twice as large as for all other samples-32% as compared with 15 to 17%. Subjects in the general population are the closest to physicians in terms of altruism. The higher altruism among physicians compared with the other samples cannot be explained by income or age differences. By contrast, physicians' preferences regarding equality-efficiency orientation are not meaningfully different from those of the general sample and elite subsample and are less efficiency oriented than medical students.

Is physician implicit bias associated with differences in care by patient race for metastatic cancer-related pain?

RATIONALE: Implicit racial bias affects many human interactions including patient-physician encounters. Its impact, however, varies between studies. We assessed the effects of physician implicit, racial bias on their management of cancer-related pain using a randomized field experiment. METHODS: We conducted an analysis of a randomized field experiment between 2012 and 2016 with 96 primary care physicians and oncologists using unannounced, Black and White standardized patients (SPs)who reported uncontrolled bone pain from metastatic lung cancer. We assessed implicit bias using a pain-adaptation of the race Implicit Association Test. We assessed clinical care by reviewing medical records and prescriptions, and we assessed communication from coded transcripts and covert audiotapes of the unannounced standardized patient office visits. We assessed effects of interactions of physicians' implicit bias and SP race with clinical care and communication outcomes. We conducted a slopes analysis to examine the nature of significant interactions. RESULTS: As hypothesized, physicians with greater implicit bias provided lower quality care to Black SPs, including fewer renewals for an indicated opioid prescription and less patient-centered pain communication, but similar routine pain assessment. In contrast to our other hypotheses, physician implicit bias did not interact with SP race for prognostic communication or verbal dominance. Analysis of the slopes for the cross-over interactions showed that greater physician bias was manifested by more frequent opioid prescribing and greater discussion of pain for White SPs and slightly less frequent prescribing and pain talk for Black SPs with the opposite effect among physicians with lower implicit bias. Findings are limited by use of an unvalidated, pain-adapted IAT. CONCLUSION: Using SP methodology, physicians' implicit bias was associated with clinically meaningful, racial differences in management of uncontrolled pain related to metastatic lung cancer. There is favorable treatment of White or Black SPs, depending on the level of implicit bias.

Must Consent Be Informed? Patient rights, state authority, and the moral basis of the physician's duties of disclosure.

Legal standards of disclosure in a variety of jurisdictions require physicians to inform patients about the likely consequences of treatment, as a condition for obtaining the patient's consent. Such a duty to inform is special insofar as extensive disclosure of risks and potential benefits is not usually a condition for obtaining consent in non-medical transactions.What could morally justify the physician's special legal duty to inform? I argue that existing justifications have tried but failed to ground such special duties directly in basic and general rights, such as autonomy rights. As an alternative to such direct justifications, I develop an indirect justification of physicians' special duties from an argument in Kant's political philosophy. Kant argues that pre-legal rights to freedom are the source of a duty to form a state. The state has the authority to conclusively determine what counts as "consent" in various kinds of transactions. The Kantian account can subsequently indirectly justify at least one legal standard imposing a duty to inform, the reasonable person standard, but rules out one interpretation of a competitor, the subjective standard.

Financial Profit in Medicine: A Position Paper From the American College of Physicians.

The steady growth of corporate interest and influence in the health care sector over the past few decades has created a more business-oriented health care system in the United States, helping to spur for-profit and private equity investment. Proponents say that this trend makes the health care system more efficient, encourages innovation, and provides financial stability to ensure access and improve care. Critics counter that such moves favor profit over care and erode the patient-physician relationship. American College of Physicians (ACP) underscores that physicians are permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high-quality, appropriate care within the guardrails of medical professionalism and ethics. In this position paper, ACP considers the effect of mergers, integration, private equity investment, nonprofit hospital requirements, and conversions from nonprofit to for-profit status on patients, physicians, and the health care system.

Centenario de Médica, el legado mayor del Dr. Mario E. Dihigo / The centenary of Medica, the biggest legacy of Dr. Mario E. Dihigo

RESUMEN Introducción: el Dr. Mario E. Dihigo Llanos, junto a un grupo de colegas emprendedores, fundó en Matanzas, en 1921, la revista Médica (devenida Revista Médica Electrónica en 1997). Objetivos: resaltar el centenario de la publicación y contribuir a la preservación de la memoria del eximio pedagogo. Materiales y métodos: fueron utilizados métodos de la investigación histórica, como el analítico-sintético y el deductivo-inductivo, así como los submétodos cronológico y geográfico. Se realizaron entrevistas y se revisó el legado documental del Dr. Dihigo. La información fue triangulada con las fuentes referenciadas y con otras bibliografías y documentos consultados. Resultados: se resaltaron algunos de los aspectos más significativos relacionados con la vida y la obra del Dr. Dihigo, y se realizó una caracterización de las primeras etapas de la revista, donde se abordan su significación histórica y científica. Conclusiones: sus aportes en Medicina y Pedagogía, así como sus esfuerzos por establecer la revista Médica, son los mayores legados de Dihigo (AU).

ABSTRACT Introduction: Dr. Mario E. Dihigo Llanos, and a group of colleagues-enterprisers, founded the journal Medica (renamed Revista Medica Electronica in 1997) in Matanzas, in 1921. Objectives: to highlight the centenary of the journal and to contribute to keep the memory of the prominent pedagogue up. Materials and methods: methods of the historical research were used like the analytic-synthetic and the deductive-inductive ones, and also the chronological and geographic sub-methods. Interviews were made and the documental legacy of Dr. Mario Dihigo was reviewed. The information was compared with the referenced sources and the other referred bibliography and documents. Results: some of the most significant features of Dr. Dihigo's life and work were emphasized. A characterization of the first stages of the journal was carried out, approaching its historical and scientific significance. Conclusions: the main Dihigo's legacies were his contributions to Medicine and Pedagogy, and his efforts for founding the journal Medica (AU).

Ramón Madrigal Lomba, médico e historiador / Ramón Madrigal Lomba: doctor and historian

RESUMEN Las ciencias médicas matanceras, a lo largo de su historia, han contado con personalidades reconocidas por sus conocimientos y entrega a sus respectivas especialidades. En el campo de la Cirugía contemporánea, se destaca el doctor y profesor Ramón Madrigal Lomba, quien unió a su desempeño quirúrgico y pedagógico la pasión por la historia, lo que también lo llevó a sobresalir en esa disciplina. El objetivo del presente trabajo fue contribuir al conocimiento de su vida y su obra (AU).

ABSTRACT Medical sciences in Matanzas have had, for many years, the contribution of many personalities known by their knowledge and devotion to the medical specialties they have practiced. Contemporarily, doctor and professor Ramon Madrigal Lomba stood out in the specialty of Surgery; he summed up to his surgical and pedagogical performance a passion for History, a subject where he also excelled. The objective of this work was modestly contributing to the knowledge of his life and work (AU).

Uninformed consent: Who knows what Ivan Ilyich would have thought?

ABSTRACT: In the modern era, when prolonging life is not an option, the end-of-life discussions are unavoidably influenced by Neuroethics. Despite this, it is interestingly evident how the sentiments of a terminal patient of 1885 and a physician of 2020, are still comparable. This paper pre-sents the arguments behind the so-called "Therapeutic Misconception" and the aim of palliative care to provide dying patients support. It is essential to address priorities of informed consent, signed before any remedy is provided. A key component of the newest Neuroscience research is the analysis of motivation and free will. So, it is necessary to comprehend if the patient struggles to feel at peace with these aspects of his "right to die": Is he free to choose or is he influenced by the doctors? Is this confusion an example of "Therapeutic Misconception"? Is his Informed Consent totally "Informed"? In order to broaden our understanding, we account for many critical situations, such as the mentally impaired Psychiatric patients or the famous Italian case of Eluana Englaro. In addition, we suggested some current approaches such as Artificial Intelligence, useful in preserving some cognitive functions the patient may have lost. Furthermore, research in this field is very critical and in some Catholic countries like Italy, people faced difficulties accepting the idea of the "Anticipated directives". In general, whatever the mental status and whatever the terminal state, the patients seem still far from handling their own auto-determination and their Consent, even if the ultimate goal is to die with dignity.