Within the healthcare system, it is important for healthcare professionals to maintain ethical standards, including those that govern respect for persons, a primary component of which is autonomy, and beneficence.

According to R.G. Rodriguez, Ph.D. (2009), autonomy is an element within the professional code of healthcare ethics that allows for a patient to govern themselves in the event that they are rational, competent, conscious and not coerced. This definition is significant because it provides indications both for the patient’s autonomy as well as situations where the requirements for autonomy have not been met and autonomy should therefore not be fully granted. Spicer (2005) qualifies autonomy by adding that patients must be informed in order to make an appropriate decision; must have the capacity to decide; and must be free from coercion. These definitions differ slightly in the emphasis of information required to be autonomous; however, capacity as defined by Spicer (2005) encompasses rationality, competency and consciousness. In effect, both definitions are mutually supportive and establish complementary guidelines in determining autonomy.

The definition offered by Fremgen (2009) is limited as it describes autonomy as “independence for their beliefs” (pg. 176). The definition provided fails because it addresses only religious considerations, as well as a person’s right to decision-making based solely on competence: “As long as a person is competent, he or she has the right to make his or her own decision” (pg. 176). This does not address matters of relevance involved with determining autonomy, including consciousness or freedom from coercion. “Bioethical and legal issues arise when a person is called upon to make this decision, based upon his or her own religious beliefs, for another person such as a child or an elderly or incompetent adult” (Fremgen, 2009, pg. 176). The assumption that religious considerations are the main contributing factor for dilemmas of autonomy is myopic and impractical as many social, cultural, familial, personal and financial components may contribute to a person’s decision making with regards to healthcare treatments and options. The aforementioned definition given by Fremgen also implies that people without religious considerations would not have ethical dilemmas when making healthcare decisions for themselves or others. However, one would conclude that the complexity of the human condition is still relevant even in the absence of religious belief. Therefore, in consideration of the inefficiency and of the definition provided by Fremgen, the definitions given by Rodriguez and Spicer will be used to analyze the following dilemmas.

Within the ethical guidelines of the healthcare profession, therapeutic privilege offers an option for nondisclosure under certain guidelines. “Physicians may withhold information about a patient’s diagnosis or treatment when disclosing it would pose a serious psychological threat, so serious a threat as to be medically contraindicated” (Wynia, 2004, p. 14). Following the guideline of therapeutic privilege, the provider may not disclose information simply because the information would cause the patient to choose a different course of action, but only in the event that the information would cause significant unnecessary harm if disclosed and is therefore determined to be medically contraindicated (Wynia, 2004). In this way, providers partially disregard the first ethical principle, selectively disclosing information and therefore not being fully truthful and allowing for the necessary information for complete autonomy, in lieu of the second and third principles, beneficence and non-malfeasance. However, beneficence is not sufficient; the judgment must be subjective to preventing actual harm.

The second principle within healthcare ethics is beneficence (Fremgen, 2009; Rodriguez, 2009; Gauthier, 2005). Beneficence means to “act with charity and kindness” (Rodriguez, 2009); it means to use one’s skills and professional authority to care for, comfort, and if possible, cure a patient. Beneficence implies that one will fairly and justly provide services with the intention of another’s improving the patient’s wellbeing. Rodriguez’s definition is valid because it indicates the primary values of beneficence.

When deciding ethical dilemmas, it is important to not only consider the ethical obligations; respecting a person and acting with beneficence, but it is also necessary to consider the legal implications of actions within the context of the healthcare setting. The following scenarios are presented with both ethical and legal considerations:

In the intensive care unit, you are working on a patient in a very unstable state. The woman and her children (who were all killed) had been in an accident. It is clear that further emotional trauma would be disastrous to the patient and may cause her death. In a lucid moment, she looks at you and asks, “How are my children?” Is this an instance when therapeutic privilege seems reasonable? Whether you decide yes or no to the therapeutic privilege question, write a sentence that you think would be the most appropriate answer for the patient.

The primary principle of healthcare ethics being respect for persons, it is important to reflect on the components of respect, mainly: autonomy, truthfulness, confidentiality and fidelity (Rodriguez, 2009). It is necessary to carefully consider the provider’s responsibility to the patient as well as the ethical duty expected by the profession. Beyond justice, the provider has a duty to respect the person, therefore allowing for autonomy as well as being truthful; beneficence, acting in a way that lends comfort, care and possible cure to the patient; and non-malfeasance, meaning that there is no harm caused.

The above mentioned scenario offers an ethical dilemma that may appear to be conflicting. It is the provider’s duty to be truthful, but also to cause no harm. In the event that the provider is truthful, harm, even death, is possible.

If the provider tells the patient that her children are dead, given the current situation, the patient may die due to the additional emotional trauma. In this manner, by telling the patient that the children have died, the provider would be causing harm; risking the patient’s death due to this additional emotional trauma would be medically contraindicated.

However, if the provider does not inform the patient of the news, then the provider is not being fully truthful and respectful of the patient. Under absolutely no circumstances should the provider lie to the patient; saying that the children are fine or any other statement simply to offer comfort. Such a lie would constitute a breach of ethical standards as it is not truthful and may cause greater long-term damage when the woman learns of their death. Lying to the patient is inadvisable and may lead to civil litigation since it would be outside of the professional ethical norms.

Under the guidelines of therapeutic privilege, a provider may not disclose information if such knowledge is dangerous, causing such significant emotional trauma as to be medically contraindicated. In this scenario, one may consider the immediate disclosure to be a matter of therapeutic privilege because the emotional trauma resulting from the information would cause significant emotional trauma possibly resulting in death. Given the likelihood of significant danger at the current time, the provider should not answer the question, but also not offer any false hope or lies. Additionally, autonomy is contingent on rationality; in the patient’s current condition of shock and significant physical trauma, she does not qualify for complete autonomy.

One appropriate response may be to redirect the patient’s focus to her own injuries and treatment, for example: “Ms. Doe, we are doing everything possible to help you right now. We need to ask you some questions about your medical history.” As the patient is not consistently lucid, this redirection would offer additional time to stabilize her condition before adding the additional emotional burden of her children’s death.

You are working late and you enter the patient’s room to find that she has climbed out on the window ledge. She appears to be crying and tells you to leave her alone.

In the abovementioned scenario, the woman on the ledge offers another ethical consideration, contrasting the autonomy of the patient’s wishes to be left alone against the provider’s responsibility for offering care. The patient exhibits clear signs of lacking the necessary components of autonomy. Her actions are clearly not rational and arguably not competent as they are likely indications of mental illness, risk of self harm or even suicide. In this matter, the clear decision is to not fulfill her wishes to be left alone. However, staying in the room or climbing out on the ledge is not a sufficient answer to this situation. This situation needs immediate response: security and police/EMS services need to be notified. Any and all possible means to prevent harm need to be taken.

Beyond the ethical considerations, it is necessary to consider the legal impact of inaction. Had the provider observed the patient’s wishes, he or she would have been liable for any harm that came to the patient (Jenner & Welch, 2001). When a patient is under professional care, it is important for the provider to protect them from harm, even if the harm is caused by themselves as in the case of psychiatric disorders. If the provider fails to reasonably safeguard against actions of self-harm or suicide, he or she will likely be civilly liable for malpractice and negligence (Jenner & Welch, 2001).

Your elderly patient hates to have the bed rails up and tells you to leave them down.

Ethically, this scenario does not offer enough information to conclude if there is a legitimate dilemma: whether or not the patient is autonomous is unclear. The indication of age does not necessarily indicate any potential harm. There is no mention as to whether there are physician orders regarding the matter of the bed rails. The setting of the situation is unclear. More information needs to be obtained before any actual ethical determinations may be made.

However, while this scenario could offer an ethical dilemma given additional information, the more significant consideration is that of the legality of the action. Bed rails qualify as restraints; restraints must be used under the order and direction of a physician (Greenwich Hospital, 2005). Restraints are used only when absolutely necessary; to use them in any other fashion or without proper indications or medical direction could constitute unlawful confinement and may open the provider and healthcare site up to civil or criminal ramifications.

Considering all aspects of a dilemma is important, however it is necessary to consider not only the ethical factors but also the legal responsibilities within the healthcare setting.

References

Fremgen, B. (2009). Medical law and ethics (3^rd ed.). Upper Saddle River, NJ: Prentice Hall Health.

Gauthier, CC, PhD. (2005). The virtue of moral responsibility and the obligations of patients. Retrieved 21 November 2009 from  http://wf2dnvr6.webfeat.org/qxkBN12932/url= http://content.ebscohost.com/pdf9/pdf/2005/MPS/01Apr05/16999952.pdf?T=P&P=AN&K=16999952&S=R&D=aph&EbscoContent=dGJyMNHX8kSeqK84zOX0OLCmrlGep7RSsqq4TbeWxWXS&ContentCustomer=dGJyMPGvtEyvrbVLuePfgeyx44Hy7fEA.

Greenwich Hospital. (2005). Restraint/bed rail entrapment information guide. Retrieved 21 November 2009 from http://www.greenhosp.org/pe_pdf/genmed_restraint.pdf.

Jenner, R. & Welch, B. (2001). Suicide watch: liability for negligent psychiatric care. Retrieved 21 November 2009 from http://www.medlawlegalteam.com/article_jenner_suicide_watch.html.

Rodriguez, R., Ph.D. (2009, November 19). Chat posting. Retrieved from AIU Online Virtual Campus. Chat 1 week 2. The ethical and legal aspects of healthcare: HCM410-0904B-02 website.

Spicer, J. (2005). Consent autonomy and the new practice nurse. Retrieved 21 November 2009 from http://wf2dnvr6.webfeat.org/qxkBN12924/url=http://web.ebscohost.com/ehost/ detail?vid=2&hid=11&sid=8ddc3e69-4ea1-4d2c-b570-228fdecf7b81@ sessionmgr110&bdata=JmxvZ2lucGFnZT1Mb2dpbi5hc3Amc2l0ZT1laG9zdC1saXZl#db=buh&AN=18776068.

Basic Service Components

The basic service components in a complete health care system include any personal medical care services: including prevention, diagnosis, treatment and rehabilitation (Library Index, 2009). These service components include the for-profit and not-for-profit organizations that finance and deliver services. A complete health care system includes medical, dental, vision, and pharmaceutical services.

Preventative services include health promotion and disease prevention services (Williams & Torrens, 2008). According to the Center for Disease Control and Prevention’s Office of Strategy and Innovation (2009), the primary goal is to increase the number of healthy people at all stages of life through healthy life choices, disease prevention and injury/violence prevention. These services may be provided through routine health services, public health education, or other external resources.

Diagnostic services may be part of routine provider contact, or may be resultant from an acute injury or illness. Diagnostics may include emergency services, including ambulance and first responder services. Technology is a key component in the current health care era that allows for easier diagnosis through the use of various radiological and laboratory sciences.

Treatment services include medical interventions, and may include short-term or long-term ambulatory, inpatient, or related services for physical and mental health conditions (Williams & Torrens, 2008). Pharmaceutical services may be included in both prevention and treatment of conditions, acute and chronic illnesses, and acute trauma. Treatment components may encompass inpatient care for simple or complex conditions, long-term or hospice care in either in-home or institutional environments, or inpatient or outpatient social/psychological conditions (Williams & Torrens, 2008).

Rehabilitation services include both inpatient and outpatient services following illness or injury.

These are the basic service components because they include the continuum of care necessary for total health treatment and prevention. If one of these elements is missing or unavailable due to interfering or limiting factors, an individual’s health may be compromised. Without access to prevention, diagnostic services, treatment options (both short and long term), and rehabilitation services, an individual may not be able to obtain or maintain a viable level of health. Chronic illness or under treatment may result in decreased contribution to individual and societal needs, thereby recreating and reinforcing the inability to access proper treatment.

Individual Experience

While these are all components of a complete health care system, it is often the case that not every individual will have access to all the basic components. In some limited settings, the entire health care system is developed internally and individuals are directed between services with smooth transitions and effective referrals. In most cases, however, individuals are responsible for coordinating and communicating between various levels of services; their physician, pharmacist and dentist are connected only through the individual. In other cases, due to limited community or personal resources, individuals may be unable to find all elements of the basic health care service components and will resort to familial resources for treatment and care options.  By carefully analyzing the basic service components as well as their utilization, we may gain valuable information as to the operations of the health care system.

References

Center for Disease Control and Prevention (CDC) (2009). CDC – office of strategy and innovation – goals. Retrieved 12 October 2009 from: http://www.cdc.gov/osi/goals/people/infants.html

Library Index. (2009). The nation’s health care system – the components of the health care system. Retrieved 12 October 2009 from: http://www.libraryindex.com/pages/1817/Nation-s-Health-Care-System-COMPONENTS-HEALTH-CARE-SYSTEM.html

Williams, S. & Torrens, P. (2008). Introduction to health services (7th ed.). Clifton Park, NY: Delmar Cengage Learning.

Physicians and caretakers are often faced with difficult dilemmas that require assisting patients and families to choose a specific course of action. Few environments are as demanding on the professional relationship as within medicine; treatment plans, end-of-life decisions and day-to-day recommendations balance risks with the patient’s best interests. Especially in the medical field, providers’ recommendations must maintain ethical standards. Ethical is defined at Dictionary.com (n.d.) as: “being in accordance with the rules or standards for right conduct or practice, esp. the standards of a profession”.

While persuasion is often used for beneficial or malefic purposes, as a method in itself it is amoral. However, given the responsibility of the vulnerable patient-doctor relationship, it is necessary to remain ethical and to avoid manipulation. Willingness to keep the patient’s best interests at heart helps create persuasive reasoning that is not only effective but also ethical. The key to ethical persuasion is motivation. Someone may persuade people to vote, knowing that citizens that are active in the selection of their representation will be happier than those who passively tolerate the rules and laws placed upon them. This persuasion has the audience’s well-being at heart, and would therefore be considered ethical. However, if the same person used strong-arm tactics, deception or manipulation to force people to vote for the persuader’s candidate, it would be unethical.

Persuasion can be ethical if all the facts, the pros and cons, are honestly presented. Persuasion is imperative, potentially leading to many beneficial ends, when it is done ethically. Ethical practitioners inform patients of the benefits of a treatment, prescription, surgery, or an action so that the patient can recognize just how well the idea, option or action will satisfy their need. Through ethical persuasion, patients should be able to face their fears and uncertainty in order to consent to the best options while staying fully informed of possible negative aspects of the course of action. By appealing to both the logical and emotional factors, the patient may be reasonably motivated to make the best choice.

For example: a pediatrician may persuade a parent to have their child receive a new vaccination. If the doctor maintains an audience-centered approach, keeping in mind the benefits to the child, this would be ethical conduct, following the standards of the profession. However, if the doctor did not fully disclose the risks of an elective procedure or vaccination, instead pressuring the parent with the intention of boosting their own treatment statistics, this would be unethical (and potentially illegal) behavior that is not within the standard of the profession. “To maintain the highest standards of business ethics, make every attempt to persuade without manipulating (Thill & Bovée, 2007, p. 308).”

References:

Ethical. (n.d.). Dictionary.com Unabridged (v 1.1). Retrieved September 14, 2008, from Dictionary.com website: http://dictionary.reference.com/browse/ethical

Thill, J. V. & Bovée, C. L. (2007). Excellence in Business Communication (7^th Edition). Upper Saddle River, New Jersey: Prentice Hall.

Over a period of many years, concluding with the bankruptcy of Enron in 2001, corporate and individual corruption and fraud cost shareholders millions of dollars (paraphrased, Einstein Law, 2008). “All of this debt was concealed from shareholders through partnerships with other companies, fraudulent accounting, and illegal loans” (Einstein Law, 2008). Because of the fraudulent business deals and special ghost companies that were created to hide the company’s debt, investors kept pouring more and more money into the stock. The artificial inflation of the stock price kept the executives rich, fed with outlandish bonuses. “Enron trussed up its corporate structure with hidden debt instruments, supported by the belief that reward could be divorced from risk (Steffy, 2008).”

Decision Making – Halo Effect

Enron was ranked as one of the top companies in the world. The corporate culture was both fun and challenging, and was viewed as the business model of the future (paraphrased, Ivanovich, 2004). Everything that Enron did appeared to be the best. “Fortune magazine named Enron the nation’s most innovative company five years running and, a year before Skilling’s resignation, ranked Enron among its ‘10 Stocks to Last the Decade’” (Ivanovich, 2004). The business was associated with its people, all of whom were top-notch. “The company also was obsessed with recruiting brilliant, aggressive people” (Ivanovich, 2004). In almost a hero-worship fashion, the brilliance of the executives carried over to the brilliance of the company. Everything looked perfect from the outside. The books looked great, and no one challenged the incredible profits that were being reported.

In retrospect, it is likely that stockholders and analysts should have been more cautious, scrutinizing the reports and actions of the company. I think that the primary reason that people did not investigate deeper into Enron was because of the halo effect. The people reacted to Enron because of the context-dependant stimulus (paraphrased, Plous, 1993). By seeing the executives as highly intelligent, brilliant and successful, fun and creative, the halo effect lead stakeholders to believe that they were also fair and ethical people, and that the business was run in a moral and ethical manner. Because of the halo effect, assumptions were made, based on the context of all the wonderfully positive things being said about the management; these assumptions eventually left employees and stockholders taking a major loss, facing long-term suffering.

Descriptive Models – Satisficing

Enron executives did not make the best decisions for the long-term good of the company or the collective. They did not even make the best long-term decisions for themselves, especially considering the lasting effects of their law-breaking on themselves and their families. However, I think that they chose their course of action by using the satisficing decision making model. “To satisfice is to choose a path that satisfies your most important needs, even though the choice may not be ideal or optimal” (Plous, 1993, p. 95). The executives committed fraud to fulfill their immediate need (or greed, in this case) for money. By fraudulently producing deceiving reports, they were able to keep a continuous flow of money into their own pockets. I imagine that the millions that they illegally gained helped to meet all their immediate needs, and to give the illusion of security. By choosing to address only their most primitive and narrow needs, without considering other all the other options that would be ideal or even optimal, the fraud committed is an example of satisficing.

Heuristics and Fallacy

Using the representativeness heuristic, people often judge probabilities by how much one thing appears to resemble another thing (paraphrased, Plous, 1993). However, this heuristic can cause problems when people fall into the “conjunction fallacy”, meaning that they assume that because there are more details, something is more likely to happen (paraphrased, Plous, 1993). In the case of Enron, I think that the executives used the conjunction fallacy of the representativeness heuristic to deceive the investors. With each additional factor, the probability is reduced (paraphrased, Plous, 1993); however many people feel that the more details the more likely something is. In the example of Enron, it created false companies to help hide its losses and substantial debt. By providing highly specific scenarios and ghost companies, many people did not question, but fell into the conjunction fallacy; assuming that, since there were so many details regarding the false companies, the lies must be truth. Fake companies, such as Chewco, JEDI, and Southampton (Einstein Law, 2008), helped to hide the billions of dollars of debt. By falsifying details such as the company names, stakeholders fell into the conjunction fallacy, and the executives were free to act as unethically as they wanted.

Another reason that I think Enron executives were able to execute such a grandiose fraud was because of their advantage using the availability heuristic. “People often use heuristics (or shortcuts) that reduce complex problem solving to more simple judgmental operations” (Schwarz, 1997). Using the availability heuristic, people judge probability on the frequency or prevalence of memory associated with a similar event (paraphrased, Plous, 1993). “The Enron mystique is due, in part, to the fact it was first in the recent wave of corporate scandals” (Ivanovich, 2004). Since there was yet to be a precedence of corporate fraud on such a massive level, no one suspected it. In fact, the company established such a reputation that its crash from on high was of tragedy proportions. Investors and watchdogs using the availability heuristic would not have perceived that such a massive fraud could take place, since there was no previous and readily available example of such events.

Overconfidence and Behavioral Traps

“Enron seems to have achieved primacy because it has all the earmarks of classic tragic drama, in which hubris causes the fall of the mighty” (Ivanovich, 2004). The mighty Enron, powerhouse and a sort of prince among large companies, became overconfident. The executives assumed that they would not be caught, that their deceiving and fraudulent tactics would continue without recompense. “No problem in judgment and decision making is more prevalent and more potentially catastrophic than overconfidence” (Plous, 1993, p. 217). Because the executives became overconfident in their own brilliance, they took risks that reasonable people would never enter into, particularly the defrauding of their investors, employees, and the general public.

Another major behavioral trap that the Enron executives fell into was the time delay trap. “When Kinder left and Skilling took over the presidency,” Strong said, “I started feeling that people were not looking at the longer-term perspective” (Fowler, 2004). Similar to saticficing, time delay serves only the short term, most immediate needs, without searching out the most ideal long-term decision. In this scenario, they fulfilled their immediate greed, but destroyed their futures, some by serving jail terms, another through desperation, shame and suicide (Einstein Law, 2008).

I would argue that a third behavioral trap that played a major role in this fraud was the investment trap. After completing the first fraud, they had little additional to lose to complete the second, the third, and so forth. Once the line was crossed into fraudulent and illegal behavior, it did not greatly affect the situation if they continued to behave in this way. Essentially, they had already invested too much, and could not withdraw from their immoral actions without even greater loss. Hence, it was easier for them to continue on the path than to withdraw and return to ethical business practices.

Yet another trap would be the collective trap. This small group of people benefitted greatly, but at a huge loss to the collective; costing not only the business entity, but the persons involved to suffer extensively. Lost jobs, lost wages, lost investments; stakeholders of all sorts were impacted by the selfish greed of this élite group. This trap seems to be especially cruel, since it shows a premeditated choice to injure so many other individuals. The evidence of the collective trap shows that the group of executives felt themselves above the rest, with a morally and ethically superior value.

The Social Side – Groupthink

I think that it is obvious that this group of executives fell victim to groupthink (Plous, 1993). Some of the most common symptoms that were demonstrated by the Enron group were: the illusion of vulnerability, collective efforts to rationalize warnings, and unquestioned morality (paraphrased, Plous, 1993).

Conclusions

There is no doubt that the Enron executives were brilliant, and that they used many theories and fallacies of common decision makers to extort and defraud millions of dollars from stakeholders. By utilizing their knowledge of the processes of decision making, they were able to mislead and manipulate the situation. They took advantage of the halo effect to make themselves look better than they were. They were satisficing; serving only their immediate needs. By exploiting the heuristics used by stockholders, they were able to continue to increase stock prices while the actual business portfolio plummeted. Their eventual downfall was a direct result of their overconfidence.

While it is embarrassing that such an event happened, it is important to understand how and why so that there is not a repeated scenario. Investors and the general public need to be aware of how immoral people can manipulate the situations, thereby controlling the cash flow. Awareness and knowledge are the best defense against such fraudulent behavior. These same concepts need to be applied to all aspects of healthcare; no department or field is beyond the possibility of flawed decision making.

References

Einstein Law. (2008). Enron fraud, the history of Enron, the Enron investigation. Retrieved 8 March 2009 from: http://www.lawyershop.com/practice-areas/criminal-law/white-collar-crimes/securities-fraud/lawsuits/enron/

Fowler, T. (2004). Enron’s implosion was anything but sudden. Retrieved 8 March 2009 from: http://www.chron.com/disp/story.mpl/special/enron/2655409.html

Ivanovich, D. (2004). Everybody knows Enron’s name. Retrieved 8 March 2009 from: http://www.chron.com/disp/story.mpl/special/enron/2655424.html

Plous, S. (1993). The psychology of judgment & decision making. New York, McGraw Hill.

Schwarz, S. (1997). SFB 504 glossary: heuristics. Retrieved 28 February 2009 from: http://www.sfb504.uni-mannheim.de/glossary/heurist.htm

Steffy, L. (2008). Meltdown highlights our own failings. Retrieved 8 March 2009 from: http://www.chron.com/disp/story.mpl/business/steffy/6038997.html

HealthTechnica: Health Care Professional’s Social Network List

To better understand the impact of decision making on the medical field, I have chosen to evaluate an organization whose purpose it is to support and advise healthcare providers, both in policy making and treatment options.

Identification of Company

The Society for Medical Decision Making (SMDM) is an international organization that assists physicians and other medical professionals in improving healthcare outcomes by promoting efficacious decision making that is based on valuable resources exchanged through academic forums (paraphrased, Society for Medical Decision Making, 2007).  Because of the broad range of members’ expertise, hospitals and physicians are able to draw healthcare information from global resources.  By approaching medical decision making and policy formation from a multi-dimensional perspective, the informed communication will lead to better and more effective outcomes, which may lead to overall health benefits.

The Services Provided

The main goal of the SMDM is to “improve the health and clinical care of individuals and assist health policy formation by developing and promoting the use of systematic methods to deal with the uncertainties of health care decisions (SDMD, 2007).”  In other words, the society is designed to help the healthcare providers and policy-makers make better decisions, especially when the decisions are difficult to make.  Many hospitals: made up of the directors, administrators, and physicians, are faced daily with difficult situations that may lead to life or death decisions.  Like any other business, hospitals are reliant on their ability to make good decisions, even in difficult situations.  Poor decision making may lead to monetary loss from malpractice suits, bad publicity, and other negative impacts such as cuts in government funding.  If hospitals and doctors make bad decisions, lives may hang in the balance.  However, if systematic approaches are developed to ensure the best possible choices are made, than the hospital also has much to gain.  By using the services provided by the SMDM, the hospital may improve risk management and ensure positive healthcare outcomes.

Global Impact of Improved Decision Making

Framing is the context and perspective a person uses to evaluate a choice; what the decision maker sees as the outcome and possibilities of a particular act (paraphrased, Plous, 1993, pg 69).  If physicians and hospital policy-makers are attendant to the examples set by the Society for Medical Decision Making, they may be able to persuade patients to make the best choices, despite their fears. By framing the information in terms of their survival rate, possible benefits v. side effects or risks, care givers may be able to provide the most beneficial view of data, helping patients to allay fears or shock related to the illness so that they can make the best choices possible.

Conclusion

The SMDM provides a valuable service, allowing both medical professionals and the general public to become more informed and secure in their decision making. Because of the cross-cultural and multi-disciplinary membership, the SMDM promotes better decisions, resulting in better global healthcare outcomes.

References

Plous, S. (1993). The psychology of judgment and decision making. New York. McGraw-Hill.

Society for Medical Decision Making – SMDM. (2007). Mission Statement / Values. Retrieved 15 February 2009 from: http://www.smdm.org/mission_values.shtml

Now, I find myself speaking to physicians who are stressed out both from their careers and from their imploding personal lives.  While I won’t stop hearing from my scientist colleagues anytime soon from exploring alternative career transitions, I anticipate connecting with more medical doctors in the next few years. Many of these doctors no longer recognize the profession they used to love amid the increasingly hostile healthcare environment.

What worries me more is that many of these doctors no longer know who they are.

When you have invested years of your life: about two decades worth of yourself and your life to schooling to become a physician, your career decision has been deeply ingrained (i.e. family heritage) or deeply personal (i.e. personal value around making a difference as a healer). After all, it takes courage and commitment to choose a career where, when you’re finally ready to “start”, most of your peers in other professions are in their mid-career journey.

No wonder, for doctors, it can be harsh and hard to walk away from an identity that has been decades in the making.

If you are a physician, try this: describe yourself without making reference to your profession; without saying “I’m a doctor” or what clinical tasks you perform on a daily basis.

What are you left with?

If you don’t like the answer, make a plan to create one that you can live with and be fulfilled by for the rest of your life. Too often physicians settle for a role (“doctor”) as their identity, and when that role becomes threatened, they find that their identity becomes threatened. They feel out of control with who they are, what they stand for, and how they live their lives.

Now is the time for physicians to start facing this consuming identity crisis before they no longer recognize their lives or worse – themselves.

Electronic Patient Health Records

Having just got back from a series of meetings in Cambridge this week at the “Healthcare Special Interest Group – ‘Meet the Clinic: Personal Health Records‘” seminar, I wanted to share some of my thoughts on electronic patient health records and the technology that is currently available and being developed. This is by no means meant to be an exhaustive introduction, but just a summary of my understanding and opinion.

You may or may not have heard of Electronic Patient Health Records, or you may have heard of Electronic Health Records, or Health 2.0, or Health 3.0, or Patient Empowerment or even “the ability to securely and confidentially access your GP-held health” and you weren’t quite sure what that meant! It’s understandable, to be honest.

It’s a bit like Web 2.0, the term was used by every digital company going, every piece of marketing, every sales pitch; yet, when you asked someone to define web 2.0, it would usually follow with a long awful silence and some mumbling about big shiny font. Of course, now it’s ‘social media’, but anyway… that’s another story.

Some of you will probably be frustrated, shouting at the screen “Of course I know what electronic patient health records are! It’s my health record, in an electronic format”. You’re not wrong, but you’re not right either. It is your health record, the one your GP stares at on his/her computer screen–that computer screen that you always wondered what was on it, but the angle just wasn’t quite right for you to be able to see what was written about you; well, electronic patient health records now enable both you, and your doctor to stare into the computer screen and view your health notes, and more…

I’m making this sound really great aren’t I? and you want to know where you sign-up and login, don’t you?

Everything is a bit up in the air at the moment, certain groups are playing the thin line of bureaucracy whilst other are fighting to establish their dominance; and this is just within the NHS! Then we actually come to the digitalising of patient health records, which too is still being established and roles defined. So, for the moment I’m going to talk about where we are right now, today.

To me online learning of clinical skills almost sounds like an abomination or contradiction in terms. You learn them knee deep in blood, saliva, urine you name it but not behind a computer screen.

Recently an article was published about the experience of developing an online learning resource that supplements the learning of basic clinical skills for undergraduate medical students. Supplements, so it doesn’t replace the learning of clinical skills completely. This got me interested about their experience with this kind of online learning resource. Mind you, this is not a randomized controlled trial but just some wise advice and clear instructions on how to make a video to be put online for e-learning.

But first the wise advice, The bottom line from the Belfast Experience:
Online learning (Clinical skills) is best placed in conjunction with other traditional forms of clinical teaching, in a blended approach. Educators must be sure that online learning augments the students learning experience. It must not inadvertently promote learner isolation or a reduction of patient-centred teaching.

Especially this last warning is very important. Ah, we have a beautiful comprehensive online learning program so we can sit back and wait for skillful clinicians to be delivered.

Concerns that the uptake of such educational mediums may be influenced more by novelty than by pedagogical evidence, has driven the need for educationalists to share their experiences of e-learning

Sequence of events when producing an online clinical skills video from the discussed article:

• Preparation and planning
• Identify the clinical skill
• Establish any funding requirements (for example, simulated patients and audio-visual fees)
• Ensure that there is a clear understanding of the learning outcomes and relevance to the curriculum
• Produce a storyboard
• Hold a meeting with audio-visual specialists, clinicians and educationalists to approve the story board
• Co-ordinate a date and book a location for filming (ideally at a quiet time)
• Book the audio-visual and relevant clinical equipment
• Book a simulated patient
• Practice the skill to be filmed
• Day of filming
• Brief team on filming sequence
• Gain written consent from simulated patient(s) and participating clinician(s)
• Set up scene, including lighting and sound checks
• Perform a dry rehearsal of the skill
• Film the complete skill
• Film any further specific takes (for example, close-up shots, etc.)
• Debrief on video, and consider re-filming any sequences (difficult to undo after the film has been edited!)
• Post filming:
• Record audio narration, if required
• Edit film, with the addition of text and ? or graphics, if required
• Project team and clinical experts approve final version
• Place on website for streaming

Learning clinical skills is a two phase process in this curriculum. First students learn basic clinical skills such as history taking, clinical examination and simple procedural skills, with the use of mannequins, simulated patients and peer examination. In this first phase they have a website at their proposal. From the home page, students can select a number of options: for example, information and contact details, an updated news section, a ‘Frequently asked questions’ page and a general student support area.

However, the main focus of the website is on the pages and videos of the basic clinical skills taught. The students can review a step-by-step online guide of how to perform this skill by means of text, relevant images and videos. Built into the learning material are links and connections that help to vertically and horizontally integrate this new knowledge.

Advantages of this online learning of clinical skills:

• Students can access learning material whenever and wherever they choose
• Access to online videos are particularly useful for visually intensive clinical skills
• Allows for greater transparency of learning outcomes for both students and teachers
• Facilitates improved communication between teachers and students over a large geographical ‘clinical campus’
• Allows both students and teachers to make wider connections with other aspects of the curriculum
• Promotes greater standardisation of teaching
• Complements traditional methods of clinical skills learning in a blended fashion
• Promotes interprofessional education and sharing of reusable learning objects

They arrive better prepared to the next phase of the teaching of clinical skills: attend in small groups clinical ‘bedside’ attachments, where they have the opportunity to progress these clinical skills on
real patients. They can also rehearse their instructions online on PC or PDA.

What do you think, or do you have experience with this kind of online teaching?

Gerry Gormley, Ian Bickle, Clare Thomson, Kate Collins (2009). Online learning in clinical skills: the Belfast experience The Clinical Teacher, 6 (1), 46-50 DOI: 10.1111/j.1743-498X.2008.00253.x

• If I get in to Medical School at twenty-seven, followed by five years training before foundation years, how many years am I actually going to get practising medicine?
• How old will the other students be at Medical School and will I be singled out as the ‘oldy’ or simply just not fit-in?
• Can I financially and socially adapt to the change of becoming a full-time student?
• Academically, after so many years in the ‘real-world’, will I be able to cope with amount of work required and what about the assessments and exams?

The list goes on and on and we’ll all be able to add and remove different questions that concern us individually. I think the first thing to remember is that you’re not alone and the internet is a great place for finding like minded mature pre-med and medical students. The other thing to remember is that many medical schools are now keen to recruit maturer students.

“Mature students bring a breadth of life experience,” says Peter McCrorie, who runs the graduate entry course at St George’s, “Some school leaving students have that too, but people who are older have more life experiences and that’s a very useful thing to have in medicine.”

We also have many other things going for us, admitadely we might not be able to drink as much as our fellow younger students, but we make-up for that in that we tend to work harder and often achieve better grades, we have life experiences that we can apply to medicine and our studies also.

I recommend reading the following article on Student BMJ, Does age matter?