Monday, 28 January 2008

A Lesson in Ethics

Today's communication skills session was on ethics, it was a useful session and brought up some interesting discussion. Its also a potential OSCE station for finals so it was useful in that respect too. The session was based around simulated consultations and I thought I'd share some of the cases with you to get your thoughts and opinions.

1) You are an FY2 in GP practice, an elderly patient's relative comes to see you. They are concerned that their elderly relative is unfit to drive. They would like you to contact the DVLA.
The elderly patient does not see that he has a problem despite arguments with his relatives and is reluctant to come and see you.

What do you do?

2) Last week a pregnant young woman came to see Dr Pickles at your practice with PV bleeding. Today, her sister has come to see you to complain that Dr Pickles did an internal examination on the pregnant woman without informing her that he would do so and without having a chaperone. The sister is also concerned that this internal examination may have led to the patient having a miscarriage later that day.

What do you do?

3) You are an F1 on the ward, a patient comes to you and reports that she just saw a more senior doctor "sniffing a white substance". She is reluctant to make a written statement or to follow-up the complaint, although she is very concerned.

What do you do?

4) You are an F1 on the ward. A social worker has asked to see you about Miss 'Caine, unfortunately Miss Caine discharged herself earlier that day and her whereabouts are unknown, you hope her GP will persuade her to return. Miss Caine was an IV drug abuser who has Hepatitis B. The GPs referral letter mentions that Miss Caine's 13yr old son, Tom, has Hepatitis B. As far as you know, Miss Caine, and her son, may or may not be aware of this diagnosis. Tom is currently in social services care, he is in a house with 2 other children and has been known to bite in the past. The social worker wants to know about Miss Caine's care and about Tom. She needs to know if he has Hep B and is a danger to those around him.

What do you do?

I ended up having number 4, which was apparently the hardest, fortunately the argumentative simulated patient was away today. I'll post what I said in the comments later.

Answers on a £10 note to the usual address.


sillyvicky said...

Some of them look like the shockers I got at interview for med eek here’s my answer below probz 100% wrong.

1) Erm hard one as really should you be getting involved I would say contact the DVLA and get him retested. As at the end of the day what if he kills someone tomorrow hes going to have to love with that for the rest of his life. Tho seen as you’re an F2 I would say take advice from a senior partner as well.

2) Go oh shit in your head as it looks like your going to get sued. Then I would say to the sister that you can’t comment on her sister case but if her sister wishes to discuses the matter with you, you will be more than happy to do this. I would also consider contacting the relevant bored as isn’t it illegal for him to do an exam without a chaperon

3) Inform the consultant senior that a patient has made the comment and let him follow it up. I would be doing this out of concern for the colleague. On the other hand if I was friendly with the senior doctor I may ask him first incase it was a simple misunderstanding.

4)I would say test the kids he has bitten to see if they need treatment as you need consider their welfare over keeping Tom and his mothers condition private as they are minors and in social services care is it not possible to do this without telling them what you testing for because of their age.

I would also inform the GP so he can look into the mothers care if necessary. I would also begin treating the Tom for the infection.

AMiB said...

ok, I'll give it a shot (I always sucked at things like this...especially when a Sim patient is involved)

1) First off, try and find out if the elderly relative actually is a danger behind the wheel...if they have done something in the past to make them one, I think it is your duty to report them to the DVLA (I had to report a patient to the DMV [our equivalent] who had stopped taking her dilantin [phenytoin]). Ask the relatives why they are concerned, and try and set up a session with all of them together to work out the problems?

2) First of all, what does an "internal examination" encompass?? lol...we don't venture that far in our preclinical years. Firstly, if these exams are indicated in cases of vaginal bleeding (which I assume they are), then I think you shoudl try and express to the sister that the examination was necessary (if it was). If it wasn't, however, I would go to Dr. Pickles and get his side of the story, before going any further. Why taint someones GMC record if they've done nothing wrong?

3) Haha what sane person would sniff coke in the middle of a ward? I would first off try and talk to the patient and tell them they are probably mistaken (while trying not to sound patronizing lol - then maybe do a quick psych exam :-P). Of course, following up with the "senior doctor" would be important to...although if they are your senior, this could essentially be a career-jeopardizing move...but by 'law' it's necessary, isn't it?

4) First off, that is quite the immature 13 year old...although he has obviously been through some tough times. Human bites are one of the recognized means of transmission of Hepatitis B (or at least Google tells me so), and so I would consider Tom a danger to his house-mates. Explaining to him his condition could go two ways - 1) it could make him stop biting or 2) he would use it as a threat/means of retaliation towards those around him (more likely, based on the story). I would advise that he be moved out of the house and placed somewhere where he is less of a danger. Psychological counseling sounds like it would be beneficial as well.

Misha said...

What rubbish we have to contend with eh...Q3 especially. I'm sure I'm wrong but I'd be tempted to have a chat with the person in question first - all this whistleblowing stuff makes me uncomfortable, it's not really the done thing between mature adults - and as the poster above said, make sure I wasn't acting on hearsay that would surely ruin someone's career. Benefit of the doubt for the doctor required there, I reckon.

the little medic said...

Ok, here is what we came up with:

1) Its a question of duty to patient compared to duty to society. You can't just go behind his back and report him. You'd need to persuade him to come in to see you then you could talk about it and assess the reasons why he might not be a safe driver. If he isn't then you should explain why and tell him that he should contact the DVLA himself. Only then, if he doesn't, and he is a danger on the roads should you report him to the DVLA but you should tell him you're doing so.

2) Basically 2 issues here. Firstly did the internal (vaginal examination) cause the miscarriage as the sister suspects: well no, its very unlikely, there is no reason why it should have and the sister should be reassured as such. Secondly the issue of the inappropriate examination, there is no need to do an internal examination on a pregnant woman who is bleeding. She should be referred for ultrasound instead. You should look at the GPs documentation of the consultation to see if she was offered chaperone then you could speak to the GP in question or report it to a senior collegue. It would be best to get the patient herself to come in and discuss the situation

3) This seems far-fetched but in-fact its not. It happened in a hospital round here recently which apparently made this scenario difficult to teach. If there is any chance that this doctor has been abusing drugs, whilst at work, he should be suspended immediately pending investigation. YOu should take this up with a consultant and encourage the complainant to put her version of events down on paper.

4) The idea of this situation is that social worker is asking you to break patient confidentiality. When I did it, I refused to tell her anything about the two. I suggested that they find Miss Caine so we could discuss the whole thing together. Ben - not being my patient, has nothing to do with me so I suggested the social worker speak to his GP. The group agreed that no information should be given to the social worker. There was no care order in place giving social services parent's rights.

There aren't black and white answers to these situations. They are all open to interpretation.

Elaine said...

For the first question, I fail to see that you should take any action. You have not seen and assessed the patient and therefore have no direct knowledge.

Also, it is not only doctors who can approach the DVLA, so if the relative is so concerned, they can contact DVLA directly theirself.

Calavera said...

You got option 4? That completely sucks.

These scenarios are all so difficult - almost glad that I'm immersed in the far more straightforward world of academic medicine instead of these ethical dramas!