Andrew G. Shuman, MD, Assistant Professor, Department of Otolaryngology, University of Michigan
"When Not to Operate: The Dilemma of Surgical Unresectability"
One of the most anguishing choices a surgeon can make is deciding not to embark upon an operation because a tumor is deemed unresectable. Despite the widespread acceptance of patient autonomy and transparency in medical practice, there remains an unstated paternalism “behind the mask,” within the confines of the operating room. The concept of surgical unresectability derives from a complex combination of tumor factors, patient factors, and surgeon factors. In many cases, these decisions are intensely personal and subjective, with disagreements even among surgeons in the same field. There is a risk that the voice of the patient may be lost in making these decisions, as surgeons weigh these intangible variables in ways that may be incommunicable. However, the consequences of proceeding with an operation unlikely to achieve its intended outcome may be similarly terrifying. In this presentation, a cancer surgeon and reconstructive surgeon will discuss these dilemmas from multiple perspectives using real-life case examples from their practice. We will collectively try to tease out the inherent biases informing such decisions from the standpoint of doctors, patients, and clinical ethicists. The theoretical underpinnings of the authority of surgical judgment will be explored, noting that pursuing goods internal to the practice of surgery requires such decisions, and asking whether Polanyi’s concept of tacit knowledge explains (or even permits) a degree of paternalism.
Phoebe Danziger, BA, MD expected May 2014
"Beliefs, Biases, and Ethical Dilemmas in the Perinatal Counseling and Treatment of Severe Kidney Anomalies"
Anomalies of the kidney and urinary tract are the most common prenatally diagnosed fetal structural abnormalities, and are a major cause of end-stage kidney disease in children. Severe, prenatally diagnosed cases present a number of unique ethical issues with respect to the care of the pregnant woman, fetus, and neonate. We will use a case-based approach to explore these issues in the context of prenatal counseling, and in the neonatal period. On a case-by-case basis, efforts are made antenatally to coordinate counseling from appropriate consultants such as maternal-fetal medicine, neonatology, and pediatric urology and nephrology. We argue, however, that significant differences exist both between individual physicians and between subspecialties more broadly with regard to beliefs about prognosis, therapeutic interventions available, and appropriate utilization of palliative versus life-prolonging options. Unlike for other high-risk perinatal conditions such as extreme prematurity, no guidelines or standardized interprofessional processes exist for the provision of coordinated, timely, and non-directive care to these patients. This has implications for choices made regarding prenatal care, resuscitation efforts at birth, and utilization of palliative and life-prolonging care options, and we argue that the implicit biases and differences in both counseling and practice must be explicitly addressed and considered in order to facilitate more effective counseling for families facing these diagnoses. We will discuss the prenatal use of the term “lethal pulmonary hypoplasia,” a term that implies an unequivocal outcome but is a tissue-based diagnosis that can only be made after birth, not on the basis of obstetric ultrasound. We will also discuss the strikingly different rates of utilization of and attitudes towards dialysis initiated in the neonatal period, both between individual care providers and between institutions.
Kathryn L. Moseley, MD, MPH, Assistant Professor, Pediatrics and Communicable Diseases, University of Michigan
"Electronic Medical Records: Challenges for Clinical Ethics Consultation"
Electronic medical records (EMRs) are rapidly replacing their paper counterparts. Their advantages include readability, access, organization, and comprehensiveness. The qualities that make EMRs so attractive also create new challenges for the clinical ethics consultant and the consultation process. This transition from a handwritten record of examinations and diagnoses that resided in close proximity to the patient to an electronic record that can be read remotely creates a number of concerns uniquely problematic for ethics consultation.
We identify 4 hazards that EMRs present to ethics consultants:
• Accessing significant medical information remotely, before face-to-face contact, can bias the consultant and lead to the premature development of conclusions/recommendations.
• The ability to access medical information remotely can tempt the consultant to be less thorough in face-to-face information-gathering.
• The paucity of nuanced information about the patient/family social and emotional situation and the content of patient/family meetings can misinform and mislead the consultant.
• Remotely accessing information can delay communication with the patient and family, potentially undermining their trust in the objectivity of the ethics consultation process.
We propose the following 3 recommendations for training programs and ethics committee members to begin to address the concerns above:
1) Training programs for ethics consultants should emphasize the importance of face-to-face encounters with all stakeholders as soon as possible after receiving a consult. Telephone only consults should be discouraged.
2) Hospital ethics committees should create procedures and processes that encourage and support face-to-face information gathering.
3) New consultants should be educated about the limitations of the EMR, especially as an accurate source of information about the emotional or social situation of the patient/family and the content of patient/family meetings.
Helen Morgan, MD, Department of Obstetrics and Gynecology, University of Michigan
"Academic Integrity in the Pre-Health Undergraduate Experience"
Introduction: There is evidence that academic misconduct early in a student’s career can initiate a continuum of later unethical behaviors. Multiple studies have reported that the best predictor of whether a student will cheat in medical school is whether they had a history of cheating in college. Cheating in medical school has been found to be the strongest predictor of disciplinary action by state medical boards for practicing physicians. There is a paucity of data on perceptions of academic integrity in pre-health students. Methods: In the fall of 2013, we administered a survey on academic integrity to first-year pre-health students in the Health Science Scholars Program. The curriculum for their course included sessions on academic integrity in the health care profession, and in the pre-health experience. Follow-up assessments in the spring of 2014 included a re-administration of the same integrity survey, as well as a survey on students’ perceptions of what pressures and justifications lead to cheating behaviors. Results: In the fall, students reported that 7.5% had cheated already in college, 26.2% had witnessed cheating in college, and 59.4% believed that academic misconduct was a problem at the University of Michigan. In the spring, the percent of students who reported cheating in college was unchanged at 7.1%, and there was an increase in the number of students who reported witnessing cheating in college at 40.8% (p=0.027). Students cited admissions requirements for graduate programs as the highest sources of pressure to cheat. Conclusion: This pilot data demonstrates that there is a need for curriculum development that could potentially prevent academic misconduct in vulnerable pre-health students.
Tanner Caverly, MD, MPH, Health Services Research Fellow, Ann Arbor VA Medical Center and Clinical Lecturer, University of Michigan
"How transparent are cancer screening & prevention guidelines about the benefits and harms of what they recommend?"
Transparent risk information -- that is, presenting absolute risks on both benefits and harms -- is essential for medical decision making. Without this information clinicians and policy-makers cannot know how much an intervention helps, whether the potential benefit is worth the potential harms, or whether one service is more helpful than another service. We recently did a structured review of clinical practice guidelines and two widely-used clinical resources. We found that few recommendations are accompanied by transparent risk information on the benefits and harms of the recommended cancer prevention service (only 23%). This talk focuses on how risk information WAS presented and the implications of our findings.
Susan D. Goold, MD, MHSA, MA , Professor of Internal Medicine and Health Management and Policy, School of Public Health, University of Michigan
"Controlling Health Costs: Physician Responses to Patient Expectations for Medical Care"
Background: Physicians have dual responsibilities to make medical decisions that serve their patients’ best interests but also utilize health care resources wisely. Their ability to practice cost-consciously is particularly challenged when faced with patient expectations or requests for medical services that may be unnecessary. Objective: To understand how physicians consider health care resources and the strategies they use to exercise cost-consciousness to respond to patient expectations and requests for medical care. Design: Exploratory focus groups of practicing physicians were conducted. Participants were encouraged to discuss their perceptions of resource constraints, experiences with redundant, unnecessary and marginally beneficial services, and asked about patient requests or expectations for particular services. Participants: Sixty-two physicians representing a variety of specialties and practice types participated in 9 focus groups in Michigan, Ohio, and Minnesota in 2012. Measurements: Iterative thematic content analysis of focus group transcripts. Principal Findings: Physicians reported making tradeoffs between a variety of financial and nonfinancial resources, considering not only the relative cost of medical decisions and alternative services, but the time and convenience of patients, their own time constraints, as well as the logistics of maintaining a successful practice. They described strategies and techniques to educate patients, build trust, or substitute less costly alternatives when appropriate, often adapting their management to the individual patient and clinical environment. Conclusions: Physicians often make nuanced trade-offs in clinical practice aimed at efficient resource use within a complex flow of clinical work and patient expectations. Understanding the challenges faced by physicians and the strategies they use to exercise cost-consciousness provides insight into policy measures that will address physician’s roles in health care resource use.
