MMI practice for 2011

[kylamonkey]

OK- so I have really not started to prep for interviews yet, except for skimming "Doing Right".

It would be great if there are some who have more prep than me to talk about some of these ethical questions.

I thought this was an interesting question- no idea if it's even the type that might be on a UBC MMI, or a UofS MMI or what, but let's start!

 

 

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You are a second year student shadowing a doctor in the O.R. Once the patient, an obese female, has been given general anesthetic and the procedure is underway the doctors start to make comments about her weight and call her names that you find inappropriate but most of all unprofessional. Do you talk to the doctor about his comments or do you keep your comments to yourself? Why?

 

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[hking03]

This is a dilly of a pickle...

The short answer to this is- I probably wouldn't say anything without first speaking to either the person responsible for my placement or a counsellor within the hospital.

It could be viewed as unprofessional and brash to tell a superior how you feel regarding how they operate their OR... Having said that, rules are most likely in place that state this behavior is unacceptable and should be reported to person X and will be dealt with accordingly.

[LupeFiasco]

Agreed.

 

Their behaviour is unprofessional. I would follow the same steps as stated above.

 

^^^+1

[sfuguy]

My 2 cents...I actually think that if this happened in real life, many second year students wouldn't do anything!!! The power differential is huge and afterall, you are JUST a second year student with 3rd and 4th year to come, residency interviews etc... so i think it is first important to acknowledge this conflict and the difficulty which is real!

 

Second, since you do not know whether the doctor does this all the time or if this was just an isolated incident, I think that rather than ruining the doctors reputation by reporting them, I would just mention DIRECTLY to the doctor that YOU felt uneasy with the conversation that went on during the procedure. Chances are that they will ask you how you think things went so you might have an opportunity them. You know, we all make mistakes and sometimes feedback on our performance will help more than discipline!

 

Remember, your goal as physician is to work together with other members of the medicAL TEam to deliver care and sometimes this means counselling and providing feedback to other team members, so getting a doctor in trouble, perhaps suspended might not be the most helpful or appropriate way to solve the problem. Perhaps a simple self reflection might do the trick. I think I would not jump the gun, with the reporting of this incident.

 

Of course if this repeatedly occurs then perhaps I would follow the above route.

[hking03]

I considered speaking directly to the doctor, but chose a different route because of the power differential and the fact that if a surgeon who is running an OR is insulting a patient in front of others it is more than likely he/she has done it before...

 

As for the power differential this surgeon would more than likely have several years of experience and be a few years older than you. Couple those with the fact that he/she is your superior and may not take the suggestion well I would report to the person who gets paid to deal with these types of situations and can keep everything anonymous without tarnishing anybodies reputation.

 

 

Think about it this way- if the surgeon doesn't take it well or thinks you were being disrespectful you may have created an issue for the next few weeks/months. Better to play it safe and go to the professional unless you are confident that the surgeon will take your opinion seriously and not think you are overstepping.

 

It's a difficult situation for sure and I think it is important to note that the support you develop for your stance is probably more important than what position you ultimately take.

 

Kyla- bring on the next question!!!

[sfuguy]

hey hking

 

you do have a point, a really good one!!

 

But if everyone is taking part in the joking (as the original scenario suggests) and if you report, and if that office does something about it, then the doc will know it is you because who else could it be? So then, not only did you over step, but now, to put it bluntly, you dont have the guts to stand up for what you think is right and you're a tattle tale! If the office just records the info for the record then that might help patients, but not for a while until they get more such cxomplaints from students and likely many students would just not do anything!

 

There are ways to casually bring things up. You don't have to make it confrontational! I have had the experience to 'critique' my supervisors many times and more often than not they appreciate it! Although in this case it could be different.

[repede]

Both hking03 and sfuguy have good points, but I'll have to side with hking03 on this one. It would depend on the doctor's personality, but I think the power differential is too large. Chances are that he could be offended by your feedback (whether he'll show it or not), and future encounters could become very unpleasant. You can sugar-coat your "constructive commentary" as much as you want, but it will put him on the defensive. He probably wouldn't like that very much.

 

When a formal report is submitted for an incident like this, there is usually an investigation before any action is taken. Should the investigation prove fruitless, no one will hear of the incident, and the doctor's reputation will not be harmed. If another student submits a similar report later, there will at least be a record that it has happened before, which would help with a later investigation. However, if the investigation uncovers something substantial, whoever deals with these issues will have much more authority to take action than you do. I would think that it's done in a way so the "source" of the complaint wouldn't easily be traced to you.

 

Also, regardless of whether it is an isolated or repeated incident, I think it is inappropriate enough to warrant a report to whoever has the ability to deal with these things. Making fun of a patient like that (even if he/she cannot hear) is completely unprofessional and disrespectful. Sure, we may all cross the lines here and there, it doesn't mean we should be able to get away with it.

 

Plus, if it isn't reported, there is no way to know whether it will continue or not. If the doctor agrees to your feedback, he may just stop doing it in front of you but may continue doing it when you're not there.

[kylamonkey]

Here's a new one. I made it up myself- please note that I have NO experience with MMIs and I've only done a little research. Feedback on how good/realistic my question is would be great too.

 

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Dr. Paolo Zamboni recently published new and controversial treatment for Multiple Sclerosis (MS) called "Liberation therapy".

 

Scenario: You are a GP, and have a patient with MS. She makes an appointment with you and says she is interested in this therapy, and she is planning on going to Mexico to have the procedure performed. She is not financially well-off, as her condition doesn't allow her to work and her only income is a government stipend. The cost of the therapy is approximately $10,000 CDN.

 

She wants to know your professional opinion on the process, and if it is likely to help her condition. She also wants to know your opinion regarding how likely it is that the treatment will be offered in Canada soon, as this may save her a lot of money and be performed by Canadian doctors.

 

What do you say to her?

 

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[future_doc]

I think the question is superb and there is no right answer. I think it is all about how you approach the question. She is looking for relief, there is a time span to be considered once you overcome the obstacle of the value of liberation therapy and the dr. would be in no position to know if and when the govt will jump through the hurdle of going for it. It is unlikely that a GP wouold haver any informed opinion on the process.

[hking03]

Interesting scenario...

 

If she wants to know what my professional opinion on her getting the treatment in Mexico is... Hypothetically speaking, I would ask to see the information she has on the treatment and the doctors involved... I would ask her to let me do some research if I was unfamiliar with the procedure/treatment and refer her to a specialist in the area that may be more involved with MS research.

 

I would research as much as I could and provide my professional opinion based on the information that I get from that.

 

As for offering her a timeline for when such treatments could be available in Canada- it is hard to say without being involved in the "MS research stream". It could be coming up in the next year, 5 years, 10 years... we may have had something brought up at a recent conference that I could talk to her about. Ultimately, I would be as forthcoming as possible with the information I have and formulate a suggestion based on that. Ultimately, the decision is hers but I would just want her to be as educated as possible before investing her money and possible future in a treatment... regardless of the location.

 

On a similar note, my aunt has MS and is trying to get involved with the studies that are currently being conducted in BC and Saskatchewan based on a "potential breakthrough" treatment developed by an Italian physician... it's a difficult process and she is trying to stay positive through the ups and downs.

[kylamonkey]

I don't know that much about the procedure scientifically, and I would be up front with her regarding that. However, I would offer to do the research for her and get back to her.

 

One of the things we have to remember is that we are science professionals, and one of the things we can do with our knowledge is read complex, technical research articles, take the important information, and translate it to our patients. A typical MS patient might know a lot about her condition, but she probably won't be able to understand the language contained in a research article. She might not even have access to these journals- many are available to subscribers only!

 

The second part of this question is a little bit more ethically difficult. If I DID have some sort of inside knowledge that the treatment was going to be made available soon, I would probably be bound to not reveal that to the public. Descision boards don't want news to be leaked before they have made official announcements, and giving the information to one patient over another would be ethically wrong.

 

That said, as a physician, your primary responsibility is to your patient. You want to give them every opportunity, every option, and all the information you can so they can make their best-informed choice.

 

If it was the case that I had inside knowledge, in this case I would not divulge it. her health will not suffer if she spends to money to have the procedure done in maxeico, only her wallet.

 

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I just realized I went totally off on a tangent from my own question.

It's actually based on a real woman i know who has just returned from having the treatment done in mexico- I haven't been in touch with her husband since she has returned but he told me a few weeks ago that it may have helped a little. In the town I live in, I have heard of at least 4 people going to mexico/india to have the procedure perfromed, and some have even held fundraisers.

It will be interesting to see what happens with this.

I actually think this topic would be a good one for an MMI- to my knowledge it was not even in the news until after last year's interview cycle (someone please correct me if I'm wrong).

[kylamonkey]

Question #3!

 

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Dennis Rafael, is a Professor of Health Policy and Management. He found that only 10-15% of increases in longevity in the past century have been attributable to medical advances, and that social factors such as environment, working conditions, housing, public health education is more important to increasing longevity among Canadians.

-How do you respond to this? Do you agree wth Prof. Raphael?

-If you do agree with this, how would you incorporate it into your practice as a physician?

 

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Again, I am totally a newbie at MMI stuff and i have no idea whether this is a realistic question or not.

[DXO]

I am part of the MS Society. I received this email regarding liberation therapy in my inbox this morning:

 

_____

http://www.angioplastyforall.com/content.php?doc=3

 

To all our local MSer's. Please click on the attached link, which will

take you to AFA, Angioplasty For All. They are launching a legal class

action suit against the government of Ontario to make CCSVI available to

all who need it. Their position is that MS is being discriminated

against, because the gov't is requiring much more stringent parameters

than it ahs applied to other new therapies. Their website describes it

better than I.

_____

 

What do you think?

[hking03]

Kyla, very interesting situation...

 

I would want to see if each of the variables were measured on their own and see what impact they had on longevity alone or if it was only when they are considered together that a large difference was noted.

 

I would also say that medical advances are responsible for some of the biggest increases in longevity and that they often tie into the variables mentioned... research done in the medical field has helped us understand that all of the variables mentioned are tied together with medicine. Diseases that were caused by environmental issues have been significantly reduced due to advancements in medical knowledge- so what gets credit for the increase- the change in environmental conditions or the medical advancement that paved the way?

 

I would agree in the sense that yes, those factors are important to increasing longevity, but I would want to note that they are tied to medicine and the research that has been done in the field.

 

I would incorporate this into my practice by trying to consider these variables when developing a treatment plan, diagnosing a patient or looking at patient outcome...

 

this may not make any sense at all as I felt I was rambling a bit...

[DXO]

This might be useful: http://fhs.mcmaster.ca/mdprog/documents/Manual_for_Interviewers_2006.pdf

[kylamonkey]

This might be useful: http://fhs.mcmaster.ca/mdprog/documents/Manual_for_Interviewers_2006.pdf

 

OMG- thanks!!

[ryacha]

OK- so I have really not started to prep for interviews yet, except for skimming "Doing Right".

It would be great if there are some who have more prep than me to talk about some of these ethical questions.

I thought this was an interesting question- no idea if it's even the type that might be on a UBC MMI, or a UofS MMI or what, but let's start!

 

 

********************************

You are a second year student shadowing a doctor in the O.R. Once the patient, an obese female, has been given general anesthetic and the procedure is underway the doctors start to make comments about her weight and call her names that you find inappropriate but most of all unprofessional. Do you talk to the doctor about his comments or do you keep your comments to yourself? Why?

 

********************************

 

A little late in the game on this one but I though I would take a stab at it. To me there are 2 problems rolled up into one:

 

Problem 1: The Doctor is being disrespectful to the patient whether or not she is awake

Problem 2: The comments are negatively effecting your work space.

 

My solution: The first thing is to recognize that this is going to a sensitive topic to approach, and to address it well, it will take some careful thought that is not produced on the spot. An on the spots reaction will be based on in the moment emotions and these will likely make your discussion less effective. In addition to that, in the OR while a patient is under anesthesia is not the appropriate time to approach the issue.

 

The second thing is to weigh the benefit and cost of raising this concern. On the one hand we have the positive of asserting yourself and protecting both the patients rights and your own, but on the other hand, if this is an isolated incident you may be making a mountain of a mole hill. If this is indeed an isolated incident I would do nothing. If this is a consistent and repeated issue then it becomes time to approach it.

 

To approach it, the reality is that the surgeon probably cares very little for problem 1, the patient is under anesthesia, and and the Doctor is completely aware that the comment is disrespectful and will likely not appreciate being told how to do their job. What the Dr. does not know is how that experience effected you. I would integrate a personal experience to demonstrate why this type of comment makes you uncomfortable in your workspace.

 

You must be committed and prepared to deal with any fall out that may occur as a result of the comment. This is a risk that you are running. If the comment is made, yet the Dr. continues to make such comments it would then be time to speak to your coordinator.