Anyone preparing for CASPer?

[DXO]

I'm not an expert at all in this field, but if you research the ACC/AHA Preoperative Cardiac Risk Assessment chart, you can take note that if a preoperative assessment of a patient wishing to undergo non-cardiac elective surgery determines that the cardiac risk is too great, then one should "consider delay or cancel non-cardiac surgery."

 

Although there is no right or wrong answer to this question, I certainly don't consider cancelling the surgery as "paternalistic" or "unilateral." It was a judgement made based on a risk/benefit analysis, the best interest of the patient, and the surgeons expertise.

 

Either way, I liked your writing and felt that you did a good job of supporting your answer.

 

Thanks! It's hard to dissect ethical issues. I think that making ethical decisions and learning to take all aspects of the issue into account will be the most challenging aspect of becoming a physician. The main point of the CASPer and MMI will probably be supporting your answers and showing that you have begun to think about ethical issues, but it obviously takes years to become an expert. Even then, some cases cause even professionals unease. It is difficult to balance and prioritize all of the different aspects.

 

I found a video on YouTube... I can't remember the name of it... but I think the following might be helpful when we're doing the CASPer and MMI. It used the mnemonic of the "ABC"s of ethics to help make decisions.

 

A - autonomy

B- beneficience

C- confidentiality

D- do no harm (aka nonmaleficience)

E- equality (aka justice)

[maka28]

Here is my attempt at this case, I would really appreciate all your comments/criticism!

 

1. No, I will not perform the surgery. The risks outweigh the benefits

 

and based on my experiences in working on cases similar to this, the

 

outcomes have not been satisfactory. This is why I have thus far

 

refused to commit to the surgury. You mentioned that your life has

 

been significantly impacted by the pain, however, suppose in the worst

 

case scenario, peralysis will prevent all such opportunities. You must

 

realise that there are alternative options to reducing the pain and we

 

can direct you to centres and agencies that will provide this service

 

for you.

 

 

 

2. No, not all the liabilities. If the surgeon were to agree to this

 

procedure then he must ensure that he follows standard practises of

 

care and procedures. There must be no negligence or malpractise

 

involved. However, if the surgery was not a success and resulted in

 

peralysis, the surgeon would not be solely liable as the patient had

 

given direct consent to the procedure.

 

 

 

3. No the patient should not be allowed to sue because this surgeon is

 

not the only available surgeon that is able to perform this operation.

 

As there are many surgeons available, the patient is not restricted in

 

any way. Moreover, since this is not a life-endagering situation, and

 

the risks are otherwise significantly high. The surgeon then is able

 

to defend the reasons he would not perform it, through illustrating

 

the significant disadvantage that the risks present to the life and

 

livelihood of the patient.

[dzimmerman]

I think these are good answers, but I have a different answer for 3. Anyone is allowed to sue you. The patient is completely within his rights to try and sue a physician who refuses to perform an elective surgery, however he is unlikely to win given the circumstances.

[suziep100]

Here are my answers

1. The main issue underlying this dilemma is the high risks associated with surgery versus patient's autonomy. In this scenario, the patient, a "normal" adult who is capable of making sound judgments on his own, appears to be fully aware of the risks yet is willing to take the risks. As a professional surgeon, when my fully capable patient is determined on undergoing a certain treatment, I would treat the patient. However, before hastily undergoing the surgery, I will first thoroughly review the procedures and long-term effects of the surgical process with the patient to ensure that he and his family understands the risks.

 

2. I do not beileve that the surgeons are thoroughly relieved from all responsibilities. Instead, I believe that the liability issue depends on the root of the problem. When a test goes wrong, it may be due to technical difficulties that are beyond the surgeon's control, but it may also be due to the surgeon's carelessness. In case of unfortunate outcomes, I believe that the cause of the problem should be initially identified. Once the cause of the problem is identified, I would then impose responsibilities on the surgeon if he/she caused the problem due to his/her careless mistakes, and vice versa.

 

3. Even though the patient has the legal "rights" to sue the doctors, I do not believe that the patient, in this scenario, can sue the surgeon. Lawsuits can be imposed when the actor had an intention to mentally or physically harm the recipient. In this example, the surgeon refused the surgery because he was concerned about risks of the surgical procedure, his awareness of the limits to his surgical skills, and his fear of assuming the responsibilities in case the outcomes of surgical procedures go awry. The surgeon refused the surgery because of his concern for the patient's health. Since the surgeon did not refuse the surgery with an intention to physically or mentally harm the patient, I do not believe that the patient can sue the surgeon and expect to win.

[cnb88]

I think these are good answers, but I have a different answer for 3. Anyone is allowed to sue you. The patient is completely within his rights to try and sue a physician who refuses to perform an elective surgery, however he is unlikely to win given the circumstances.

 

While anyone is allowed to "try" and sue for anything, chances are it would never make it to court. Could you imagine the amount of cases that would be in the system right now if patients could sue for physicians refusing elective surgery when there are high risks involved? According to you, every MS patient that wants the CCSVI surgery to "cure" their MS should be able to sue the doctor- they are in a great deal of pain and their life is adversely (severely in many cases) affected by it- so why isn't there several class-action lawsuits against all docs in Canada that won't perform the procedure? Because you can't. If there is a medical reason (ie risk, or lack of solid clinical evidence) to not perform the surgery, you can't sue. Also, if a doctor is against abortion or circumsision (for example), they don't have to (themselves) provide it. They are required to "pass you off" in a timely manner to a doctor they know will do it. They are not allowed to bar you from the care you wish, but if they are against it, they don't have to perform the surgery themselves.

[DXO]

I learned a legal term today that would help to explain questions like #2. The patient's consent to the procedure will help the surgeon defend against a charge of battery. To be charged of "battery" in medical circumstances would mean that you have performed the surgery without consent. (Opinion: It might be possible to be charged of battery if you do not fully disclose all risks and benefits to the patient before performing a surgery.)

 

Charge of negligence is obviously a different issue and would arise if you did not perform your surgical duties adequately or did not arrange for appropriate aftercare. The patient may not be able to charge you for battery in this case, but may still charge you for negligence.

[DXO]

Here are my answers

1. The main issue underlying this dilemma is the high risks associated with surgery versus patient's autonomy. In this scenario, the patient, a "normal" adult who is capable of making sound judgments on his own, appears to be fully aware of the risks yet is willing to take the risks. As a professional surgeon, when my fully capable patient is determined on undergoing a certain treatment, I would treat the patient. However, before hastily undergoing the surgery, I will first thoroughly review the procedures and long-term effects of the surgical process with the patient to ensure that he and his family understands the risks.

 

2. I do not beileve that the surgeons are thoroughly relieved from all responsibilities. Instead, I believe that the liability issue depends on the root of the problem. When a test goes wrong, it may be due to technical difficulties that are beyond the surgeon's control, but it may also be due to the surgeon's carelessness. In case of unfortunate outcomes, I believe that the cause of the problem should be initially identified. Once the cause of the problem is identified, I would then impose responsibilities on the surgeon if he/she caused the problem due to his/her careless mistakes, and vice versa.

 

3. Even though the patient has the legal "rights" to sue the doctors, I do not believe that the patient, in this scenario, can sue the surgeon. Lawsuits can be imposed when the actor had an intention to mentally or physically harm the recipient. In this example, the surgeon refused the surgery because he was concerned about risks of the surgical procedure, his awareness of the limits to his surgical skills, and his fear of assuming the responsibilities in case the outcomes of surgical procedures go awry. The surgeon refused the surgery because of his concern for the patient's health. Since the surgeon did not refuse the surgery with an intention to physically or mentally harm the patient, I do not believe that the patient can sue the surgeon and expect to win.

 

I think it is a very good idea to state the ethical conflict as you have in Question 1. This is probably a very good approach to the CASPer, because it indicates that you clearly understand the dilemma that is taking place. I think a good strategy would be to state the conflict (use the ABCs to help you out), attempt to rank priorities & give reasons for this ranking, and then state how you would personally resolve the conflict.

[DXO]

I think these are good answers, but I have a different answer for 3. Anyone is allowed to sue you. The patient is completely within his rights to try and sue a physician who refuses to perform an elective surgery, however he is unlikely to win given the circumstances.

 

I agree with your answer, but I do think that you need to be specific about what the circumstances are when writing your CASPer. (Just some constructive criticism.)

[maka28]

I agree with your answer, but I do think that you need to be specific about what the circumstances are when writing your CASPer. (Just some constructive criticism.)

 

Thanks a lot, I appreciate that!

[aqm]

Can the people who underwent the trial/previous versions discuss their questions too (if there weren't sworn to secrecy by Mcmaster?)

 

I am very slightly confused re MMI vs CASper. McMaster students will only be doing CASper which is like an MMI ya?

[astrogirl]

On the trial I did, the only real question was the one that's given as an example on the casper website (with the guy who wants the risky back surgery).

[future_doc]

I am very slightly confused re MMI vs CASper. McMaster students will only be doing CASper which is like an MMI ya?

 

CASper is before a computer and yes, you have to react quickly to the scenarios given to you. For those selected, then you will also have a MMI.

[aqm]

also have an MMI............got it thanks.

[placenta]

Are we allowed to type in Word and copy and paste into the text box? Of course if time permitting.

 

Or would this a problem given they are going to check typing speed/rate

[medguy5367]

So just to summarize, what can we do to prepare ourselves?

 

-Practice prompts/familiarize oneself with CASPER

 

-Read "Doing Right"

 

-....???

[aqm]

I may be freaking out and freaking others out but:

 

1) This discussion of the scenario sounds like we are lawyers. I know it is ethics but I am wondering if law-student would be better at writing the CASper than us. Also, is covering our ass the whole point of medicine - is it no longer about compassion and altruism?

 

2) I totally fail to understand how students that have taken even the most basic bioethics/research ethics course do not have an advantage to otherwise naive students who are hearing the terms 'fiduciary concern' and the three aspects of 'informed consent' or the 5 aspects of establishing malpractice for the very first time in their lives - and YA...I know at least two mature students who will be hearing it for the first time when they take a bioethics course in medschool.

 

I have only completed a basic nursing ethics course but strongly feel that students who are gona attempt to pull this off without any prior education/crash course in bioethics are at a HUGE loss. However, I have also read that they want your instinctual answer that one should not prepare for. Would that not back-fire if one can't use terminology such as 'full disclosure', 'autonomy vs privacy vs confidentiality' appropriately to identify and define the ethical dilemmas and be able to defend their actions and consequences?

 

Hence, although no true and tried method has been found that selects the best few potential MDs of us all, CASper may (& probably does) not account for those with a masters in bioethics or even with an undergrad in bioethics. I mean one would have to be like a true total bioethics virgin to be able to answer these questions based on instinct and defend it successfully without using the terminology.

 

That's all folks - just a pre-CASper rant.

 

Best of luck to those who are studying for this and to those who are not.

 

Ciao.

[deeman101]

Prior knowledge is not an absolute necessity but a definite asset. I think mac's reasoning is if you're an ethically sound individual then you should be saying/doing the same thing that someone who has background on the issue would do anyways. You might also see it on their MMI. (Its also how I think a lot of UNethical people game their way past the system too...just say the right words in the right way)

 

As for unfair questions, the first time I interviewed at mac I got asked what Mac's marking scheme was like by one of the interviewers. At the time I was just finishing 3rd year of undergrad, wtf did I know about mac's marking scheme! Made me look like a tool.

[repede]

Kind of funny that I was the one that started this thread, yet I haven't done ANYTHING to prepare. There just hasn't been any time... too much other stuff to do from school. Six courses in 4th year with an undergraduate thesis to do - definitely a mistake, but it's too late to do anything about it now. Looks like I'll be winging this one!

 

Hm I just did the System Pre-Test and they chose a pretty cool first video. The second one was kinda lame, lol.

[bj89]

Well i think using ethical terms isn't the epitome of doing well in CASPer like others have mentioned. I think that the logical way for them to grade this is to search for the presence of the main principles of ethics within our answers. For example, you don't have to dish out big terms like fiduciary relationship, but if you talk about the compassion, trust, and rapport building between the physician and patient (all things that are common sense to anyone with familiarity with medicine), then you are showing the foundations of building a fiduciary relationship without stating it explicitly. I mean as a pre-med you aren't expected to be a pro at medical ethics... that's why you take ethics classes in med school. But you should have some basic exposure to it. If the graders can find the roots of the basic principles of ethics in your answers, then that might be satisfactory.

 

Keep in mind that I have no insight into CASPer whatsoever and am just going off of my gut instinct about this. I'll be writing it tomorrow at 12:30 PM... Kinda glad I'll be getting it over with early.