Mock 9: What's the most important characteristic of a doc?

[Guest stargirl]

Here's a question I remember from my previous U of O interview:

 

What do you think is the most important characteristic of a good physician?

 

 

 

 

 

Edited the subject heading to standardize them. -Ian

[Guest sally2001]

i'd say compassion.

[Guest peachy]

I would say smarts.

 

While I think that compassion (people skills, etc) are important, I'd personally rather have an abrasive doctor who know exactly what he was doing, than a very kind and friendly doctor what was incompetent...

 

eg Romano from ER.

[Guest sally2001]

good point effective communication skills would be up there too. i hate questions that limit you to a single answer, but what can you do?

[Guest cheech10]

Empathy.

 

No patient really knows if their doctor is competent, and the quality that makes the most impact on a patient's perception of their physician is empathy.

[Guest Lactic Folly]

Having their patient's best interests in mind at all times.

[Guest kellyl20]

peachy: I believe I saw something similar to your argument which was debated under UBC school last year's thread on this forum

[Guest Orangelifesaver]

Interesting comments,

 

i've visited this site many times in last several months but this

is my first post..............

 

i agree with cheech10 in that when we visit docs we assume they know their stuff........not always the case

 

so i'd look for confidence and respect in a doctor....enough so that they are able to give power to their patient when it comes to making a medical decision.

 

- i think it's about time we gave patients their autonomy back

[Guest MayFlower1]

I'm also going to say the most important characteristic of a physician is "to have the patient's best interest in mind at all times"...I totally agree with lactic folly.

 

This is SO important in a physician as it encompasses everything a physician does...was meant to do. For example, If a physician doesn't feel completely comfortable dealing with a particular situation...if they had the patient's best interests in mind they might choose to refer the patient to another doctor for that particular issue...if they didn't have patient's best interest in mind they might deal with the situation themselves in a less than optimal fashion out of embarrassment or ego (i.e., not thinking about what is best for the patient, but rather, what's best for themselves). Similarly, if there are a range of options for treatment, a doc with the patient's best interest in mind would always involve the patient and come to a decision on the best method of treatment taking into account how various options will affect the patient and, as well, what would be best given the patient's physical, social and psychological situation. The doc who doesn't have the patient's best interests in mind might suggest the method with the least effort.

 

Peter

[Guest Ian Wong]

I'm also going to say the most important characteristic of a physician is "to have the patient's best interest in mind at all times"...

In our fourth year, we are currently revisiting ethics and medicolegal issues in preparation for our LMCC exams.

 

One of the ethicists at UBC, Dr. Alistair Browne, recently gave us a very interesting presentation, and the most interesting part about it was the discussion between patient autonomy vs what's best for the patient, and what to do if those two principles conflict.

 

For example, off the top of my head, is the example of a Jehovah's Witness, who will not accept blood transfusions. If such a patient were to come into the hospital with massive bleeding (say from a car accident), yet refused a life-saving transfusion, then you have a direct conflict between patient autonomy, and having the patient's best interest (at least from the physician's point of view) at heart.

 

In that vein, allowing the patient's best interests to over-ride the patient's own autonomy (ie. by deciding to transfuse against the patient's wishes, thereby saving his/her life), is tantamount to paternalism.

 

Just an example of how always keeping a patient's best interests in mind can lead into ethical dilemmas all their own.

 

Here's an interesting link regarding Jehovah's Witness's and how to approach this particular problem. There is an example of such a case which went to the courts in Canada: (Malette vs Shulman).

 

Article on Google:

 

Ian

UBC, Med 4

[Guest shutterbug]

I was asked this question at my UT interview last year.

 

MVA, signed JW card, and bleeding to death...the ONLY thing that will save her life is a transfusion - I tried to explore other options but the inteviewers said they 'wouldn't work'. Anyways, I transfused arguing that the serious consequences of not transfusing warrants direct refusal from the patient. Also, the patient was not explained the consequences of not transfusing (they were unconsious of course)...had they understood the nature of their situation they may have changed their mind....whereas the JW card was not likely signed under the same circumstances.

 

After reading the responses in the link I am not so sure that I would transfuse if given the same situation. If a competent (legal aged) individual refuses live-saving treatment then who am I to argue against it.

 

What are the interviewers looking for in the response to this type of question?

[Guest Kirsteen]

Hi shutterbug,

 

Although you are not expected to be knowledgeable in every area of ethics/the law when interviewing for medical school, the Jehovah's Witness/transfusion scenario is a pretty standard one, and one to which I'd argue most interviewees should have a solid answer.

 

If a patient is carrying a JW card stating that blood transfusions are against his/her religion and hence, they should not be performed, then you are acting against the law if you transfuse the patient. The very situation faced my pal who is in obs/gyn and who came across a JW patient in her practice. The patient could have used some transfusing after a birth but given her JW status, my pal could not transfuse her (as much as it was stressing her to want to do so, given the potential ease out of a dire physiological situation had a transfusion been performed). Thankfully, the woman survived without need of a transfusion.

 

To hammer the point home, there was one scenario that I read about last year, where a patient was brought into the ER and needed to be transfused to survive. Short on time, the doctors ordered up the transfusion and subsequently saved the patient's life. However, the patient was a JW, but the card had not been found on their person--in fact, no-one had looked for the card (in the interest of time). The card was there. The patient sued the hospital. The patient won.

 

It is a patient's choice (being of sound mind, etc.) as to whether or not he/she receives any medical intervention. If they have prior statement wishing no intervention then although you may be in a position to provide an intervention that may even ultimately save a life, if the patient does not wish that intervention to be applied, then you cannot force it to be--no matter how much duress it may cause you not to apply it.

 

Cheers,

Kirsteen

[Guest shutterbug]

Thanks for the input Kirsteen.

 

I realised soon after the interview that I handled the situation wrong....and have been kicking myself since. It was also the first question they asked...so, there goes the first impression.

 

I think you're right that if you've exhausted ALL your options you have to let the patient bleed to death - BTW what's the situation on synthetic blood...are those accepted?

 

I'm not going to try to be hero or break new ground everytime something like this happens (although I would try to persaude them)...I'm not even sure if its worth it...that is, getting sued isn't going to help you, your (other) patients, hospital, etc.

 

Personally, I think everyone should have a shot at life in these types of instances...but, if you've signed it away then so be it!

[Guest Kirsteen]

Hi shutterbug,

 

A similar ethical situation that is much more common and mirrors the Jehovah's Witness scenario is do not resuscitate (DNR) orders. Same principle: if the patient signs a piece of paper indicating that certain medical interventions that could prolong their life should not be used, then that's a choice that holds up in court (all else being "normal", i.e., sanity, lack of duress, etc.). Although a physician may hold the knowledge that the use of a respirator could extend the life of a patient entering respiratory failure, a DNR is a DNR, and a physician is not powerful enough to override that patient's wish. I suppose that's one reason why the medical school selection factors are not wholly focused on academics: all the marks in the world are not necessarily going to arm you with the gusto and sagacity that it takes to be resilient within such trying situations.

 

Cheers,

Kirsteen

[Guest cassica]

Guys, this is what I got at my interview: what if a toddler needed a blood transfusion to live and his parents were adamantly against it (for religious reasons). What do you do?

[Guest Lactic Folly]

The issue of blood transfusions is interesting.. I don't know much about JW (so this may not be accurate), but if they risk their immortal soul then I wouldn't consider that in their best interest as physicians need to take care of the entire patient, not just their physical symptoms.

 

Synthetic blood sounds promising, but I don't know if that would be allowed in an interview context

Regarding the toddler, I don't know much about Canadian law with respect to such situations, but a case for giving the transfusion would have some more justification since the toddler wouldn't be able to make the decision for himself or herself.

[Guest kellyl20]

go to court

[Guest Kirsteen]

Hi there,

 

Wasn't there a case akin to this, a few years ago in Saskatchewan? It surrounded a younger boy (not a toddler) who was refusing traditional therapies for cancer in favour of naturopathic approaches being offered to him (and supported by his parents) in Mexico. The medics did end up taking the parents to court and lost. The boy did end up receiving his wish of being treated naturopathically, without traditional interventions. Therefore, in some provinces at some time, taking the family to court may have been a valid (but not necessarily successful) option.

 

Cheers,

Kirsteen

[Guest Namgalsip]

Here's another quote from CMAJ-bioethics article.

 

"In the case of children who are incapable of making their own health care decisions, parents or legal guardians generally have the legal authority to act as surrogate decision-makers. The surrogate decision-maker is obliged to make treatment decisions in the best interest of the child. Health care providers who believe that a surrogate's decisions are not in the child's best interest can appeal to provincial child welfare authorities. The courts have the authority to assume a parens patriae role in treatment decisions if the child is deemed to be in need of protection. This issue has arisen most commonly with respect to Jehovah's Witnesses who refuse blood transfusions for their children on religious grounds, and courts have authorized treatment in recognition of the state's interest in protecting the health and well-being of children."

 

I assume this would be the same in Canada. Can anyone correct me if I'm wrong?

 

Nams

[Guest Koggetsu]

Yeah, I think that you are basically right. The doctor can try to appeal if they believe the parents decision may not be the best decision for the child.

[Guest Namgalsip]

But what happens in an emergency? There's no time to appeal while the child is dying and in need of a transfusion.

[Guest kosmo14]

In Canada the Supreme Court has ruled that the State does have the right to intervene when it comes to children. If the parents refuse to allow a child to undergo a transfusion then the state can take temporary custody of that child and in effect force the transfusion. This was a ruling given by the Supreme Court of Canada in 1995. It was somewhat validated (although the circumstances a little different) last July in Alberta when a 16 year old girl went to court to stop her from being forced to undergo transfusions. As of July she had lost her court battles, with the Supreme Court refusing to hear her case after the Alberta Court of Appeals upheld the provinces decision to make her temporary custody of child services.

 

I think there is sufficient precident to transfuse children, particularily in emergency situations. When they become mature enough to make thier own decisions (no specific age set) then there are furthur factors to consider. In this case the girl was 16 and was not able to determine whether she was allowed to refuse treatment.

 

Kirsteen, just one quick note to your comments on the DNR order. I think most of the time that is a valid order, but there are still situations when you must question it. Certainly in a situation where you have a patient who has this signed piece of paper someone dug up that was dated 10 years ago you might want to do some more investigating. It is really important to determine if that paper represents that persons desires at this point in time. A lot can change in 2, 5, 10 years and in some instances enough that this DNR order is not what the patient envisioned for themeselves at this particular point in thier life. That is were a good proxy is helpful. A proxy (someone who speaks on your behalf when you can no longer do so) that knows that patients wishes, and is up to date on thier feelings in most situations. It is very important for a family doctor in counselling patients when they write DNR or advanced directives that they encourage them to keep poeple up to date on thier will in medical situations, and to name a proxy that will truely speak for that patients wishes.

[Guest Kirsteen]

Hi kosmo14,

 

I agree with you completely. There are often all sorts of interesting and at the same time obfuscating, big and little wrinkles associated with ethics. There is hardly enough room (or memory) to post all of them here (not that I think I even could!).

 

Cheers,

Kirsteen

[Guest wileycoyote]

very sad.

www.cbc4kids.cbc.ca/general/whats-new/daily-top-stories/1999/week-28/monday/default.html

[Guest UWOMED2005]

My understanding is that it is possible to get a court order to transfuse minors when the parents refuse. One of our profs last year made reference to the fact that now as a child of JW parents is about to be delivered and they forsee transfusion necessary, they immediately contact the appropriate legal channels at the Hospital to get a court order to transfuse.

 

It's also interesting to note that there are JWs who disregard the Watchtower's (the Watchtower is the ruling body for Jehovah's Witnesses, akin to the Vatican for Catholics) position on refusal to use blood products. Check: www.ajwrb.org/index.shtml.