Guest MayFlower1 Posted February 5, 2003 Report Share Posted February 5, 2003 I thought it might be interesting to start a thread in which people could pose "mock interview" questions and those of us who are interested could throw around some food for thought...here's one to start...I can't remember where I read it ...or whether this is the exact same situation...but here it goes: It is 10 years from now...you are a practicing physician. You are with the military...you are stationed at a refugee camp somewhere in nowhere ville. One of the refugees you see in your clinic has a potentially life threatening disease. If they get no treatment...they will very likely, but not necessarily die from the disease...there is about a 10% chance of full spontaneous recovery with this particular disease. If they get full treatment (four injections over a one month period) they will absolutely make a full recovery from the disease. Partial treatment (i.e., not all of the four injections at the prescribed intervals) will actually cause the disease to get considerably worse and will actually cause them to die a horrible and painful death. The challenge for you as a doctor is that refugees in this area of the world don't stay in one particular camp for more than two weeks. You will have no way of knowing where they will be sent to and have no way of ensuring they will get the rest of their treatment once you have given them the first two injections. What do you do? Do you treat them or not? :rolleyes I honestly don't remember what the "best" solution was or if there is any one correct answer. I look forward to the discussion that this will hopefully stimulate. Peter Edited the subject heading to standardize them. -Ian Link to comment Share on other sites More sharing options...
Guest peachy Posted February 5, 2003 Report Share Posted February 5, 2003 I would think that asking the refugee what he would prefer would be the obvious thing to do....? I must be completely missing the point here.. [i think mock interview questions are a great idea. But perhaps the "interview" forum would be a better place than the "ottawa" forum?] Link to comment Share on other sites More sharing options...
Guest Ian Wong Posted February 5, 2003 Report Share Posted February 5, 2003 Ditto. This is exactly the kind of discussion which should go into the Interview forum; I think it'd be a great venue for getting different points of view. I'm going to move this into the Interview forum from the Ottawa forum... Ian UBC, Med 4 Link to comment Share on other sites More sharing options...
Guest MayFlower1 Posted February 5, 2003 Report Share Posted February 5, 2003 Sorry Ian...thanks for moving it to the best location. Peter Link to comment Share on other sites More sharing options...
Guest Koggetsu Posted February 5, 2003 Report Share Posted February 5, 2003 interesting scenario... actually i think the first thing is to ask the patient what they want to do too cause u shouldn't make the choice for them (basically same as what Peachy said) Link to comment Share on other sites More sharing options...
Guest UOMeds05 Posted February 5, 2003 Report Share Posted February 5, 2003 Boy, I hope that none of you get questions like this! Was this an actual question? In my 2 year applying experience, never got anything that difficult. I guess I was lucky... here is what i got wrt ethics, I will thus ask you: "what are some potential ethical issues that physicians may face?" "Of your list, pick one and discuss it".... love open ended questions... (Your first instinct is probably to say, that is easy, which I agree, it is. But sometimes these open questions allow you to go off in an unorganized tangent... you'd be surprised the things that you say that you wish you hadn't!) Link to comment Share on other sites More sharing options...
Guest Ian Wong Posted February 5, 2003 Report Share Posted February 5, 2003 My opinion only. If the refugee/interviewer wants to make it tough on you and refuses the decision, saying that "you're the doctor; you make the choice for me", and there was absolutely NO way that the patient could take two syringes with him/her and do it herself at the right intervals, I'd probably not initiate treatment at all. There's lots of examples in medicine where criterias have to be fulfilled before you initiate treatment. Just being HIV positive isn't necessarily enough to warrant you getting anti-retroviral treatment. If you are not reliable to take the drugs on their consistent basis, or are not reliable enough for consistent follow-up by a physician, then you don't get anti-retroviral meds (at least what I've seen in Vancouver). The rationale being that the full course is the course which actually has therapeutic effect, and if you regularly miss your dosages, there's a huge hazard that you will breed resistant viral particles, in addition to the drugs not helping you. It's also analogous to beginning an operation for cancer, despite not knowing if you'll be able to stick around to close up the wound once the tumor's out. Sure, you've initiated the start of a treatment which ultimately will likely help out the patient (otherwise you wouldn't do it), but if you aren't able to close up the wound, then you've inflicted additional harm on the patient. I'm sure others will disagree with me, and this is one of those questions that has to be dealt with situationally on a case-by-case basis (as with so much else in medicine and life in general), but given just the information above, I'd elect not to treat. I'm not going to give someone a treatment that will likely kill them with such a low chance of cure (the way you've phrased it, it sounds like they definitely will not be around after the initial two weeks). Just like a surgeon wouldn't open a patient up if they weren't certain they had the time and resources to close up afterwards. Ian UBC, Med 4 Link to comment Share on other sites More sharing options...
Guest UOMeds05 Posted February 5, 2003 Report Share Posted February 5, 2003 btw, my response to the Peter's scenario would be teaching the refugee about the medications, their importance, and than how to self medicate safely, and provide him/her with the 4 doses, if their decision was to pursue treatment and there were no guarantees of the refugee being able to return. Link to comment Share on other sites More sharing options...
Guest UOMeds05 Posted February 5, 2003 Report Share Posted February 5, 2003 oh, ian beat me to it! Good answer. Link to comment Share on other sites More sharing options...
Guest UWOMED2005 Posted February 5, 2003 Report Share Posted February 5, 2003 Wow, don't know how the U of O interviews are but you certainly wouldn't get a question this nerve-wracking at Western! :eek At most you'd get ONE of these questions during the interview. I'd think that much more important is how you'd answer more conventional interview questions such as "Why do you want to practice medicine" or "What are your greatest strengths and/or weaknesses." But it is a great question, though. I hope you don't mind me answering even though I won't be getting an interview this year! Personally, I'd interview the patient more and discuss the option of treatment, fully explaining that he must follow-up with the treatment and discuss whether he could stay at this refugee camp (or even be admitted to the clinic or tent - he sounds deathly ill!) If it sounded like he'd stay around and I'd be able to follow up, I'd not hesitate to treat. If not. . . whoo, that's a toughy. The Hippocratic Oath states "do no harm," and in that case a partial treatment would be harming the patient, so I might not treat - the disease might remit on its own. But it's a 100% vs. 10% recovery chance. That's tough. Any chance, if this patient refuses to either be admitted or at least stay at the refugee camp, we could use a Form 1? :rolleyes Link to comment Share on other sites More sharing options...
Guest Koggetsu Posted February 5, 2003 Report Share Posted February 5, 2003 actually my original answer was that i would inform the authorities about the condition and ask if they could keep him there for 4 weeks to treat him, especially if his condition was contagious. But the problem after I thoguht of this answer was that it was a logical answer rather than specifically about ethics or medicine, so I didn't give this answer. thats a very hard part of these questions is that I'm never sure if they wnat me to give a logical answer or does it have to relate back to a specific medical ethics problem or something like that? can someone comment on this and on my answer? Link to comment Share on other sites More sharing options...
Guest MayFlower1 Posted February 5, 2003 Report Share Posted February 5, 2003 Hmmm, Many great points have been raised...this could be a wonderful thread... I must admit, I get itchy when I think about getting a question like this in my interview! I take a slightly different approach to the problem. Although I'm certainly no expert in medical ethics, I think one of the really important parts of this particular situation would be to sit down with the patient and provide him/her with information about the disease and the options available to him/her and myself as the doctor. I would ensure they were given and understood consequences (positive and negative) for full treatment, partial treatment and non-treatment. Once the information was communicated to the patient, I would want to ensure that they were capable of understanding the information. I would ask them how they felt about the various options and which treatment/non-treatment path they would prefer. During this dialog, I would want to ensure that the person was able to make an informed voluntary decision. If the patient chose no treatment, I would be worried about psychosocial or psychological "pressure" which might cause them to make an involuntary decision...for example, perhaps they hate their life so much as a refugee...they have been separated from kids, family and other loved ones...that death might seem quite attractive...I might want to see if there are such "pressures" whether they can be alleviated to ensure the patient is making an informed AND voluntary decision. If the patient was fully informed and they were found to be capable of making the decision in a voluntary fashion and they chose "no treatment...I'll take my chances with the 10% spontaneous recovery". I would likely want to also ensure they could articulate the risks of that particular decision. I would also present, if possible in the situation, the possibility of partial treatment by me and then self medication for the last three doses (see below as to why I say three self-administered doses). If the patient's decision was still not to treat then I would feel compelled to respect those wishes and offer any other form of treatment (psychological or physical) which could alleviate any of the symptoms of the disease while I could. If the patient chose the "partial treatment with self-medication" I would want to ensure, again, that I had their consent, and that they were capable of making this decision in a voluntary fashion. I would also want to make sure that the person was highly motivated to self-treat and that the situation would enable self-treatment to occur. I would also strongly reinforce the negative consequences of not completing the full course treatment...and then ensure the patient could and would follow to end of treatment. Assuming this was the case, I would use the first treatment to teach the patient how to administer the medication...I would encourage discussion around questions they might have with respect to the procedure and fears, etc. The second treatment would be used to have the patient self-treat in a monitored situation...coaching and feedback would be integral to the session. I would then package and give to the patient all of the materials they would need to take the last two doses of treatment with a specific schedule and written instructions, if required. If, for some reason, it was found that the patient was not capable of making an informed voluntary decision or if I was not able to ensure that they would either receive full treatment from another physician or through self-medication then...boy...it gets a bit tougher for me. This is where the point about not harming certainly would come into play. If I partially treat, I then eliminate the possibility of the 10% spontaneous recovery from ever happening...I don't think I could do this personally. :\ That's my 2 cents... Peter Link to comment Share on other sites More sharing options...
Guest me maniac Posted February 6, 2003 Report Share Posted February 6, 2003 I also think that, along with informed consent, the health of individuals is as much their responsibility as it is the doctor's. They not only ought to know what is happening inside/to them, but also how to practice what the doctor preaches (ie quitiing smoking, getting excercise, etc). This brings me to another scenario I heard of from a guy that interviewed at UBC last year. The interviewee played the role of the doctor. The interviewer played the role of the patient. The "doctor" was to convince the "patient" (who was a smoker, very obese, and did not listen to anything the doctor said) to take better care of herself (ie quit smoking). Everytime the doctor said something like "you should quit smoking because you are harming yourself", the patient would say something like "it's my body. I'm going to die sometime anyway. I want to live my life how I want to. I don't want to quit smoking." Then the doctor would say something like "why don't you cut down on smoking then". But always, the patient would have a smart alec comment to throw back. Needless to say, the "doctor" was very flustered in his interview! How would you handle that? me Link to comment Share on other sites More sharing options...
Guest peachy Posted February 6, 2003 Report Share Posted February 6, 2003 I think that there's something fundamentally wrong with the scenario, and at some point I would refuse to play along. It's the physician's responsibility to help the patient as much as they want to be helped. If the patient is not willing to stop smoking or lose weight then that is that - it is completely obnoxious of the doctor to try to "convince" the patient to change these habits. These are things that have such deep effects into every part of a person's life that it's the worst kind of paternalism (imho) to assume that you're going to be able to change them. At best, the patient will ignore it. At worst, the doctor becomes the patient's enemy. The patient is no longer comfortable coming to the doctor to ask questions, or to deal with other health problems. The doctor should make sure the patient is aware of the facts, offer whatever kind of assistance they can [eg support groups, medications that can help, etc], and then leave it at that. Anything beyond that is goint to hurt more than help. Link to comment Share on other sites More sharing options...
Guest Ceds Posted February 6, 2003 Report Share Posted February 6, 2003 I agree with peachy that patient's must take ownership for his/her own health as well. Having said that, as a physician it is our responsibility to INFORM the patient as to the potential consequences of his/her acceptance/refusal of treatment. I feel that peachy is right, however, in stating that it is not a physician's place to try to "convincing" the patient of the "best choice". Good comment about Paternalism, it is a view that seems to have been abandoned because of the recognition of patient's rights. Link to comment Share on other sites More sharing options...
Guest carletongirl Posted February 8, 2003 Report Share Posted February 8, 2003 Peter, bravo! I'm currently working on a case study for my Contemporary Ethical Theory class which forces me to look at the people involved in the case, along with their preferences, stakes, etc. Your response really dealt with the idea of making sure that the patient's preferences were dealt with considering it would be partially his/her decision in the end, and that he/she would be the one most impacted by it. Also, it is important to make sure that the options you give in your answer to such a question, or your final decision, be one that a reasonable-minded and informed individual be able to make. In this case, by informing the patient of all the options and their consequences, you were giving him/her all of the information required to make the best decision. Link to comment Share on other sites More sharing options...
Guest MayFlower1 Posted February 8, 2003 Report Share Posted February 8, 2003 Thanks for the feedback carletongirl. Welcome to the e-mock! Do you have any other ethical dilemmas you could offer for us to ponder? Peter Link to comment Share on other sites More sharing options...
Guest strider2004 Posted February 8, 2003 Report Share Posted February 8, 2003 Here's looking at that question from along the same lines. I probably wouldn't ever ask this question myself because it would take too damn long to say. Prisoners in Russia often test positive for tuberculosis. The treatment in Canada is a $90 4 drug cocktail for 2 weeks, then a 2 drug cocktail for 4 weeks so let's assume it's the same in Russia. Prisoners are started on the treatment but then they're released from prison before they can complete the treatment. Those little mycobacteriae brew little drug resistant progeny since they weren't eradicated. The prisoner, being a real crook, gets arrested again and put back into that tiny prison for 10,000 people. But hey, he's there with his friends who were also released and brought back to prison. Now you have a situation where thousands of people are harbouring drug-resistant or multi-drug resistant TB. Instead of costing $90 to treat, this form of TB costs closer to $14,000 to treat. The Russia prison system obviously can't afford that so the prisoner goes untreated and dies in an emaciated state inside or even worse, outside of prison (TB used to be called consumption, you know). Not only that, but a multi-drug resistant TB has been has now been released into the world. Oh yeah, if you didn't treat him to begin with, he would also die of consumption. So....you are a doctor in Syberia. A prisoner comes to you hacking and coughing (probably on you!!) and this looks like the first time he's even been like this. His sputum stains positive for Acid Fast Bacilli and all you have are these bottles of INH, Rifampin, and maybe a little Ethambutol. You have no idea how long this guy will stay in jail because the prison system is inconsistent at best. Would you treat? And no, you can't do a culture and sensitivity. Link to comment Share on other sites More sharing options...
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