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Blog Posts (4866)

January 21, 2018

Legislative Solutions for Unrepresented Isolated Patients

I enjoying discussing the challenges of healthcare decision making for incapacitated patients without surrogates at UCLA last week.  While the ongoing CANHR litigation has created some uncertainty and concern in California, it at least highlights ...
January 21, 2018

Deceased Organ Donors Exceed 10,000 for First Time

During 2017, the number of deceased organ donors in the United States topped 10,000 for the first time, according to preliminary data from United Network for Organ Sharing (UNOS), which serves as the national Organ Procurement and Transplantation Network (OPTN) under federal contract. 

For the year, organs were recovered from 10,281 donors, representing a 3.1 percent increase over 2016 and an increase of 27 percent since 2007.

A total of 34,768 organ transplants were performed in 2017 using organs from both deceased and living donors, according to preliminary data. This total is a 3.4 percent increase over 2016 and marks the fifth consecutive record-setting year for transplants in the United States. Record number of donor organs were recovered and transplants occurred for each of the four most common organs transplanted – kidney, liver, heart and lung.

Approximately 82 percent (28,587) of the transplants performed in 2017 involved organs from deceased donors. Living donor transplants accounted for the remaining 18 percent (6,181). 

Broadening of clinical criteria for potential donors accounts for some of the ongoing increase in deceased organ donation and transplantation. In 2017, as compared to 2016, a higher proportion of donors had medical characteristics such as donation after circulatory death as opposed to brain death, drug intoxication as a mechanism of death, age of 50 or older, and/or being identified as having increased risk for blood-borne disease.

January 20, 2018

Difficult Patient vs Difficult Doctor

One cannot ignore the potential for conflictive behavior as a potential in medical patient-physician relationships (and indeed associated with other individuals in the medical system interacting with patients and patients interacting with them.) This behavior can be disruptive to attain important professional relationships and effective diagnosis and treatment. 

The following is a brief analysis of the dynamics associated with such behavior and hopefully toward resolution as researched and written by a first year medical student.  The obvious goal, hopefully, is resolution of potential conflicts to promote a therapeutically effective doctor-patient relationship.  My visitors' views on this issue are welcome.  ...Maurice.

                   DIFFICULT PATIENT VS DIFFICULT DOCTOR
                                                           
                                           Surabhi Reddy
                                   First Year Medical Student

A doctor’s worst nightmare? A patient that is impatient, inattentive, rude, and demanding. A patient’s worst nightmare? A doctor that is impatient, inattentive, rude, and demanding. A so-called “difficult patient” or “difficult doctor” represent two sides of the same coin, with similar behavioral and communicative factors causing conflict. Occasionally, the difficult relationship may culminate in a
messy outburst – as recently seen in a violent altercation between a Gainesville doctor and patient.1  The duality of the patient-physician relationship allows us to examine (from both perspectives) what underlying actions and issues initiate the conflict – and eventually focus on mediation and resolution. Addressing the “difficult” nature of these parties is a vital first step towards creating positive patient-physician relationships and health outcomes.

You may hear the phrase “difficult patient” offhandedly thrown around in a physician’s lounge – a blanket term like “problem child” or “one of those” that draws universal understanding but little clarity on the specifics of the interaction. Physicians characterize 15-20% of all patients as “difficult.”2,3 Such encounters point to a strong association between the “difficult” characterization and patient mental disorder – namely, depression, panic disorder, and anxiety.2,3 Doctors note these patients are either 1) not interested in a medical opinion whatsoever, or 2) have repetitive, non-specific complaints.However, it was also noted that difficult patients are hard to describe and characterize as a group.4 Mental health does not preclude a difficult interaction. In a series of interviews, physicians described “difficult” as conversational issues such as patients being “violent, demanding, aggressive, rude and [seeking] secondary gain.”5 Physicians describe their primary motivations as the desire to solve medical problems and help others – and anything that stymies this process sadly draws the label “difficult.”

The onus is not completely on the patient, however. One study points out that the difficulty may stem from the doctor’s work style, belief system, and/or cultural barriers.5 The more experienced a family medicine physician is, the less likely he/she is to characterize a patient as “difficult” – suggesting that there is a burden on the doctor to develop the interpersonal skills to handle the interaction. Collectively, physicians that report high frustration with patients are those that are younger, work longer hours, and have symptoms of depression, anxiety, and stress.6 While physicians often characterize patients as difficult, patients are less likely to describe their physician as so. In most studies, patients are evaluated for their “satisfaction,” which includes many aspects of their medical care, including perceived expectations, the underlying medical condition, and other members of the healthcare team. This may also reflect the power dynamic between patient and physician. Patient complaints may be dismissed, once again, as the patient being “difficult” - leaving the physician immune to criticism.

The difficult patient-physician relationship involves both behavioral (mental disorders, stress) and communicative (rude and aggressive language) factors from both parties. Ultimately, cooperative relationships stem from respect, empathy, and patience. As one physician stated in his interview, “First of all, what I have learned with the years is being empathetic toward [patients].” Taking the time to understand another’s perspective can go a long way in making the difficult into easy.5



Sources

1.       Bever, Lindsey. (2017). A doctor shouted at a sick mother to 'get the hell out.' Now he's under criminal investigation. Washington Post.
2.       Hahn, S. R., Kroenke, K., Spitzer, R. L., Brody, D., Williams, J. B., Linzer, M., & Verloin deGruy, F. (1996). The difficult patient. Journal of general internal medicine, 11(1), 1-8.
3.       Jackson, J. L., & Kroenke, K. (1999). Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Archives of Internal Medicine, 159(10), 1069-1075.
4.       Koekkoek, B., van Meijel, B., & Hutschemaekers, G. (2006). " Difficult patients" in mental health care: a review. Psychiatric Services, 57(6), 795-802.
5.       Steinmetz, D., & Tabenkin, H. (2001). The ‘difficult patient' as perceived by family physicians. Family practice, 18(5), 495-500.

6.       Krebs, E. E., Garrett, J. M., & Konrad, T. R. (2006). The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data. BMC health services research, 6(1), 128. 


 GRAPHIC: From Google Images.
January 20, 2018

Southern California Bioethics Committee Consortium

The Southern California Bioethics Committee Consortium (SCBCC) is a group of health care professionals who meet regularly to discuss the medical, legal, and ethical dimensions of “doing” bioethics in Southern California.

Since I happened to be in town this week, I was fortunate to be asked to drop by the regular SCBCC meeting. There were around 30 ethics folks from Cedars, UCLA, Kaiser, Loma Linda, and other systems and facilities. In short, SCBCC is a great example (like MHECN) of a still too-rare successful regional bioethics consortium.

Here is a copy of the presentation I made on "Five New Bioethics Cases in California Courts."

January 19, 2018

US DHHS Forms New Conscience and Religious Freedom Division

The U.S. Department of Health and Human Services (HHS) has formed a new Conscience and Religious Freedom Division in the HHS Office for Civil Rights (OCR). The Conscience and Religious Freedom Division has been established to restore federal enforceme...
January 18, 2018

What’s really happening with doctor-assisted suicide?

Recently, Wesley Smith posted on the National Review’s “Corner” blog new concerns that Oregon’s “Death With Dignity” law may not be as tightly regulated as advertised.  Specifically, a Swedish fellow named Fabian Stahle, who evidently is troubled by the prospect that his country might embrace doctor-assisted suicide, claims to have carried out an e-mail exchange with someone in the Oregon Health Authority to ask how... // Read More »
January 18, 2018

Tulsa Zoo’s Oldest Elephant Begins Hospice Care

The Tulsa Zoo announced that it is starting hospice care for its 67-year-old elephant. Gunda is among the oldest elephants in human care.
January 18, 2018

Fostering Civil Discourse - and Humor - in a Partisan Era

By Tarris Rosell, PhD, DMin
Fifteen years ago in the aftermath of 9/11, I was invited to respond as an Ethics panelist to a new, self-published book, The Fundamentals of Extremism (Blaker, et al., New Boston Books, Inc., 2003). The authors aimed to expose “the Christian Right” as a danger to democracy. While I sympathized with chief editor Kimberly Blaker’s agenda, the book itself struck me as taking much the same rhetorical tack as the religious fundamentalists that she and her co-authors vociferously critiqued.

My invitation to a book-signing event came with the expectation that I, a progressive clergyman ethicist, would be an enthusiastic proponent who might also help sell a few books. While preparing remarks, I was challenged with the dilemma of not wanting to disappoint a young author with worthy aims, while also engaging in truth-telling as I saw it. Most importantly, I wished not to support or practice the very thing we both condemned: divisive, speculative, paranoid, demonizing fundamentalist—or even anti-fundamentalist—rhetoric. Unfortunately, to my Ethics eyes, The Fundamentals of Extremism was pretty much what it denounced.

So, for my panel presentation, I resorted to writing poetry, or possibly doggerel - an Ethics response in rhyme.

It seemed to me then, and now, that our ideological divisions are ameliorated best by civil discourse laced with mutual respect and a dose of good humor. This is difficult, and especially so when the stakes appear high, as they did back then, and now. Yet, if we who disagree with political or religious extremism engage in the same sort of rhetoric and behaviors as those we oppose, if our own claims are factually challenged anecdotes and innuendo, we only foster more schism and less democracy.

This is the poem I wrote (with minor edits). I think it still works in the partisan era of Trump.

An Anti-Fundamentalist Confession


Tarris Rosell
© 2003, 2018

I’m fundamentally opposed to fundamentalism,
And separate myself from those who foster any schism.
I feel an obligation to expose the boorish Right
And other such extremists whom the rest of us must fight.

I fear their chief ambition is to slay democracy;
Their paranoia leads them to engage conspiracy.
They’d have us all subservient to Fundie* ways of being,
Dichotomize and simplify our thinking and our seeing.

Black and white, or good and bad, on absolutist values
Strikes me as absolutely wrong, as I’m compelled to tell you.
Yet, in my strident anti-fundamentalist critique,
Another thought has struck me, and has left me feeling meek.

One problem with Conservatives in all their stridency
Is one that tempts both Right and Left as human tendency.
While exorcism of their demonizing fits the facts,
Sometimes I look into the mirror and see “Them” looking back.

The rhetoric we choose to use, the labels we assign,
The latitude we grant to those across the picket line,
Our attitude of hubris, or of apt humility—
All these demark the difference between Us and Them
Or We.

* A pejorative slang abbreviation that refers to religious fundamentalists of any religion or denomination.

Dr. Rosell is the Rosemary Flanigan Chair at the Center for Practical Bioethics. He is also Professor of Pastoral Theology at Central Baptist Theological Seminary, Clinical Professor, History and Philosophy of Medicine at the University of Kansas Medical Center, School of Medicine, and Chair of the Department of Bioethics at Kansas City University of Medicine and Biosciences.

January 17, 2018

Mostly Incapacitated Patient Can Fire Healthcare Agent

The California Court of Appeals has correctly ruled that capacity is decision specific. Even a largely incapacitated patient may still have the capacity to name and fire surrogates. Earlier this month, the appellate court upheld a trial court ruling d...
January 17, 2018

Selection of embryos in IVF to increase birth rates

A recent article in the Daily Mail brought my attention to recent research by the British assisted reproduction scientist Simon Fishel (see abstract) on a technique which can help select which early developing embryos produced by IVF are most likely to result in a live birth when they are implanted. This technique in evolves repeatedly photographing the developing embryos and using a computerized process to... // Read More »

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Published Articles (71)

American Journal of Bioethics: Volume 18 Issue 1 - Jan 2018

From “Longshot” to “Fantasy”: Obligations to Pediatric Patients and Families When Last-Ditch Medical Efforts Fail Elliott Mark Weiss & Autumn Fiester

American Journal of Bioethics: Volume 18 Issue 1 - Jan 2018

Managing Expectations: Delivering the Worst News in the Best Way? Alyssa M. Burgart & David Magnus

American Journal of Bioethics: Volume 17 Issue 12 - Dec 2017

Our Life Depends on This Drug: Competence, Inequity, and Voluntary Consent in Clinical Trials on Supervised Injectable Opioid Assisted Treatment Daniel Steel, Kirsten Marchand & Eugenia Oviedo-Joekes

AJOB Primary Research: Volume 8 Issue 4 - Dec 2017

Counseling parents at risk of delivery of an extremely premature infant: Differing strategies Marlyse F. Haward, Annie Janvier, John M. Lorenz & Baruch Fischhoff

AJOB Neuroscience: Volume 8 Issue 4 - Nov 2017

Ahead of Our Time: Why Head Transplantation Is Ethically Unsupportable Paul Root Wolpe

AJOB Neuroscience: Volume 8 Issue 4 - Nov 2017

HEAVEN in the Making: Between the Rock (the Academe) and a Hard Case (a Head Transplant) Xiaoping Ren & Sergio Canavero

AJOB Neuroscience: Volume 8 Issue 4 - Nov 2017

The Rubicon Already Crossed Karen S. Rommelfanger & Paul F. Boshears

American Journal of Bioethics: Volume 17 Issue 11 - Nov 2017

Empowerment Failure: How Shortcomings in Physician Communication Unwittingly Undermine Patient Autonomy Peter A. Ubel, Karen A. Scherr & Angela Fagerlin

American Journal of Bioethics: Volume 17 Issue 11 - Nov 2017

Reasons to Amplify the Role of Parental Permission in Pediatric Treatment Mark Christopher Navin & Jason Adam Wasserman

American Journal of Bioethics: Volume 17 Issue 11 - Nov 2017

To Whom Do Children Belong? John Lantos

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News (2085)

January 2, 2018 9:00 am

Retirement home shut down months after attack on 86-year-old (CNN)

December 29, 2017 9:00 am

Doctor faces charges over opioid prescriptions and 5 patient deaths (CNN)

A Pennsylvania doctor charged with causing the deaths of five patients by unlawfully prescribing opioids surrendered his license to prescribe controlled substances at a federal court hearing.

December 15, 2017 9:00 am

After mistakenly declaring newborn dead, New Delhi hospital loses license (CNN)

The Delhi government has canceled the license of a private hospital where a newborn baby was mistakenly declared dead.

November 7, 2017 9:00 am

How Should Organizations Promote Equitable Distribution of Benefits from Technological Innovation in Health Care? (AMA Journal of Ethics)

Technological innovations typically benefit those who have good access to and an understanding of the underlying technologies. As such, technology-centered health care innovations are likely to preferentially benefit users of privileged socioeconomic backgrounds. Which policies and strategies should health care organizations adopt to promote equitable distribution of the benefits from technological innovations?

October 12, 2017 9:00 am

Birth control: Trump expands opt-out for workplace insurance (Washington Post)

President Donald Trump is allowing more employers to opt out of providing no-cost birth control to women by claiming religious or moral objections, issuing new rules Friday that take another step in rolling back the Obama health care law.

September 21, 2017 9:00 am

As Federal Government Cuts Obamacare Ads, Private Insurer Steps Up (NPR)

Open enrollment for Affordable Care Act insurance doesn’t start for another six weeks. But the quirky insurance startup Oscar Health is launching an ad campaign Monday aimed at getting young people to enroll.

September 5, 2017 9:00 am

F.D.A. Approves First Gene-Altering Leukemia Treatment, Costing $475,000 (The New York Times)

The Food and Drug Administration on Wednesday approved the first-ever treatment that genetically alters a patient’s own cells to fight cancer, a milestone that is expected to transform treatment in the coming years.

July 5, 2017 10:00 am

For Parents of U.K. Infant, Trump’s Tweet Is Latest Twist in an Agonizing Journey (The New York Times)

The long journey for Connie Yates and Chris Gard, whose infant son, Charlie, cannot breathe or move on his own, appeared to have come to an end last week. The courts had ruled that the baby’s rare genetic condition was incurable and that the only humane option was to take him off life support. The couple announced that they were getting ready “to say the final goodbye.” Then Pope Francis and President Trump weighed in, offering statements of support and thrusting a global spotlight onto a heart-rending case that has become a cause célèbre in Britain.

June 20, 2017 10:58 am

Trump ‘simply does not care’ about HIV/AIDS, say 6 experts who just quit his advisory council (Washington Post)

The first hints of an uncertain future for the Presidential Advisory Council on HIV/AIDS came last year, when Donald Trump’s presidential campaign refused to meet with advocates for people living with HIV, said Scott Schoettes, a member of the council since 2014. That unease was magnified on Inauguration Day in January, when an official White House website for the Office of National AIDS Policy vanished, Schoettes said. Last week, he and five others announced they were quitting the Presidential Advisory Council on HIV/AIDS, also known as PACHA.

June 6, 2017 9:00 am

Superantibiotic is 25,000 times more potent than its predecessor (Science)

The world’s last line of defense against disease-causing bacteria just got a new warrior: vancomycin 3.0. Its predecessor—vancomycin 1.0—has been used since 1958 to combat dangerous infections like methicillin-resistant Staphylococcus aureus. But as the rise of resistant bacteria has blunted its effectiveness, scientists have engineered more potent versions of the drug—vancomycin 2.0. Now, version 3.0 has a unique three-pronged approach to killing bacteria that could give doctors a powerful new weapon against drug-resistant bacteria and help researchers engineer more durable antibiotics.

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