1. Professional Behavior
Tom Heston, MD

2. Case Study 1
• A physician over time becomes attacted to a
current patient
• The physician and patient mutually agree to
end the physician-patient relationship
• The physician now asks the former patient out
on a date, and they go on several additional
dates.
• What do you think?

3. Case Study 1
• Relationship soured
• Complaint made to the state medical board
• Physician was disciplined by the state medical
board and license was restricted for 2 years

4. Principles
• Physicians are in a position of power
• Patients can be vulnerable to their influence
• Physician power should only be utilized for
medical purposes, not personal gain
– Romantic relationships with a current patient is
not allowed
– Some states prohibit the treatment of family,
friends, or employees

5. Doctor-Patient Relationship
• Both parties must agree
• Physicians do not have a legal obligation to
enter into a doctor-patient relationship with
anyone, however note that:
– Emergency departments must treat everyone
– Physicians working in such settings have agreed to
provide treatment to all patients seeking care
• Ending the relationship: reasonable notice,
provide alternatives, maintain records

6. Gifts From Patients
• Small gifts acceptable
• Large gifts should be refused
• Patients may be vulnerable, and as a result
give a provider a large gift.

7. Impaired Physicians
• Substance abuse
• Physical disability
• Mental illness
• Old age resulting in poor performance

8. Principles to Follow
• Self Regulation
– Surgeon with advanced arthritis stops operating
– Elderly physician retires
– Physicians have a duty to do their very best to self
regulate their medical practice
• Physician Colleague Regulation
– Must ensure that the impaired physician gets help
– When discovered, all physicians have an ethical
obligation to ensure impaired physicians get help
– Physicians are often in the best position to
identify impairment in a colleague

9. Medical Malpractice
• Error and mistakes occur. This alone does not
equal malpractice
• Must prove the 4Ds: dereliction of duty results
in damage directly to the patient
– Dereliction: giving substandard medical care
– Duty: a physician-patient relationship exists
– Damages: actual damage to the patient occurred
– Directly: damages were the result of dereliction

10. Impact on Physicians
• All physicians are at risk of getting sued
– ~10% per year in US historically
– Top specialties: surgery, ob/gyn, anesthesiology
• Malpractice is a tort, i.e. a civil wrong.
– Compensation typically is financial.
• Physicians occasionally, but rarely, accused of
a criminal malpractice violation
– Result can be jail time

11. Types of Damage
• Compensatory
– Reimbursement of medical bills
– Reimbursement of lost wages
– Pain and suffering
• Punitive Damages
– Designed to punish the offending party
– Designed to set an example

12. Deviation From the Standard of Care
• Generally determined by LOCAL practice
• Practice guidelines – http://guideline.gov
• Medical society guidelines

13. Informed Consent
• Not simply a signature on a page
• Fully Informed
– Procedure
– Alternatives
– Benefits
– Risks
• Informed Refusal
– This is a high-risk situation
– Frequently occurs in emergency room settings
– Must fully document and ask patient to sign out AMA

14. Patient Obligations
• Fully inform the physician
• Ask questions
• Be honest
• Follow medical advice

15. Medical Errors
• Ethical duty to inform patients of an error if it
will impact the patient’s care.
• Minor errors that will have no impact upon
care do not need to be reported to the patient

16. Case Study 2
• Patient with high blood pressure admitted to
hospital
• Order for “Diovan” misinterpreted as for
“digoxin”, possibly due to sloppy handwriting
• Patient overdosed on digoxin requiring a
prolonged stay
• Patient successfully treated, being unaware of
situation
• What are the principles here?

17. Case Study 2
• Physician, pharmacist, and nurse all made a
mistake
– Dosage difference for digoxin vs Diovan should
have been caught by pharmacist and nurse
– Physician should have written more legibly
• Harm occurred, even though patient unaware
– although no long-term harm, the patient did have
a prolonged hospital stay

18. Case Study 3
• What is the role of the Risk Management
team in a hospital?
– Patient advocacy?
– Improve clinical care?
– Ensure the ethical treatment of patients?
– Minimize legal risk to the hospital?

19. Case Study 3
• Risk Management Teams are tasked with
reducing the legal risk to the hospital.
• May or may not lead to improved clinical care
• Sometimes, but not always, also reduces the
liability risk of physicians and nurses.

20. Case Study 4
• Adult patient with leukemia informed
(procedure, alternatives, benefits, risks)
regarding bone marrow transplantation
versus chemotherapy
• Patient agrees to bone marrow
transplantation
• Patient dies and lawsuit filed
• What is the likely outcome?

21. Case Study 4
• Lawsuits can be filed for any reason
• In states with no tort reform, outcomes are
unpredictable due to high emotion and low
level of medical expertise of non-professional
(lay public) jurors.
• Theoretically, the physician should not lose
this lawsuit because of documented, full
informed consent, and the therapy being
within the standard of care

22. Case Study 5
• Patient with acute myocardial infarction
• Angioplasty offered
• The procedure and risks were fully explained
to the patient
• Patient decides to go with medical therapy
alone
• Patient dies
• What is the medico-legal situation here?

23. Case Study 5
• Consent was not done properly: the
alternatives and benefits were not discussed
• Procedure and associated risk of procedure
explained, but...
– Benefit of procedure not explained
– Alternatives (and their risks) not explained

24. Case Study 6
• Resident disagrees with medical management
by attending physician
• What should the resident do?

25. Case Study 6
• The resident should first discuss the case with
the attending, using evidence-based medicine
• If no satisfactory response, then resident
should bring the issue to a higher local
authority
– Do not go to the patient
– Do not go directly to the state board
– Go to a local, higher authority

26. Case Study 7
• Elderly women admitted to hospital with
gastroenteritis and dehydration
• Does not complain of dizziness
• Left alone to use the toilet, gets dizzy, and
falls
• Sues hospital for negligence
• What are the legal principles here?

27. Case Study 7
• Patients are required to fully inform physician
of medical condition and physical complaints
• Patients required to inform nurses about
dizziness when it affects nursing duties
• Fall precaution policies in hospitals try to
prevent this situation from occurring.

28. Case Study 8
• Patient with osteomyelitis
• You forget to reorder antibiotics, and the
patient misses 2 days out of his 6 week course
of antibiotics (2 days out of 42 total)
• The patient does not experience any clinical
deterioration
• Condition successfully treated by 6 weeks
• What should you do?

29. Case Study 8
• This is a medical error but not malpractice (no
damage occurred)
• You should inform the patient and reassure
them that they will be okay

30. Case Study 9
• Patient admitted with massive intracranial
bleed
• Patient on a ventilator
• Brain death confirmed
• What do you do?

31. Case Study 9
• Inquire about organ donation
• Death is determined by the physician, not the
family
• Brain death = death
• Cardiopulmonary arrest resistant to
rescussitation = brain death = death
• Remove the ventilator after speaking with the
family

32. Case Study 10
• A parent brings a 5-year old child to the ER
• You suspect child abuse
• What do you do?

33. Case Study 10
• Report the situation to child protective
services
• You are ethically and legally required to report
even a suspicion of abuse
• You are legally protected even if it turns out to
not be abuse

34. General Principles
• The patient comes first
• Open communication
– Tell the patient what you know
– Expect reciprocity from the patient
– Try to remove barriers to communication
such as computers, other family members

35. General Principles
• Work on long-term relationships
• Negotiate rather than order. Paternalism is
out.
• Admit errors
• Never “pass-off” care. Stay involved even
after referral to subspecialist.

36. General Principles
• Ensure you understand the patient first
• Patients do not get to select inappropriate
treatments
• Best answers serve multiple goals. Consider
both short-term and long-term issues.

37. General Principles
• Never lie.
• Accept the health beliefts of patients
– Expect to come across folk remedies
– Explain your care in plain language
• Accept and honor religious beliefs of patients,
participate if appropriate
• Anything that improves communication is
good

38. General Principles
• Have a good bedside manner and be
respectful
• A good rapport increases patient satisfaction,
compliance, and physician satisfaction

39. References
• Kaplan Medical USMLE Medical Ethics (2006)
• Deja Review USMLE Step 1