Obligation of the Physician and Physician Deception Top

1. Did you agree with the physician's decision to alter the evidence and deceive the chief of police?

2. If you were the physician, what would you have done?

3. If the physician suspected Earl was killed by Kitty, what are the physician's legal obligations to report the murder?

   Review: A review of state laws that require health providers to report violence-inflicted injuries reported that by 2001, all but 5 states (Alabama, New Mexico, South Carolina, Washington, and Wyoming) had laws requiring health providers to report injuries resulting from firearms, knives, or other weapons to law enforcement. The authors note that in "the majority of states with mandated reporting of injuries, failure to report the injury to law enforcement is considered a misdemeanor." And the "state laws do provide immunity for physicians or other health providers who make a good faith report."

   Houry, D, et al. Violence-Inflicted Injures: Reporting Laws in the Fifty States. Ann Emerg Med 2002;39:56-60. http://www.ncbi.nlm.nih.gov/pubmed/11782731

   Virtual Mentor: On the American Medical Association's online Journal of Ethics, an attorney and associate for the AMA Council on Ethical and Judicial Affairs identifies situations in which physicians are obligated to report violence-related injuries.

   http://virtualmentor.ama-assn.org/2009/02/hlaw1-0902.html]

4. Are there physician codes that proscribe the proper course of action?

   ACP: The fifth edition of the American College of Physician's Ethics Manual, published in 2005, covers a wide variety of ethical challenges encountered in medical practice. Sections of the manual include issues that involve the relationship of physician and patient; the care of the patient near the end of life; the ethics of practice; the physician and society; the physician's relationship to other clinicians, and ethical concerns encountered in research.

   Regarding the issue faced by the physician in Playing God, the Manual notes that "all physicians must fulfill the profession's collective responsibility to advocate the health and well-being of the public. Physicians should protect public health by reporting disease, injury, domestic violence, abuse or neglect to the responsible authority as required by law."

   ACP Ethics Manual: http://www.acponline.org/running_practice/ethics/manual/

   AMA: Opinion 5.05 of the AMA Code of Ethics states "when a patient threatens to inflict serious physical harm to another person or to him or herself and there is a reasonable probability that the patient may carry out the threat, the physician should take reasonable precautions for the protection of the intended victim, which may include notification of law enforcement authorities." http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion505.shtml

5. What ethical theories or ethical approaches can be used to help determine the best course of action for the physician? What are the benefits and limitations of using each of these?

   Ethical theories

   • Consequentialism (Utilitarianism) - http://plato.stanford.edu/entries/consequentialism/
   • Deontological (Kantian) - http://plato.stanford.edu/entries/ethics-deontological/
   • Casuistry - http://jmp.oxfordjournals.org/cgi/content/abstract/16/1/29?ijkey=249b1423b74b1de1fa550f5a485beed3605328a0&keytype2=tf_ipsecsha (open PDF file within link)
   • Ethic of Caring - Link to: http://caae.phil.cmu.edu/Cavalier/80130/part2/II_7.html
   • Virtue Ethic - Link to: http://plato.stanford.edu/entries/ethics-virtue/
   
   

   Ethical Approaches

   Perspective: Physicians may find clinical ethics teachings unhelpful in managing the common day-to-day patient care conflicts that arise in primary care. A family physician describes his approach to clinical ethics problems. The physician considers the various ethics principles and chooses the "one that bests illuminates what to do in a specific case, depending on the ethical question, the clinical details, the personalities and needs of the patient and family."

   Tunzi, M. Ethical Theories and Clinical Practice. One Family Physician's Approach. Arch Fam Med 1999;8:342-344 http://archfami.ama-assn.org/cgi/content/full/8/4/342

   Perspective: In an accompanying editorial, the author discusses that when a physician is confronted with an ethical dilemmas, an ethical analysis should always precede a legal analysis. When there is near consensus that a current law is unethical, the medical profession should seek to change the law.

   Bauman, S. Clinical Ethics. What's Law Got to Do With It? Arch Fam Med 1999;8:345-346 http://archfami.ama-assn.org/cgi/content/full/8/4/345

6. What are examples of conflicts that physicians may have between the welfare of their patient and their obligation to society?

   Bloche MG. Clinical Loyalties and the Social Purpose. JAMA 1999;281:268-274 http://jama.ama-assn.org/cgi/content/abstract/281/3/268

   T <_.p>he author, a physician and attorney, reviews the many conflicts physicians face between their patient's interest and the interest of society. Categories of conflicts include public health purposes (selective use of antibiotics), nonmedical ends (treatment that returns wounded troops for combat), and activities such as managed care gatekeeping. The author argues that the tension between the personal and societal expectations of medicine cannot be reconciled, but rather managed using ethical principles so to balance the obligations the physician has to the patient and to society.

7. Is it common for physicians to deceive a third party for the benefit of a patient? What are examples of physician deception?

   Novack DH, Detering BJ, Arnold R, et al Physicians' Attitudes Toward Using Deception to Resolve Difficult Ethical Problems. JAMA 1989;261:2980-2985 http://jama.ama-assn.org/cgi/content/abstract/261/20/2980

   407 practicing physicians were sent a survey to explore their use of deception to resolve difficult ethical problems. Of the 211 (52%) respondents, the majority would lie about a patient's diagnosis in order to allow insurance re-imbursement of a mammogram, and the majority would lie to the wife of a patient who was diagnosed with gonorrhea. When forced to make difficult ethical choices, most physicians indicated a willingness to deceive. Moreover, most physicians adopted a consequentialist approach: to appeal to the good consequences produced and the bad consequences avoided by deception.

   Beach MC, Meredith LS, Halpern J, et al. Physician Conceptions of Responsibility to Individual Patients and Distributive Justice in Health Care. Ann Fam Med 2005;3:53-59 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1466786/

   505 primary care physicians in managed care organizations were sent a survey to assess their sense of responsibility to individual patients and their egalitarian conception of distributive justice. Of the 414 (83%) respondents, 70% agreed or strongly agreed to the statement: "the physician's main responsibility is to each individual patient rather than to society." Physicians reporting a strong sense of responsibility to individual patients were more likely to be older (43% of physicians older than 50 years reported a strong sense of responsibility to individual patients, compared with 26% of physicians aged 36 to 50 years, and 21% of physicians younger than 35 years, p = .009)

Intimate Partner Violence Top

This document provides a brief summary with supporting bibliography about intimate partner violence (IPV). For further reading, please refer to the references. The outline addresses the following: demographics, costs of IPV, health consequences of violence, children and abuse, legal issues, screening for abuse, what do you do once you detect IPV, documentation, education about abuse, barriers for victims, IPV in special populations, and modern literature.

The last two parts list a selection of modern literature which depicts global violence against women. There is also a link to further educational opportunities about IPV, using interactive videos.

1. LaCombe places this story of chronic domestic abuse in a rural town, Taylor County. What are the demographics of abuse in the US and worldwide? Are there risk factors that enhance the chance for abuse in a relationship?

   Demographics

   Global:

   United Nations Development Fund for Women. 2003. Not A Minute More: Ending Violence Against Women. http://www.unifem.org/resources/item_detail.php?ProductID=7

   The United Nations Development Fund for Women estimates that at least one of every three women globally will be beaten, raped or otherwise abused during her lifetime. In most cases, the abuser is a member of her own family.

   WHO Multi-country Study on Women's Health and Domestic Violence Against Women. World Health Organization 2005. http://www.who.int/gender/violence/who_multicountry_study/en

   A 2005 World Health Organization study of 24,000 women found that of 15 sites in ten countries - women who had experienced physical or sexual intimate partner violence in their lifetimes ranged from 15 percent (Japan) to 71 percent (Ethiopia.)

   United States:

   Adverse Health Conditions and Health Risk Behaviors Associated with Intimate Partner Violence --- United States, 2005. MMWR Weekly. February 8, 2008 / 57(05);113-117. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5705a1.htm

   In 2005, the Center for Disease Control conducted a random telephone survey of non-institutionalized persons greater than 18 years old in the US. This included an optional IPV module. Of the 70,156 respondents, 24% women and 11% men had lifetime IPV victimization. Nearly one in four women in the United States reported experiencing violence by a current or former spouse or boyfriend at some point in her life.

2. When Earl wants to kill his son-in-law, the doctor dissuades him by saying that his grandchildren will hate him. "And your grandchildren will hate you for the rest of their lives," I said, "for killing their father." Do you think Al was abusing his children as well as his wife? If the children weren't the target of abuse, do you think they were affected by the violence in the home? How?

   Children and abuse: http://endabuse.org/userfiles/file/Children_and_Families/Children.pdf

   McDonald R, Jouriles EN, Ramisetty-Mikler S, et al. Estimating the Number of American Children Living in Partner-Violent Families. J Fam Psychol 2006;20: 137-142. http://www.ncbi.nlm.nih.gov/pubmed/16569098

   A 1995 interview of 4,925 participants (77% response rate) found that among 21% of couples in which violence was reported to have occurred, 60% had children living in the household. The authors extrapolated this to 2001 US population, estimating that 15.5 million U.S. children live in families in which partner violence occurred at least once in the past year, and seven million children live in families in which severe partner violence occurred.

   Graham-Bermann SA, Seng, J. Violence Exposure and Traumatic Stress Symptoms as Additional Predictors of Health Problems in High-Risk Children. J Pediatr 2005; 146:309-310. http://www.ncbi.nlm.nih.gov/pubmed/15756218

   A study of 160 preschool children exposed to violence or traumatic stress had worse health outcomes compared to their cohort. Children who witness IPV are more likely to exhibit behavioral and physical health problems like: depression, anxiety and violence towards peers; attempting suicide, abusing drugs and alcohol; other high risk behavior.

   Whitfield CL, Anda RF, Dube SR, Felittle VJ. Violent Childhood Experiences and the Risk of Intimate Partner Violence in Adults: Assessment in a Large Health Maintenance Organization. J Interpers Viol 2003;18: 166-185. http://jiv.sagepub.com/cgi/content/abstract/18/2/166

   A study of 8629 participants showed a statistically significant graded relationship between the # of childhood violent experiences and risk of IPV. Physical abuse during childhood increases the risk of future victimization among women and the risk of future perpetration of abuse by men more than two-fold.

   Anda R, Block R, Felitti V. 2003. Adverse Childhood Experiences Study. Centers for Disease Control and Prevention, Kaiser Permanente's Health Appraisal Clinic in San Diego. http://www.cdc.gov/NCCDPHP/ACE/index.htm

   Between 1995 and 1997, 17000 members of Kaiser Permanente undergoing a routine physical examination completed a voluntary survey about childhood maltreatment and family dysfunction. Participants reported a 28% prevalence of physical abuse and 21% sexual abuse. Children who experience childhood trauma, including witnessing incidents of domestic violence, are at a greater risk of having serious adult health problems including tobacco use, substance abuse, obesity, cancer, heart disease, depression and a higher risk for unintended pregnancy.

3. Kitty's physician, emergency department staff, and hospital nurses were obviously aware of her chronic abuse. Besides medical care, what legal obligations do healthcare workers have when taking care of an abuse victim? How would this be different if the abuse was not just of the spouse but of the children too? What is the Violence Against Women Act of 1994? Are there state to state differences with regards to the care of the abuse victim?

   The National District Attorneys Association lists state laws regarding domestic violence http://www.ndaa.org/apri/programs/vawa/dv_reporting_requirements.html

   Local laws vary state by state. There may be mandatory reporting laws of documented or suspected IPV. Reporting is mandatory when there is deadly weapon used, child abuse or vulnerable adult abuse occurs. Providers must know their local reporting laws or else they may be held liable for neglect.

   a href="http://family.findlaw.com/domestic-violence/federal-domestic-violence-legislation.html">http://family.findlaw.com/domestic-violence/federal-domestic-violence-legislation.html

   http://www.ovw.usdoj.gov/regulations.htm

   "The 1994 Violence Against Women Act (VAWA), with additions passed in 1996, outlined grant programs to prevent violence against women and established a national domestic violence hotline. In addition, new protections were given to victims of domestic abuse, such as confidentiality of new address and changes to immigration laws that allow a battered spouse to apply for permanent residency. According to the VAWA Act, a domestic violence misdemeanor is one in which someone is convicted for a crime 'committed by an intimate partner, parent, or guardian of the victim that required the use or attempted use of physical force or the threatened use of a deadly weapon' (Section 922g). Under these guidelines, an intimate partner is a spouse, a former spouse, a person who shares a child in common with the victim, or a person who cohabits or has cohabited with the victim. Another area this act addresses is interstate traveling for the purposes of committing an act of domestic violence or violating an order of protection. A convicted abuser may not follow the victim into another state, nor may a convicted abuser force a victim to move to another state. Previously, orders of protection issued in one jurisdiction were not always recognized in another jurisdiction. The VAWA specifies full faith and credit to all orders of protection issued in any civil or criminal proceeding, or by any Indian tribe, meaning that those orders can be fully enforced in another jurisdiction. Forty-seven states have now passed legislation that recognizes orders of protection issued in other jurisdictions. Three states, Alaska, Montana, and Pennsylvania, require that an out of state order be filed with an in state jurisdiction before the order can be enforced."

4. Kitty's father, physician, and the town were all aware of her abuse. This is often not the case. Do physicians have a role in screening for abuse? How can physicians uncover and screen for abuse? What are some warning signs that could hint at abuse?

   http://www.acog.org/departments/dept_notice.cfm?recno=17&bulletin=585

   RADAR: Remember to ask, Ask directly; Document findings; Assess safety; Refer to community services.

   Questions to ask routinely: Have you been hit, kicked, punched or otherwise hurt by someone in the past year? If so, by whom? Do you feel safe in your current relationship? What happens when you and your partner disagree? Do any situations exist in your relationships in which you have felt afraid? Has partner ever prevented you from leaving the house or seeing your friends or family?

5. Kitty's physician hospitalized her several times for abuse. When a physician treats an abuse victim, how should s/he correctly document abuse? How does this affect confidentiality?

   Isaac NE, Enos VP. Documenting Domestic Violence. How Health Care Providers Can Help Victims. National Institute of Justice Research in Brief. September 2001. 1-5. http://www.ncjrs.gov/pdffiles1/nij/188564.pdf

   Medical records can be used as evidence for obtaining protective services. Use images such as photographs of injuries or body maps to document extent of injury. In your note: write legibly, record the patient's own words in quotations and use "patient states...", avoid phrases such as "patient claims or alleges...," use medical terms and avoid legal terms, describe patient's demeanor, record time of examination and time since abuse last occurred. Document how she was injured and who caused her injuries with specific details. If there are any witnesses with the victim, document quotations from those witnesses. Note past history of violence.

6. "Each time we got the town police involved, had Earl arrested, had the complaint papers all filled out. All sealed, and delivered, except that Kitty would never sign the papers. And she always went back to him." Why do victims return to their abusers? What are the barriers to leaving? What is the power wheel? What powerful holds do abusers have over their victims?

   "Soon Kitty did go back with Earl. You had trouble saying whose sickness was worse. ...And she always went back to him." What is the cycle of violence: tension building, acute battering, and honeymoon stage? How can the physician best intervene to stop this cycle? In an effort to help the victim, how can the doctor unknowingly worsen the situation?

   Warshaw C. Domestic Violence: Challenges to Medical Practice. J of Women's Health. 1993; 2(1):73-80. http://www.liebertonline.com/doi/abs/10.1089/jwh.1993.2.73

   http://www.acog.org/publications/patient_education/bp083.cfm

   Healthcare workers need to appreciate the cycle of violence. Patients may be more amenable to intervention during the tension building and battering phases. During reconciliation the victim is showered with apologies and expressions of love and affection and assurance that the violence will never happen again. The patient may be less willing to seek help during this phase. If/when the victim decides to leave, there is often an escalation of violence. This is the most dangerous time for the victim.

   In addition to physical and sexual violence, the abuser may exert his power in other ways - this is known as the Power Wheel. The abuser uses intimidation, social isolation, coercion, threats, economic dependence, and the children to exert control and power over the victim. Thus, the victim is helpless in escaping or leaving because she is completely dependent on him.

   Cassel C. Reflections on Playing God. Ann Int Med 1992;116:163-164.

   Victims often blame themselves and think that violence is normal "if only I did ...better, then he wouldn't have to hit me." "The passivity that Kitty exhibits in the face of such abuse, her unwillingness to bring charges against her husband, and her seemingly inevitable return to him are behaviors that are common among abused women, often attributed to a history of child abuse and eroded self-esteem leading to masochism and codependency. Another way of understanding why women put up with abuse is sociologically, observing that women without the skills to earn a living may see no options to support themselves outside the abusive relationship and thus are socioeconomically 'trapped,' especially if they have children."

7. "This was probably the first time in her life she had made up her mind and stuck to it." What are some of the dilemmas and major hardships a victim faces in confronting and leaving her abused situation? What resources can physicians provide to their patients to help them reach this stage of separation successfully?

   http://www.acog.org/departments/dept_notice.cfm?recno=17&bulletin=179

   Validate & support (abuse is not acceptable and the victim is not to blame, help is available, you are not alone). Assess for immediate danger. Be aware of firearms and objects potentially used as weapons. Do not challenge the partner. Document the abuse (photos, direct questions). Does the victim have a safe place to go and the resources they need in an emergency? Start safety planning: (1) escape plan, neighbors/friends, use of code word; (2) secure documents (banking account books, birth certificates, financial receipts, license, insurance, title or deeds, passport, etc; (3) gather essentials (suitcase with clothes and toiletries, emergency cash, medications, keys, prescriptions, eyeglasses or contacts, etc.). Provide referrals/resources (shelters, crisis centers, legal services, programs & support groups, counseling). Provide ongoing support and follow up. Inform the children's school. Teach children important numbers.

8. "It was the same scenario for some ten years, Kitty coming into the emergency room, badly beaten, meekly asking to see me." "Two other times Kitty had been so severely beaten that she required hospitalization." What are the health consequences: acute traumatic, chronic medical, and psychological consequences of abuse? What are the costs to society at large?

   Costs of IPV

   Costs of Intimate Partner Violence Against Women in the United States. 2003. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. http://www.cdc.gov/violenceprevention/pdf/IPVBook-a.pdf

   In the United States, the health care cost of intimate partner rape, physical assault and stalking totals $5.8 billion each year, nearly $4.1 billion of which is for direct medical and mental health care services. Lost productivity from paid work and household chores and lifetime earnings lost by homicide victims total nearly $1.8 billion.

   Wisner C, Gilmer TP, Saltzman LE, Zink TM. Intimate Partner Violence Against Women: Do Victims Cost Health Plans More? J Fam Pract 1999;48: 439-443. http://www.ncbi.nlm.nih.gov/pubmed/10386487

   A study of 226 victims of IPV in Minneapolis & Minnesota in 1994 found that compared to a general similar sample, IPV victims cost the health plan 92% more/$1775 more.

   Varjavand N, Cohen DG, Novack DH. An Assessment of Residents' Abilities to Detect and Manage Domestic Violence. J Gen Int Med. 2002;17:465-468. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495067/

   A study of 71 internal medicine residents going through standardized patient exercises found that residents who did not diagnose DV spent nearly twice as much per patient on work-up (mean, $942.00), compared to those who diagnosed DV (mean, $421.00).

   Health Consequences of IPV

   Coker AL, Smith PH, Bethea L, McKeown RE. Physical Health Consequences of Physical and Psychological Intimate Partner Violence. Arch Fam Med 2000;9:451-457. http://www.ncbi.nlm.nih.gov/pubmed/10810951

   A cross sectional survey of 1152 women, ages 18-65, between 1997-1999, noted that 54% had ever experienced physical IPV and 14% experienced only psychological IPV. Women experiencing psychological IPV were significantly more likely to report poor physical and mental health. Psychological IPV was associated with a number of adverse health outcomes, including a disability preventing work, arthritis, chronic pain, migraine and other frequent headaches, stammering, sexually transmitted infections, chronic pelvic pain, stomach ulcers, spastic colon, frequent indigestion, diarrhea, or constipation. Psychological IPV was as strongly associated with the majority of adverse health outcomes as was physical IPV.

   Bonomi AE, Anderson ML, Reid RJ, et al. Medical and Psychosocial Diagnoses in Women with a history of IPV. Arch of Intern Med 2009;169:1692-1697. http://www.ncbi.nlm.nih.gov/pubmed/19822826

   Random telephone survey of 3568 women from a US health plan (not seeking medical care nor identified as IPV in past) found strong associations between past year IPV and a variety of medical/psychosocial conditions in 18 major areas. Abused women had consistently significantly increased relative risks of these disorders: psychosocial/mental; musculoskeletal; and female reproductive. Abused women had a more than 3-fold increased risk of being diagnosed with a sexually transmitted disease and a 2-fold increased risk of lacerations as well as increased risk of acute respiratory tract infection, gastroesophageal reflux disease, chest pain, abdominal pain, urinary tract infections, headaches, and contusions/abrasions.

   Violence Against Women: Effects on Reproductive Health. Outlook 2002 http://www.path.org/files/EOL20_1.pdf

   Sexual and domestic violence are linked to a wide range of reproductive health issues including sexually transmitted disease and HIV transmission, miscarriages, risky sexual health behavior and more. This article provides a summary of global sexual abuse and it's consequences on reproductive health.

9. Violence affects specific populations including immigrants, teenagers dating, and homosexuals. What further consequences can intimidation and violence have on these specific groups?

   Immigrant Women

   Orloff L, Kaguyutan JV. Offering a Helping Hand: Legal Protections for Battered Immigrant Women: A History of Legislative Responses. J Gender, Social Policy, Law. 2002;10: 95-183. http://www.wcl.american.edu/journal/genderlaw/10/10-1orloff.pdf?rd=1

   Immigrant women may face a more difficult time escaping abuse. In addition to the extensive common issues of abuse, immigrant women face social isolation, language barriers, and family repercussions. Batterers often exert control over their partner's immigration status in order to force her to remain in the relationship.

   Orloff LE, Jang D, Klein C. With No Place to Turn: Improving Advocacy for Battered Immigrant Women. Fam Law Quart 1995; 29:313.

   Battered immigrant women who attempt to flee may not have access to bilingual shelters, financial assistance, or food. It is also unlikely that they will have the assistance of a certified interpreter in court, when reporting complaints to the police or a 911 operator, or even in acquiring information about their rights and the legal system.

   Teen Violence

   Silverman JG, Raj A, Mucci LA, Hathaway JE. Dating Violence Against Adolescent Girls and Associated Substance Use, Unhealthy Weight Control, Sexual Risk Behavior, Pregnancy, and Suicidality. JAMA 2001;286:572-579. http://jama.ama-assn.org/cgi/reprint/286/5/572.

   A study of female 9th- through 12th-grade students who participated in the 1997 and 1999 Massachusetts Youth Risk Behavior Surveys (n=1977and 2186, respectively) found that approximately 1 in 5 female students (20.2% in 1997 and 18.0% in 1999) reported being physically and/or sexually abused by a dating partner. Furthermore, they found that teen victims of physical dating violence are more likely than their non-abused peers to smoke, use drugs, engage in unhealthy diet behaviors (taking diet pills or laxatives and vomiting to lose weight), engage in risky sexual behaviors, and attempt or consider suicide.

   Violence in the Gay population

   Greenwood GL, Relf MV, Huang B, et al. Battering Victimization Among a Probability-Based Sample of Men Who Have Sex With Men. Am J Public Health. 2002;92:1964-1969. http://www.ncbi.nlm.nih.gov/pubmed/12453817

   Men who have sex with men experience violence - perhaps more than heterosexual men. A telephone survey of 2880 men from 4 cities from 1996-1998 found a prevalence estimate of 34% for psychological/symbolic battering, 22% for physical battering, and 5% for sexual battering.

   Human Trafficking

   Trafficking in Persons Report 2008. Available at http://www.state.gov/g/tip/rls/tiprpt/2008/

   "Human trafficking is a modern-day form of slavery. Victims of human trafficking are subjected to force, fraud, or coercion, for the purpose of sexual exploitation or forced labor. Victims are young children, teenagers, men and women."

   http://www.endabuse.org/content/features/detail/794/

   "Annually, according to U.S. Government-sponsored research completed in 2006, approximately 800,000 people are trafficked across national borders, which does not include millions trafficked within their own countries. Approximately 80 percent of transnational victims are women and girls and up to 50 percent are minors. The majority of transnational victims are females trafficked into commercial sexual exploitation."

10. Does literature have a role in educating about patient care? What other pieces of popular literature address violence in our society?

    Infidel by Ayaan Hirsi Ali. Illustrated. Free press. 353 pages. ISBN: 0743289684

    My Forbidden Face. Growing up Under the Taliban: A Young Woman's Story. Latifa. Hyperion. Memoir. ISBN: 0786869011

    Burned Alive: A Survivor of an "Honor Killing" Speaks Out. Souad. ISBN: 0446694878

    The Road of Lost Innocence: As a girl she was sold into sexual slavery, but now she rescues others. The true story of a Cambodian heroine. Somaly Mam. ISBN: 978-0-385-52621-0 (0-385-52621-0)

    Tears of the Desert: A Memoir of Survival in Darfur. Halima Bashir. ISBN: 978-0-345-50625-2 (0-345-50625-1)

    Sold: One Woman's True Account of Modern Slavery. Zana Muhsen. ISBN: 9780751509519

    More Educational Opportunities about IPV: An Interactive Video

    Varjavand N, Novack D. Domestic Violence. Module 28 in Novack DH, Clark WD, Saizow RB, Daetwyler C (Eds.) doc.com - An interactive learning resource for healthcare communication. [Internet]: American Academy on Communication in Healthcare/Drexel University College of Medicine; 2005. Accessible at: www.AACHonline.org

    http://webcampus.drexelmed.edu/doccom/user/ and scroll down to Module 28 on login page. Login not required, it is a "free" module.

Physicians' Intolerance of Ambiguity Top

"A distressing feature in the life of which you are about to enter...is the uncertainty which pertains not alone to our science and art, but also to the very hopes and fears which make us men. In seeking out the absolute Truth we aim the unattainable, and must be content with finding broken portions." (William Osler)

"The Truth is a rabbit in a bramble patch. All you can do is to circle around and say, 'It's somewhere in there'. You can't put your hand on it. You can't touch that furry and quivering body" (Pete Seeger)

1. "Playing God" presents us with a situation full of uncertainties, where a black-and-white view of the world is suddenly replaced by a palette of perplexing grays. How do physicians cope with ambiguity? What separates individuals who can tolerate uncertainty versus those who cannot?

   Ghosh AK. Understanding medical uncertainty: a primer for physicians. Physicians are traditionally recruited (and trained) to value certainty over ambiguity. J Assoc Phys India 2004 (52): 739-742 http://www.japi.org/september2004/R-739.pdf

   Individuals who are intolerant of ambiguity tend to view the world in black or white absolutes, often preferring to ignore a reality of grays in order to arrive to an immediate and even premature closure. Individuals who tolerate ambiguity are instead more receptive to new ideas, can look at concepts from different perspectives, and often cope more effectively with difficult situations. All of these are desirable traits in physicians. Yet, physicians are traditionally recruited (and trained) to value certainty over ambiguity. Their continuous striving for perfection often results in frustration, discomfort, and even anxiety whenever confronted with the inevitable uncertainties of establishing a diagnosis, selecting a test, or ordering a successful therapy.

2. Is there a way to measure physicians' ability to deal with uncertainty?

   Gerrity MS, White KP. DeVellis F, Dittus RS. Physicians' reactions to uncertainty: Refining the constructs and scales. Motivation Emotion 1995;19:175-91. http://www.springerlink.com/content/764t5523515l4m16/?p=6a8e310583cb4010a2c0831ea47a8b35π=2

   Since tolerance of ambiguity plays an important role in medicine, especially among primary care providers, numerous scales have been created to measure this trait. The most commonly used is the Physicians' Reaction to Uncertainty Scale (PRU), which is a 23 item scale that deals in turn with two subscales, "stress from uncertainty" and "reluctance to disclose uncertainty" This paper describes the preparation, refinement and testing of the scale.

3. Does physicians' intolerance of ambiguity benefit or hinder their medical care?

   Merrill JM, Camacho Z, Laux LF, et al. How medical schools shape students' orientations to patients' psychological problems. Acad Med 1991; 66 (suppl. 9):4-6.

   Intolerance of ambiguity may result in negative attitudes towards patients with "fuzzy" or frustrating complaints, such as those afflicted by psychological or psychosomatic ailments, chronic pain, or alcohol abuse. This paper reviews the use of scales to assess students' attitudes towards patients; the personality of students who were "turned off" by patients with psychological problems; and the success of the scales in predicting career choices of senior students as way to avoid patients with "fuzzy" problems.

4. Does intolerance of ambiguity affect career choices?

   Gerrity MS, Earp JAL, DeVilles RF. Uncertainty and professional work: Perceptions of physicians in clinical practice. Am J Sociol 1992;97:1022-51. http://www.jstor.org/pss/2781505

   Intolerance of ambiguity may affect career choice, with more intolerant students preferring a residency in Anesthesia, Surgery, or Radiology as opposed to Internal Medicine and Psychiatry. Overall the intolerants tend to go "high-tech" while the tolerants choose instead "to cope".

5. Are there predictors of tolerance of ambiguity?

   De Forge BR, Sobal J. Intolerance of ambiguity in students entering medical school. Soc Sci Med 1989; 28(8):869-874. http://www.ncbi.nlm.nih.gov/pubmed/2705020

   Bachman KH, Freeborn DK. HMO physicians' use of referrals. Soc Sci Med 1999;48:547-57. http://www.ncbi.nlm.nih.gov/pubmed/10075179

   Surveys have shown greater tolerance of ambiguity among older physicians, family practitioners and pediatricians as compared to internists. Greater tolerance is also more common among female students, students who were older at enrollment, and students with an undergraduate major in the humanities as opposed to the natural and physical sciences. In turn, more tolerant physicians have lower referral rates than intolerant physicians, and also less burnout. Of interest, studies conducted during the early 1960s have shown a greater tolerance of ambiguity as compared to similar studies conducted in the late '80s.

6. Is intolerance of ambiguity a personality trait or a learned characteristic?

   Merrill JM, Camacho Z, Laux LF, et al. Machiavellianism in medical students. Am J Med Sci 1993; 305 (5):285-288. http://journals.lww.com/amjmedsci/Abstract/1993/05000/Machiavellianism_in_Medical_Students.3.aspx

   Merrill JM, Camacho Z, Laux LF, et al. Uncertainties and Ambiguities: measuring how medical students cope. Med Educ 1994; 28: 316-322. http://www.ncbi.nlm.nih.gov/pubmed/7862004

   In these studies conducted at Baylor by Merrill et al. intolerance of ambiguity correlated positively with authoritarianism, attraction for high-tech specialties, and higher scores on a "Machiavellianism" scale. The authors defined the latter as "students who were most willing to manipulate others to achieve their objectives", and thus "more likely to feel comfortable in specialties in which their contact with people will be at a minimum." In agreement with Guterman (The Machiavellians. Lincoln, University of Nebraska Press 1970, pp 79-80) they concluded that "Machiavellanism is a relatively stable characteristic, molded by influences during childhood and adolescence, and usually not subject to much change after a person enters adulthood". Hence, it is a trait that is well established by the time students enter medical school, and one very unlikely to change as a result of four years of professional training. In their study 15% of students were found to have a Machiavellian personality.

7. Do patients' needs for straight and clear answers influence physicians' ability to deal with uncertainty?

   Ogden J, Fuks K, Gardner M, et al. Doctors' expressions of uncertainty and patient confidence. Patient Educ Couns 2002;48:171-76. http://www.ncbi.nlm.nih.gov/pubmed/12401420

   Physicians' intolerance of ambiguity is often compounded by the patients' need for straight and clear answers. In this regard, verbal expressions of uncertainty by physicians ("I don't know", "Let's see what happens", "I haven't come across this before") can often be more disturbing to patients than behavioral expressions of uncertainty (like using a computer to find an answer, consulting another physician, or referring the patient to a hospital)

8. Does intolerance of ambiguity impact on the cost of care?

   Kassirer JP. Our stubborn quest for diagnostic certainty - A Cause for excessive testing. N Engl J Med 1989; 320 (22) 1489-1491.

   Allison JJ, Kiefe CL, Cook EF, et al. The association of physician attitudes about uncertainty and risk taking with resource use in a Medicare HMO. Med Decis Making 1998;18:320-9. http://www.ncbi.nlm.nih.gov/pubmed/9679997

   Intolerance of ambiguity often results in the ordering of more tests. And since tests often beget tests, this can translate into greater costs of medical care and higher likelihood of complications. Dr Kassirer has contributed a wonderful and thought-provoking editorial on our addiction to tests, while Allison et al. have instead estimated that 17% of excessive costs in medical care result from physicians' anxiety in dealing with uncertainty.

CONCLUSIONS

Intolerance of ambiguity is a "maladaptive" attitude towards good medical practice. Hence, admission policies to medical school should take it into consideration, and medical curricula should include ways to booster as much as feasible physicians' ability to deal with uncertainty

In this regard "Playing God" provides a wonderful way to bring an entire array of anxiety-provoking grays into a rigid black-and-white view of the world.

Physicians' Authoritarianism, Paternalism and Boundaries Top

"Intolerance of ambiguity is the mark of an authoritarian personality." (Theodor W. Adorno, 1903-1969)

1. What is the definition of an authoritarian personality?

   Adorno, TW, Frenkel-Brunswik, E, Levinson, DJ, & Sanford, RN (1950). The authoritarian personality. New York: Harper and Row

   An authoritarian personality was first described by Adorno as one characterized by dogmatic beliefs, an hierarchical orientation in interpersonal relationships, significantly greater distrust and suspicion, manipulation in relationships with others, and the pursuit of material rather than social values. In Adorno's original study this personality was quantified by using the "Adorno F scale", which was found to also correlate with the Antisemitic scale.

2. Can intolerance of ambiguity predict authoritarianism? What else can predict it?

   Merrill JM, Laux LF, Lorimor R, et al. Authoritarianism's role in medicine. Am J Med Sci. 1995;310:87-90.

   Merrill JM, Camacho Z, Laux LF, et al. Machiavellianism in medical students. Am J Med Sci 1993; 305 (5):285-288. http://journals.lww.com/amjmedsci/Abstract/1993/05000/Machiavellianism_in_Medical_Students.3.aspx

   In this study conducted at Baylor intolerance of ambiguity was a good predictor of authoritarianism. Students and physicians who were more intolerant of uncertainty also tended to rely more on high-tech medicine and moreover developed a negative orientation towards patients with psychological problems - traits that don't fit well with what we expect a physician to be like, but fit quite well with the authoritarian personality described in the non-medical literature.

   In addition to intolerance of uncertainty, "Machiavellianism" was another significant predictor of authoritarianism. In this study by Merrill et al., the measure of Machiavellianism emphasized the importance of flattery and of manipulating people as a way to "get ahead", which are also features of authoritarianism. Indeed in a separate study by Merrill (quoted below) both intolerance of ambiguity and authoritarianism predicted Machiavellanism (p's < .01 and < .001 respectively) confirming the correlation among the three traits.

3. "Playing God" presents us with a physician that could be easily described as caring but authoritarian. Is authoritarianism a common trait among doctors?

   Merrill JM, Laux LF, Lorimor R, et al. Authoritarianism's role in medicine. Am J Med Sci. 1995;310:87-90.

   Pestell R and Ball RB. Authoritarianism among medicine and law students. Aust N Z J Psychiatry. 1991 Jun;25(2):265-269. http://www.ncbi.nlm.nih.gov/pubmed/1877963

   Overall, 19% of more than the 2,000 students surveyed at Baylor by Merrill et al. were found to be authoritarian. Authoritarianism increased during medical school, with seniors scoring on average 27% higher than they had done in their freshman year. Although women had lower scores than men, they also experienced the greatest increase in authoritarianism as a result of going through medical school (42% vs. 21%). Still, senior women remained less authoritarian than senior men. A separate study by Pestell and Ball also found high rates of authoritarianism among medical students, with men scoring higher than women, and women experiencing a significant increase in authoritarianism as a result of years of study. They also found that when compared to their counterparts in law school, medical students showed a strong trend towards having significantly higher authoritarianism scores.

4. Does an authoritarian personality influence career choice?

   Merrill JM, Laux LF, Lorimor R, et al. Authoritarianism's role in medicine. Am J Med Sci. 1995;310:87-90.

   Merrill JM, Camacho Z, Laux LF, et al. Machiavellianism in medical students. Am J Med Sci 1993; 305 (5):285-288. http://journals.lww.com/amjmedsci/Abstract/1993/05000/Machiavellianism_in_Medical_Students.3.aspx

   Students who scored higher on authoritarianism tended to choose a career in surgery, anesthesiology, radiology, or pathology. The least authoritarian students chose instead residencies in psychiatry, internal medicine, pediatrics or family medicine. These differences were very similar to those predicted by "Machiavellanism", with students scoring higher in that scale also favoring fields high in technology but low in patient contact.

5. What is "paternalism"? Is the physician of "Playing God" paternalistic?

   Deverell AS. The patient-physician relationship--a return to paternalism? S Afr Med J. 2001;91:616-7.

   Loewy EW. In Defense of Paternalism Theoretical Medicine and Bioethics 2005;26: 445-468 http://www.springerlink.com/content/p473544722h7r166/

   Paternalism is defined as an action taken by one person in the best interest of others but without their consent. Till the last two decades of the 20th century it described the traditional relationship between physicians and patients. Which is not surprising considering that such relationship was, historically, between unequals: in knowledge, skills, status, and even health. Hence, it typically followed Parsons' consensus model, that is one characterized by a leading physician and a following patient. This is indeed paternalism. Still, it's important to note that by definition paternalism requires an exercise of authority for the good of another individual. Hence, the patient's interest has to be the prime motive of a true paternalistic action. In this regard, the physician of "Playing God" may be described as paternalistic. Still, paternalism often leads to condescension, and thus the latest shift away from the traditionally authoritarian interaction with patients and towards instead a more egalitarian relationship. With the rise of health consumerism this new patient-physician relationship has even assumed contractual and often conflictual tone -- almost as another provider-consumer contract. Whether this fosters or hinders the healing process is something that needs to be investigated.

6. Does the physician of Playing God exceed his boundaries?

   Linklater D, MacDougall S. Boundary issues. What do they mean for family physicians? Can Fam Physician. 1993; 39:2569-2573. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379977/

   Historically, both physicians and clergy were afforded by the public the highest measure of respect, based on attributes of wisdom and excellence, and also on behavior deemed by all to be above reproach. Today both groups do not enjoy the same blind trust. Hence, the increasingly important concept of boundary as a way to maintain this trust. In this regard a violation should be considered any disruption of the expected social, physical and psychological distance that is normally expected between a patient and a physician. Physicians have been given the privilege of a relationship with patients that is both intimate and detached. Yet, their imperative remains the same one defined by Hippocrates 2,500 years ago, that they use the trust to avoid doing harm and to always act in the best interest of their patients. Hence, they should continuously examine their behavior both from the "inside" and the "outside", to avoid doing what might seem appropriate to them but inappropriate to the patients and to society.

CONCLUSIONS

The physician of "Playing God" is exceeding his legal boundaries, but he's doing so in a way that he deems beneficial for the patient. Hence, he is exercising a form of authoritarianism that is not only illegal but also paternalistic.

Eugenics Top

"It is better for all the world if instead of waiting to execute degenerate offsprings for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind. The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes... Three generations of imbeciles are enough."

(Justice Oliver Wendell Holmes, writing for U.S. Supreme Court in the majority decision, Buck vs. Bell [1927] 274 US 201-7 With this decision the U.S. Supreme Court upheld the constitutionality of a Virginia law allowing for the compulsory sterilization of patients in state mental institutions. The argument being that, as in the case of smallpox vaccination, the public health outweighed individual rights).

"German Scientists are today making world history" (Alfred Mjoen, Norway's Leading racial hygienist, 1935) "...if we fall, then the whole world, including the United States, including all that we have known and cared for, will sink into the abyss of a new Dark Age made more sinister, and perhaps more protracted, by the lights of a perverted science." (Winston Churchill - June 18, 1940)

1. The physician of "Playing God" chooses to let a newborn "bad baby" die, since his hydrocephalus had rendered him "crippled-for-life". Is there any precedent for behavior of this sort?

   "Dr. Haiselden of Chicago Refuses to Operate to Save a Day-Old Infant. Physician, Who Acted Similarly in the Bollinger Case, Suspects Pre-Natal Influence." New York Times. July 25, 1917. http://query.nytimes.com/mem/archive-free/pdf?_r=1&res=9E06E3DF103BE03ABC4D51DFB166838C609EDE

   Black, Edwin (2004). War Against the Weak. Thunder's Mouth Press

   Harry Haiselden was an American surgeon and promoter of eugenics who in 1917 starred in a movie that recreated his experience of letting a malformed newborn baby die because he considered him a burden on society (The Black Stork). "There are times when saving a life is a greater crime than taking one", he proclaimed. Then that very same year Dr. Haiselden did it again. At the German-American Hospital of Chicago he let the day-old daughter of Mr. and Mrs. William Meter die on grounds that a life-saving operation would have just turned the baby into a "hopeless idiot", and that both society and her parents would have been best served by her death. In this case he provided the additional insight on the cause of the baby's disability, which he judged most likely the result of a "fright suffered by the mother during gestation". Dr. Haiselden was never prosecuted for these two cases, and in fact died two years later while vacationing in Cuba -- most likely as a result of a cerebral hemorrhage. He was 49 years old.

2. What is "Eugenics"?

3. Where did Eugenics find its earliest legislative approval?

   Lombardo, PA. Three Generations, No Imbeciles: Eugenics, the Supreme Court, and Buck v. Bell. The Johns Hopkins University Press, 2008.

   Kuhl, S. The Nazi Connection: Eugenics, American Racism, and German National Socialism Oxford University Press, USA, 2002.

   "Homo Sapiens 1900". Directed by Peter Cohen. 1998 Sweden.

   Part science and part twisted Social Darwinism, "Eugenics" was founded in 1883 by a cousin of Charles Darwin, Sir Francis Galton, who gave it its name and also defined it as the "science of improving the stock". In 1905 he added, "What nature does blindly, slowly and ruthlessly, man may do providently, quickly, and kindly. As it lies within his power, so it becomes his duty to work in that direction."

   It was actually a pseudoscience, but soon it gained international recognition, eventually providing academic respectability to the Nazi's theory of the Master Race. And yet, the Germans were relative late-comers in enacting Eugenics legislations. The pioneers had been the Americans.

   Beginning with Connecticut in 1896 the U.S. first passed laws that forbade anyone who was "epileptic, imbecile or feeble-minded" from marrying. Then in 1907 Indiana enacted legislation that allowed sterilization of the mentally handicapped. Eventually more than thirty states followed suit, and, ultimately, over 60,000 Americans deemed "unfit" were coercively sterilized, with California, Virginia, and North Carolina being the most frequently perpetrators. These eugenics American laws predated Germany's 1933 legislation on Preventing Hereditarily Ill Progeny, and in fact continued unabated even after Nuremberg declared such practices a crime against humanity (a third of all coercive sterilizations in the U.S. were indeed carried out after World War II). Even the 1924 American Immigration Restriction Act (which limited entry of Southern and Eastern Europeans, and essentially halted Asian immigration) was in many ways legislation with eugenics undercurrents, and as such it was praised at length by Adolf Hitler in his Mein Kampf.

   Hence, America provided an influential model, not only intellectually but also politically, for German theorists in search of international legitimacy. The Nazis, of course, took this idea of "improving the stock" to huge extremes, eventually establishing human breeding farms for "Aryans," implementing large-scale sterilization and euthanasia programs for the mentally and physically disabled, and, ultimately, instituting death camps for those races and groups they deemed "genetically inferior" or "unworthy of life."

   An example of how much eugenics theories became rooted in American society involved president Kennedy's older sister, Rosemary. A shy child whose I.Q. tests reportedly indicated a moderate mental retardation, she eventually grew into an increasingly assertive young woman, with violent mood swings and a penchant for promiscuity. Which was, after all, a trait that her father encouraged among his male children, but not one that he tolerated among his daughters. The result was a lobotomy carried out in 1941, when Rosemary was only 23. According to physicians it would have stopped both the mood swings and the nocturnal escapades, but unfortunately things did not go as planned. Rosemary became so disabled that she had to be institutionalized till her death, in 2005, at the age of 86. Of interest, she became an inspiration to her younger sister Eunice, who in 1968 founded the Special Olympics for Mentally Disabled Athletes.

4. When were Eugenics laws eventually repealed?

   Kevles DJ. Eugenics and human rights. BMJ. 1999 August 14; 319(7207): 435-438. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127045/

   Birn AE. Sterilized in the name of public health: race, immigration, and reproductive control in modern California. Am J Public Health. 2005; 95:1128-1138

   Eugenic laws were long-lived in the U.S., eventually being repealed only as a result of "Madrigal vs. Quilligan". In this 1979 class-action suit, working-class women of Mexican origin sued the State of California for violating their rights by coercing them into postpartum tubal ligations within minutes or hours after cesarean delivery. These procedures were federally financed as part of Lyndon Johnson's War on Poverty, and thus slightly different from the more than 20,000 non consensual sterilizations that had been carried out in California hospitals and state-run homes over a period of 70 years. Still, they relied on the very same legislation, first enacted in 1909 and subsequently expanded in 1913 and 1917. Over the years California's sterilization programs became intertwined with preoccupations about gender norms and female sexuality, thus extending to women who were not mentally ill, but felt to be "morally loose" or "unift for motherhood". And there were even hues of racism, with many sterilizations carried out on Mexican women (in California), and African Americans (in Virginia and North Carolina). Indeed, on September 21, 1975 The New York Times Magazine reported that doctors in major cities were routinely performing hysterectomies on mostly black welfare recipients as a form of sterilization, a practice that came to be known euphemistically among medical insiders as the "Mississippi appendectomy."

   Still, the U.S. was not the only country to take a long time in repealing eugenics laws. A few other nations maintained large-scale programs (including forced sterilization of mentally handicapped individuals), well into the 1970s. The Sterilization Act of Alberta and British Columbia, for example, was only repealed in 1972, and Sweden (that had sterilized more people than any other European state except Nazi Germany) repealed her "Sterilization Act of 1934" only in 1975. In fact, only in 1999 the Swedish government began paying compensation to the victims and their families, but just a small sum (21,000 USD per case), and only to those who had "not consented" and who subsequently applied for compensation.

Conclusions

The physician of "Playing God" can be judged as being paternalistic, authoritarian, and disturbingly prone to eugenics. Although these are aside issues from the major theme of the story, which is domestic violence, they are nonetheless important and timely too. Especially considering the latest explosion in genetics, which is now allowing a shift from "negative" eugenics (that is the elimination from the genetic pool of people deemed biologically inferior) to "positive" eugenics, which is the manipulation of human heredity to produce a superior race. A scary thought.

Other - Narrative Medicine and Rural Medicine Top

1. What is narrative medicine?

   Charon, R. Narrative Medicine: Form, Function, and Ethics. Ann Internal Medicine 2001;134:83-87. http://www.annals.org/content/134/1/83.full.pdf

   Charon, R. Narrative Medicine. A Model for Empathy, Reflection, Profession, and Trust. JAMA 2001;286:1897-1902. http://jama.ama-assn.org/cgi/content/full/286/15/1897

   In each of the articles, the author describes an area of practice by physicians called narrative medicine. Categories of narrative medicine include medical fiction, stories for non-physicians, medical autobiographies, stories about a physician's practice, or writing exercises assigned in medical training. The author reviews ethical considerations in narrative medicine such as whether the patient should be informed of the writing. Through narrative medicine, there can be "better understanding of the experiences of sick people, the journeys of individual physicians, the duties incurred by physicians toward individual patients and by the profession of medicine toward its wider culture."

2. What are some of the challenges of practicing medicine in a rural environment?

   Quality Through Collaboration: The Future of Rural Health Care. Institute of Medicine, 2005 http://books.nap.edu/openbook.php?record_id=11140

   The Institute of Medicine report, Quality Through Collaboration: The Future of Rural Health examines the quality of health in rural America. "Rural communities confront a different mix of health and health care needs than do urban areas. Rural populations tend to be older than urban populations and to experience higher rates of limitations in daily activities as a result of chronic conditions. Rural populations exhibit poorer health behaviors (i.e., higher rates of smoking and obesity and lower rates of exercise) relative to most urban populations, although there is variability in health behaviors among rural communities."

   "The quality of health care in rural areas may stem from the lack of access to 'core health care services,' including primary care in the community, emergency medical services, hospital care, long-term care, mental health and substance abuse services, oral health care, and public health services. Many rural communities have difficulty attracting and retaining clinicians because of concerns about isolation, limited health facilities, or a lack of employment and education opportunities for their families. Although steps have been taken in recent years to introduce a more favorable financial climate for rural health care providers, an underresourced health care delivery infrastructure persists."