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Teaching Medical Ethics (Informed Consent)

: paliport; November 1st, 2011

Teaching Medical Ethics (Informed Consent)

This spring I have the privilege of teaching in the required first year “Medical Ethics and Professionalism” course at Harvard Medical School. The course is taught in seminar sections. I will be working with 13 students who come to medical school with varied backgrounds and experience, but who, judging from our first class and their first weekly 500 word paper, have intelligence, enthusiasm, and idealism, in common.

Last week’s seminar focused on informed consent. They read the section on informed consent in “Principles of Biomedical Ethics” (Beauchamp & Childress) and “The Learning Curve,” a New Yorker article in which Atul Gawande discusses the tension between the patient’s wish for the best possible treatment and society’s need for training the next generation of clinicians, who have to learn by doing.

We organized the seminar around brief cases. The most gripping case involved a fourth year Harvard Medical student doing a subinternship at a local viagra cialis online pharmacy pharmacy. The chief resident asks the student to do a procedure s/he has never done. The procedure requires drawing blood from an artery in the wrist. The procedure, at best, is painful. The student has a good relationship with the 64 year old patient. Our question was – what does informed consent require telling the patient?

We all agreed that the student had to make sure that the patient understood the proposed procedure, the rationale for doing it, and the risks and benefits. That’s basic. But what about the fact that the student is…a student? All agreed that the patient should be told that the student is indeed a student, not a graduate physician. So far, so good.

Now came the tough question. Should the student tell the patient “this will be the first time I will be doing the procedure?” We pushed hard on this one, role playing the alternatives. I played the patient, and tried to be as difficult to handle as possible.

We took a vote on what to do. It split down the middle. All agreed that if the patient asked “have you done this before?” he should be told the truth. But the class was divided on whether this should be done proactively.

My take on this was to interpret the situation as a classical good vs. good conflict. Robust informed consent is a fundamental value. But so is competence, and we won’t have competent physicians in the future if we don’t train them now. Reasonable people, I suggested, could weigh these values differently, and come up with different answers.

But the students, happily, didn’t stop there. Without labeling it as such, they moved from clinical ethics to organizational ethics. I may have nudged them to think in terms of “preventive ethics,” but it seemed natural and sensible to them to ask – “how can we minimize the frequency of raw ethical problems like the one the student was facing?”

They came up with a number of good ideas. The hospital should have clear policies about training students to do procedures. How many should they be required to watch before trying? To the greatest extent possible, simulation should be used first. When the time comes to encourage the student to put hands on, there should be close supervision. And, there should be training, as was beginning to happen in the class, about how to talk with the patient. Students felt that in circumstances like these it would be much easier to conduct a robust process of informed consent:

“I am a medical student, working with Dr. X. I have not done this procedure before, but I have been trained in how to do it. Dr. X will be right here, to make sure everything goes right. Is all this OK with you?”

Organizations can’t be ethical without ethical clinicians. But it is much easier for clinicians to be ethical when organizations get their own ethical act together!

Hypnosis for Erectile Dysfunction

: paliport; October 29th, 2011

Evidence-based research demonstrates that hypnosis enhances sexuality in both women and men. Here's an informative page on hypnosis for erectile online pharmacy. Visit http://www.erectile-dysfunction-facts-you-need-to-know.com/hypnosis-for-erectile-dysfunction.html.
Hypnosis Healing Centre

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: paliport; May 24th, 2011

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A Taste of Red Medicine

: paliport; May 17th, 2011

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<p$1><p$1></p$1><div class="separator" style="clear: both; text-align: center;"><a href="#"><img border="0" src="http://farm6.static.flickr.com/5089/5310247385_b4161e8605.jpg" /></a></div><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"><br />
</span><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">I'm not a restaurant critic, but </span><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">I love going out to eat and I want honest recommendations. Consider this a conversation between friends.  </span></p$1></p$1><div><p$1><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"><br />
</span> <p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">Even though @<a href="#">koreanyenta</a> and I have been complaining about not being able to fit into any of our dresses, we've heard so much talk about Red <a href="http://softdj.net/">cheap cialis</a>, we</span><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"> wanted to see what the fuss was about.  The diet can wait another day.</span></p$1></p$1></p$1></p$1></p$1></div><p$1><div><p$1><p$1><p$1><p$1><p$1><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"><br />
</span></p$1></p$1></p$1></p$1></p$1></p$1></p$1></div><p$1><div><p$1><p$1><p$1><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"></span><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">This is the where a restaurant critic was photographed and ordered to leave.  Her photo was posted online so<span style="font-family: Georgia, "Times New Roman", serif;"> “restaurants can have a picture of her and make a decision as to whether or not they would like to serve her." Those are the words of restaurant manager Noah Ellis.  I'm a reporter, and just like all other reporters, I'm inquisitive, particularly when there's controversy.  My mouth was watering in every sense of the saying.</span></span></p$1></p$1></p$1></p$1></p$1></p$1></p$1></div><p$1><div><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"><br />
</span></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></div><p$1><div><p$1><p$1><p$1><p$1><p$1><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"><span style="font-family: Georgia, "Times New Roman", serif;"></span></span><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">The name Red Medicine may seem a bit strange, but it was inspired undoubtedly by Fugazi's punk album of the same name.  The restaurant had a warm and almost casual vibe when I walked through the door.  In fact, I felt more </span><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">like I was in Silver Lake rather than Beverly Hills.</span><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">It's decked out with high ceilings, industrial decor, handsome young men wearing checkered shirts and a hostess walking around with a big friendly smile.  Good thing I was wearing jeans and a blazer.  The dress I had tried unsuccessfully to sausage myself into not only would've been uncomfortable, I would've felt a bit overdressed.</span></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></div><p$1><div><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"><br />
</span></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></div><p$1><div><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"></span><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">We were seated promptly (by Noah possibly?) and I considered ordering the #33 cocktail ($10).  I have a weakness for Tiki-inspired rum drinks and this </span><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">was described as a Singapore Sling.  </span><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">We asked the waiter for recommendations and went for two #18s, after he asked what I normally drink.</span><br />
<p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"><br />
</span></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></div><p$1><div><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">A few minutes later, we were sipping on two drinks that tasted deliciously yet suspiciously like rum punch. We were halfway through the cocktails (we were thirsty!) when our waiter arrived with two more drinks.  Uh oh.  Apparently we were drinking another table's Singapore Slings.  He left us our #18s (kind of a twist on a lemon drop), but I'm all for happy accidents.  I ordered another #33 later!</span><br />
<p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"><br />
</span></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></div><p$1><div><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">For appetizers we ordered the crispy spring rolls ($16), brussels sprouts ($9), and chicken dumplings ($9).  The crispy spring roll ($16) may seem a bit pricey for what tasted like fancy egg rolls, but I loved it!  As for the brussels sprouts, flash frying them seems to be the thing these days.  I had some at Cleo the other night.  Try them if you've never had them before, but be warned they're a little salty and oily and they're supposed to be that way.</span><br />
<p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"> </span><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"><br />
</span></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></div><p$1><div><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">The chicken dumplings resembled meatballs and were fun to assemble into lettuce wraps, but I could've gone for less meat and more greens to better balance out the flavors.  If my husband was with me, he probably would've disagreed.  He loves big portions of meat.  </span><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">On this note, I can't help but share the first time I had chicken lettuce wraps.  It was at the French-Vietnamese restaurant Le Colonial.  It used to be on Robertson and may it rest in peace. I went there when I was in college and when they brought them to the table I was confused but pressed through, putting a little dollop of the tangy, peppery meat on my plate and then plucking a a leaf of lettuce when I was finished with my portion, thinking it was there to cleanse the palate.  The memory makes me laugh every time I order them.</span><br />
<p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"> </span><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"><br />
</span></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></div><p$1><div><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">For main courses we ordered the pintade fermier ($12), which was a delicious piece of chicken that arrived with white rice in separate pot.  The blue lantern bay scallops ($18) were perfect with a hint of lemon and butter, but the tiny new potatoes tasted strong, like lemon butterballs.  The two entrÃ©es did not fill us up (I'll order more next time) so we were eager to order dessert.  </span><br />
<p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"><br />
</span></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></div><p$1><div><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">We ordered the lemongrass pots de creme ($9) because our server raved about it. It had a big dollop of blended sweet potato and a variety of other things on top, but the custard underneath is the prize.  The bitter chocolate ($9) involved fluffy chocolate kisses dancing across a pile of cookie crumbles.  The desserts were a bit fussy for my taste, but I have to mention here that Jordan Kahn was a pastry chef at Per Se in New York and did some incredible desserts at XIV before opening this restaurant.</span><br />
<p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"><br />
</span></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></div><p$1><div><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;">With tip, we spent $100 per person for dinner and drinks.  (We were not charged for the accidental delivery.)  I am over the moon for their cocktails and it would be fun to return and sit in the bar, where I can eat more spring rolls and order off the <a href="#">lounge </a>menu.  All of their bread comes from <a href="#">Bouchon</a>, where dinner is always worth spending $100 a person.</span><br />
<p$1><p$1><p$1><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"><span class="Apple-style-span" style="font-family: Georgia, "Times New Roman", serif;"><em><br />
<a href="#">Red Medicine</a></em></span><br />
<em>8400 Wilshire Blvd.</em><br />
<em>Beverly Hills, CA 90211</em></span><em></em></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></div><p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1></p$1>

Psoriasis and sexual health

: paliport; May 3rd, 2011