Exam 2

Question 1

What are stressors for third and fourth year students?

Answer 1

1) Dealing with patients, dealing with death, disease and suffering
2) Residency choice
3) Effects on personal life
4) Financial issues

Question 2

What do physicians worry about?

Answer 2

1) Malpractice litigation
2) Change in health care system, technology and medical knowledge, hospital mergers
3) Work load and balancing work and family
4) Paying off debt
5) Residency, starting/growing a practice
6) Dealing with people’s lives

Question 3

How many stress responses are there?

Answer 3

1) There is one stress response

2) Cortisol is the stress hormone, which induces a sympathetic response

Question 4

Is there an ideal amount of stress?

Answer 4

Yes. You want some stress in your life in order to be able to accomplish the things you would like to get done

Question 5

What percentage of medical students go through burnout?

Answer 5

50%

Question 6

What consequences result from too much stress/demands in medical school?

Answer 6

1) Mental health consequences:
a) Depression
b) Substance Use/Abuse
2) Physical health consequences

Question 7

What can burnout, a work-related syndrome, cause?

Answer 7

1) Emotional exhaustion: tired, nothing left to give, no pleasure
2) Depersonalization: cynicism, going through the motions, like a robot, automatic pilot
3) Decreased sense of accomplishment: never good enough, not worthwhile

Question 8

Why is speaking about physician stress and burnout important?

Answer 8

It causes:

1) Increased medical errors
2) Lowered productivity, increased healthcare costs
3) Conflicts and difficulty making decisions
4) High physician turnover, early retirement
5) Self-care practices = more preventive counseling
6) Reduced empathy and perception of professional climate
7) Resident-perceived suboptimal patient care
8) Reduced knowledge base in IM resident (IM-ITE: Residents may use the results to identify areas of deficiency that require further learning, to compare their performance with that of their peers in training programs throughout the world, and to help career choices.); knowledge not recovered
9) Riskier prescribing
10) Dissatisfied and less compliant patients
11) Negative effect on doctor-patient relationship
12) Depression, suicidal ideations (SI), and suicide (6.4% of physicians and 10% of medical students undergo SI)

Question 9

What is the triad of compulsivity in physicians?

Answer 9

1) Exaggerated sense of responsibility: responsible for others, taking on too much
2) Guilt: Self-sacrifice put aside, don’t know needs/feeling, guilty if say no
3) Doubt: Double-check, go the extra mile, critical

Question 10

How does our medical culture mold us?

Answer 10

1) Medicine rewards: Intellect, controlling feelings to remain objective, problem-solving, people who can “take it”, don’t complain
2) Every culture has its price as you try to fit in

Question 11

How can the medical culture be transmitted via a “hidden curriculum”?

Answer 11

1) Burnout can lead teachers to role-model cynical attitudes and poor self-care practices
2) Propagates burnout in the culture

Question 12

In what way does the medical culture negatively impact our daily lives?

Answer 12

1) Long hours, hospital meeting/no day off, losing an associate, medical culture
2) Exercising less: Not counteracting the stress response
3) Lack of awareness of the impact of personality traits: “the rock” “over-responsible to partners”
4) Perceived lack of control: schedule

Question 13

What are the factors of our medical riptide that keep us stressed? How do we escape this riptide?

Answer 13

1) Our medical riptide:
a) Stresses of our profession
b) Personality traits valued in medicine
c) Demands of the medical culture
d) Work harder to stay afloat
2) Self-care is the skill we need to escape the riptide and to achieve excellence

Question 14

How can one achieve balance and self-care in medical school?

Answer 14

1) Counteract the body’s stress response
2) Control/Manage schedule, School/Life balance
3) Self-awareness: meaning, personality traits, feelings

Question 15

What is the relaxation response that can be used to counteract physiologic stress response?

Answer 15

1) Exercise
2) Relaxation techniques
3) Meditation, prayer
4) Massage
5) Yoga, Tai Chi and others
6) Letting thoughts “come and go”
7) Repetitive activity

Question 16

How can you manage your schedule and have a school/life balance?

Answer 16

1) Prioritizing what is important in your life and organizing your schedule accordingly, particularly your work/life balance
2) Assertiveness and setting limits (“saying no to lower priority items”)
3) Spend at least 20% time on meaningful work
4) Even a small amount of control can make a big difference
5) Remember that priorities change

Question 17

How can you have self-awareness of stress in medical school?

Answer 17

1) What personality traits do I have that add stress?
a) Critical?
b) Doubt/imposter?
c) Guilty?
d) Trouble saying no?
2) Meaningful activities: what do I like?
a) Service activities
b) Advocacy
c) Special hobby, music, arts, family time

Question 18

How can you focus on one thing at a time in medical school to reduce stress?

Answer 18

1) Don’t postpone: the time is now
2) Realize that self-care/burnout prevention is a process
3) Realize that your needs will change with time

Question 19

How can you use resources early to prevent excessive stress in medical school?

Answer 19

1) Talk to trusted friends/peers
2) Get ideas from others but find your own way
3) Student Health and Wellness Center, CASE (study habits, learning), Student Affairs, Student Wellness Program
4) Find a mentor

Question 20

What does society want from a physician?

Answer 20

1) Healer services
2) Competency
3) Altruistic service
4) Integrity and Morality
5) Transparency
6) Objective advice
7) Promotion of the public good
8) Accountability

Question 21

What do physicians want from their profession?

Answer 21

1) Trust and autonomy
2) Appropriate health care system: value and funding
3) Participation in public policy
4) Monopoly
5) Shared (patient and society) responsibility for health
6) Status and reward (financial, non-financial)
7) Self-regulation

Question 22

What is the purpose of the state licensing board for physicians?

Answer 22

1) “to protect the public from the unprofessional, improper and incompetent practice of medicine”
2) Questions about competence, legal trouble, pedophilia, current substance use, trouble with hospital or other accreditation bodies etc..

Question 23

If we are supposed to be professionals, then why is “outside” regulation necessary?

Answer 23

1) Depression, substance abuse (poor insight, denial)
2) Inappropriate behavior (disruptive physician)
3) Burnout or personality disorders or personal problems (vulnerability)
4) Medical errors
5) Medical conditions, cognitive impairment
6) Financial impropriety: Kick backs, insurance fraud
7) Cheating or academic dishonesty
8) “Outside” regulating bodies provide structure (rules, formal mechanism) and step in when self-regulation fails

Question 24

If it interferes with our social contract, we have a professional obligation to deal with it. How can we deal with these problems?

Answer 24

1) Prevention/self-care
2) Get help for yourself
3) Stop if ability to practice is affected/licensing application
4) Professional assistance program of NJ
5) Help impaired colleague to get help
6) Call the appropriate regulating agency

Question 25

What are boundaries in the medical profession and can you step over a boundary?

Answer 25

1) “Boundaries” are rules (regulations, guidelines or conventions) defining the personal “space” around parties to a relationship that should be respected
2) Not all boundary crossings are boundary violations. Some may be approvable and even obligatory in certain circumstances
3) We are responsible to figure out which is which

Question 26

What is the AMA code of ethics in regards to sexual or romantic interactions between physicians and patients?

Answer 26

“Sexual or romantic interactions between physicians and patients detract from the goals of the physician-patient relationship, may exploit the vulnerability of the patient, may obscure the physician’s objective judgment concerning the patient’s health care, and ultimately may be detrimental to the patient’s well-being.”

Question 27

When does crossing a boundary become a violation?

Answer 27

1) Exploitation/Coercion
2) Harm to the patient or the professional-patient relationship
3) Little or no potential to help/benefit the patient
4) Violation of professional ideals
5) Self-serving motives

Question 28

What are questions to ask ourselves when crossing a boundary?

Answer 28

1) Is there a risk to a patient or physician?
2) Is there any possible coercion or harm?
3) Can it help the patient or the doctor patient relationship?
4) Does it meet my professional ideals of being a physician?
5) Why am i considering this? (intentions/whose interest is this?)
a) Our vulnerabilities affect our responses/feelings
b) Vulnerabilities increase when stressed or burned-out
c) But because relationship is unequal, we can’t spontaneously act on our feelings

Question 29

What are sources of ethical guidance?

Answer 29

1) AMA
2) Speciality associations
3) Licensing Boards (regulations, Board guidelines and rulings in particular cases)
4) Professional literature

Question 30

What are common violations by physicians?

Answer 30

1) Misrepresentation: 30%
2) Boundaries: 26%
3) Financial irregularities: 18%
4) Others: 32%
4) Clinical errors are cited in association with the 3 major categories 11% of the time

Question 31

What is misrepresentation in medical practice?

Answer 31

1) Application for residency, board exams, hospitals, jobs
2) Licensure renewal applications
3) False advertising
4) Even in “non-professional” domains
5) Thinking that a record is “expunged”

Question 32

What are boundaries in medical practice?

Answer 32

1) Dating, sexual relationship with patients/employees
2) Gestures/words open to misrepresentation
3) Financial dual relationships (business with patients)
4) Inappropriate prescriptions: family/pain disorders, “the white knight”
5) Retribution

Question 33

What are financial irregularities in medical practice?

Answer 33

1) Poor billing practices: wrong date=billing for service not rendered
2) Incomplete documentation for billed services
3) Exaggerating a condition to bill more
4) Financial stresses
5) Investigation procedures

Question 34

What are other immoral factors that occurs in medical practice?

Answer 34

1) Blogging about a Board examination
2) Untimely responses to requests for care
3) Untimely responses to Board requirements
4) Inappropriate verification of credentials, supervision of employees
5) Abandonment

Question 35

What are two risk factors that can expose oneself to these immoral factors?

Answer 35

1) Ambulatory/solo practice

2) Foreign medical school

Question 36

The following are 17 tips on how to balance life and work from doctors. Name a few.

Answer 36

1) Don’t try to be too efficient. Take time to really listen to a couple of patient storeis a day. We need to be fed by our patients.
2) When recruiting for your practice, interview for emotional competence as well as professional competence. Ask questions such as, “What makes you satisfied? What do you find upsetting? How do you deal with the death of a much-loved patient?” Candidates who can answer questions like these have done some significant personal reflection and are likely to continue to grow and be assets to your practice and patients.
3) Take a few minutes at the end of the day to think about the things that really bugged you. Make a list of them, if you need to, and then leave it at the office.
4) Seek insight from your elderly patients. Ask them how they’ve dealt with their struggles and disappointments. Their wisdom may be surprising.
5) Sometimes say, “This just isn’t going to get done today,” and work on accepting it.
6) Take regularly scheduled days off. Your patients and your staff will eventually expect you to be off and unavailable during that time and, since it’s been working into your schedule, you won’t have to feel guilty for being out of the office
7) Share with your patients your struggle to find balance in your life. It’s likely they’ll respond with uplifting words and concerned advice.
8) Ask your family what they need most from you. It may be something different than you think. (Ask your office staff too.)
9) When you’re out socially with colleagues, make a real attempt to talk about things other than medicine. It will remind you that there’s a world out there.
10) Learn when to multitask and when to focus wholeheartedly on things that deserve your full attention.
11) Eat at least one meal a day with your family or with a friend.
12) Develop a support system. Everyone needs family and friends to rely on, but baby-sitters, house cleaners and someone to take care of the lawn can also do a lot toward relieving stress!
13) Don’t get into the habit of going into the office on the weekend “just to get caught up.” It’s rare to get caught up and rare still to stay that way. Tell your friends and family that you’re trying to break this habit so they can remind you of it when you get the urge to go to the office.
14) Make friends with a few people who will agree to never ask you to be their doctor!
15) Remember that life balance is a shifting concept and you’ll learn from your attempts to maintain it. Some days will be better than others.
16) Ask yourself a simple question, “Is doing _____ going to make me wish I was home wiht my family?” If so, graciously say, “No thanks, someone else will have to do it.”
17) Realize that each one of us has our own mountain to climb. Try to remember to pause to enjoy the view along the way and to help and let yourself be helped by others you meet on the path.

Question 37

What are five general requirements for a physician’s personal growth?

Answer 37

1) Self-awareness
2) Sharing of feelings and responsibilities
3) Self-care
4) Developing a personal philosophy
5) Nontraditional coping skills of reframing and limit setting

Question 38

What are specific individual adaptations for increasing self-awareness?

Answer 38

1) Keeping a personal journal
2) Provocative book reading
3) Religious practice
4) Continuing education outside medicine
5) Personal psychotherapy
6) Metaphysical exploration (meditation, yoga)

Question 39

What are specific adaptations to promoting sharing of feelings and responsibilities?

Answer 39

1) Protect informal time to spend with family, friends, and colleagues
2) Informal sharing: Storytelling, Discussing difficult issues, Laughing over human foibles, & Complaining
3) Group interests outside of medicine (clubs, feams, courses)
4) Experiential courses/self-awareness groups: Balint groups, Human dimensions of medical education courses, Society of General Internal Medicine Task Force on the Doctor and Patient Course
5) Consultations and referrals
6) Using multidisciplinary health care teams
7) Getting help with domestic or professional tasks

Question 40

What are specific adaptations for promoting self-care?

Answer 40

1) Attention to scheduling: Limiting on-call and weekend work, scheduling and taking frequent vacations, limiting evening work, taking minibreaks during the day, taking moments to “get ready” to see the next patient, & protecting time to be with family or friends
2) Expressing feelings: Grieving one’s losses, experiencing joy in victories, & laughing at one’s foibles
3) Regular sleep, meals, and time alone
4) Interests and friendships outside of medicine (sports, music, cooking, gardening, theater, community events, religious activities)
5) Regular medical and dental care
6) Regular physical stimulation (exercise, sex, massage)
7) Regular attention to self-awareness and sharing

Question 41

What are specific adaptations in developing a personal philosophy?

Answer 41

1) Allocating time to clarify values
2) Developing short-term and long-term goals (realistic)
3) Prioritizing goals reflective of both professional and personal values
4) Developing a time-management system
5) Excluding low-priority commitments
6) Engaging in faculty development programs for values clarification and time-management training

Question 42

What are actions to take when a colleague is impaired?

Answer 42

1) Protect patients from immediate harm
2) Determine whether further action is needed
3) Talk with the colleague directly, recommend help
4) Report the problem to responsible officials

Question 43

What is informed consent?

Answer 43

Willing acceptance to medical intervention by a patient with adequate disclosure by a physician of the nature of intervention, its risk and benefits, and also its alternatives with their risks and benefits

Question 44

What is the consent rule?

Answer 44

Physicians may not treat a patient without the informed permission of the patient or an authorized surrogate

Question 45

What are three elements of legally valid consent?

Answer 45

1) Disclosure (What the doctor says)
2) Decision process (Dialogue)
3) Assessment of capacity and voluntariness

Question 46

What is disclosure for informed consent?

Answer 46

1) Description of patient’s condition (Patient’s current medical status, including what will happen if no treatment is provided)
2) Description of proposed intervention (Interventions that might improve prognosis)
3) Potential risks and benefits
4) Probabilities of each alternative, including no treatment, and risks and benefits
5) Offer to answer questions
6) Assurance patient my withdraw consent at any time
7) Recommendation made on the basis of physician’s best clinical judgment
8) How much disclosure is enough?
a) Standard medical practice: What would a reasonable practitioner comparably situated disclose
b) Resonable person standard: What would a reasonable person need to know before making this decision?

Question 47

What is the decision process for informed consent?

Answer 47

1) Clarify patient’s goals and values
2) Elicit concerns/fears
3) Check patient’s understanding
4) Elicit questions

Question 48

What does an assessment of capacity and voluntariness include for informed consent?

Answer 48

1) Not mere acquiescence, a document, only for invasive procedures, or an ancient duty
2) Exceptions include emergencies, patient waiver, regulatory waiver, & therapeutic privilege
3) No such thing as “administrative consent”
4) Common distortions:
a) Neutral enumeration of burdens and benefits, rather than helping patients to assess and discern
b) Poor differentiation between what is properly a patient’s choice and what properly belongs to medical judgment
c) “All or nothing”/”Now or never” consent, rather than appreciation of the conditional and dynamic nature of much decision making
d) Failure to appreciate inequality of power and its implications for an obligation to further empower patients/surrogate
e) System factors: lack of training in communication skills, wide variation in “informal curriculum” and physician behavior, insufficient oversight of consent quality

Question 49

How can a physician allow for a patient to fully comprehend his or her informed consent?

Answer 49

1) Physician should give clear and simple explanations
2) Questions should be asked to assess understanding of the patient
3) Written instructions/printed materials should be provided
4) Video/computer programs for patients with complicated decisions. Example: treatment for breast or prostate cancer
5) Educational programs for patients with chronic diseases should be arranged
6) Assistance from other clinicians to enhance the information provided

Question 50

What are the benefits of informed consent?

Answer 50

1) Mutual participation, good communication, mutual respect, & shared decision making
2) Established a reciprocal relationship between the physician and patient
3) A therapeutic alliance is forged; A physician’s work is facilitated because the patient has:
a) Realistic expectations about results of the treatment
b) Prepared for complication
c) More likely to be a willing collaborator in the treatment

Question 51

What documentation is required for informed consent?

Answer 51

1) Signed consent form, entered in patient’s record
2) Document names, procedure, & risks and benefits that have been explained
3) Even a signature is not legal proof, however. The actual process and details of consent should be documented by the physician in the medical record. Now documentation is complete

Question 52

What are difficulties in obtaining informed consent?

Answer 52

1) Many physicians fail to conduct ethically/legally satisfactory consent negotiations. Process is difficult but not impossible to achieve
2) Examples of the physician’s part that make the situation more difficult include:
a) Use of technical language
b) Uncertainty intrinsic to all medical information
c) Physician doesn’t want to alarm the patient & create anxiety
d) Hurried and pressed by other duties
e) Physicians may not appreciate the rationale for the patient’s participation
f) Physician believes the process takes too much time
g) Physician does not believe the patient will be able to truly understand the information since they are not medically trained
3) Examples of patient’s part that make the situation more difficult include:
a) Limited understanding
b) Inattentive or distracted
c) Overcome by fear and anxiety
d) Selective hearing due to denial, fear, or preoccupation with illness

Question 53

What are ways to establish truthful communication in informed consent?

Answer 53

1) Statements should be in accord with facts
2) Uncertainty should be acknowledged
3) Deception should be avoided
4) Argument between beneficient deception VS truth: with informed consent, truthfulness is the ethical course of action

Question 54

How many Americans die each year as a result of medical errors?

Answer 54

1) Between 44,000 and 98,000 Americans die each year as a result of medical errors
2) This is more than vehicular accidents, breast cancer, or AIDS

Question 55

What is medical error defined as according to the Institute of Medicine Report?

Answer 55

1) Failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim
2) Errors can be due to incompetence or errors of judgment by competent physicians

Question 56

What are actions that can be used to reduce medical error?

Answer 56

1) Increased reporting and analysis of error
2) Focus on hospital safety through computerized order and medical records
3) Establishing patient safety indicators
4) Alleviate effects of fatigue for house staff and nurses

Question 57

What is medical error defined as according to the book?

Answer 57

1) Unintentional lapse in a process normally done efficiently and effectively because:
a) Inadequate information
b) Mistaken judgment
c) Defective maneuvers that may or may not be negligent or may or may not cause harm

Question 58

What is negligence in reference to medical error?

Answer 58

1) Negligence is performance that peers in a specialty would judge as departure from accepted standard of practice
2) It is important to establish if error was done due to negligence

Question 59

Can system errors cause medical errors?

Answer 59

1) Yes. For example, “u” for units can be misread as “0”

2) Remember that medical errors bring up issues of truth telling

Question 60

Who should be the one to carry out a discussion in regards to an apology for a medical error? Who should not be discussing the error with the patient or family? Who should you seek advice from?

Answer 60

1) Whoever committed the error (attending physician, advance practice nurse, or resident), the attending physician has the final responsibility for the patient’s care and should lead the discussion
2) Invite trainees to attend, since this is an important learning opportunity
3) Limit the discussion to just those healthcare professionals directly involved
4) Discourage other consultants/ancillary staff from discussing the error with the patient/family because multiple accounts of the events will likely confuse rather than clarify
5) Notify and seek the advice of your institution’s risk manager. In addition to informing you of policies and procedures specific to your institution, they will then be aware of the case should legal inquiries be made
6) Note: While it is wise to seek risk management input, remember that discussing errors with patients/families is a clinical task, part of clinicians’ obligation to openly share medical information, not a legal task

Question 61

How should the discussion of an apology be carried out with a patient and his or her family?

Answer 61

1) Have the discussion in a timely manner, as soon as possible after the error is identified, but make sure the appropriate people are there (including an incapacitated patient’s legal decision maker)
2) Set aside ample time and have the meeting in a distraction-free environment
3) Review the pertinent facts of the case so that you are prepared to answer any detailed questions that the patient/family might have
4) Be clear, concise, and honest. Avoid medical jargon or lengthy explanations
5) Give the patient and family time for questions, emotional reactions, or silence
6) If you believe the adverse outcome was a result of error (either individual or system-wide), specifically apologize for the error and its outcome
7) If the outcome was unanticipated, but not clearly avoidable express regret and sorrow. Avoid blame: “I am sorry this has happened” is not an admission of error or liability

Question 62

What steps should be taken after the discussion of an apology?

Answer 62

1) Commit yourself and your institution to investigating and remedying any individual or systematic deficiencies
2) Commit to providing ongoing, appropriate care, including comfort-oriented care for a dying patient
3) Involve the appropriate services as indicated such as chaplaincy, social work, and consultants including palliative care
4) Document your discussion; refer legal inquiries to your institution’s risk manager

Question 63

Building on the core definition of an apology, offense and remorse, what is a useful structure of apology that can be organized into 4 parts?

Answer 63

1) The first part of any apology is the acknowledgment of the offense, which includes the identity of the offender(s), appropriate details of the offense, and validation that the behavior was unacceptable
2) The second part of an apology is the explanation for committing the offense. Explanations may mitigate the offense (“I was late because of a medical emergency”) or aggravate the offense (“I left the operating room to go to the bank”). Sometimes saying, “There is just no excuse for what happened” or “We are still trying to find out what happened” can be the most honest and dignified explanation
3) The third part of an apology is the expression of remorse, shame, forbearance, and humility. Remorse is an deep sense of regret. Shame is the emotion associated with failing to live up to one’s standards. Forbearance is a commitment not to repeat the offense. Humility is the state of being humble, not arrogant. Lack of remorse, shamelessness, unwillingness to address the future, and arrogance will undo most apologies
4) The fourth part of an apology is reparation, which can range from an early scheduling of the next appointment to canceling the bill to a financial settlement
5) All 4 parts are not necessarily present in every effective apology, but when an apology is ineffective, one can invariably locate the defect in 1 or more of these 4 parts

Question 64

What are 7 guidelines for dealing with pharmaceutical companies?

Answer 64

1) Any gifts accepted by physicians individually should primarily entail a benefit to patients and should not be of substantial value. Accordingly, textbooks, modest meals and other gifts are appropriate if they serve a genuine educational function. Cash payments should not be accepted. The use of drug samples for personal or family use is permissible as long as these practices do not interfere with patient access to drug samples. It would not be acceptable for non-retired physicians to request free pharmaceuticals for personal use or use by family members
2) Individual gifts of minimal value are permissible as long as the gifts are related to the physician’s work (e.g. pens and notepads)
3) The Council on Ethical and Judicial Affairs defines a legitimate “conference” or “meeting” as any activity, held at an appropriate location, where (a) the gathering is primarily dedicated, in both time and effort, to promoting objective scientific and educational activities and discourse (one or more educational presentation(s) should be the highlight of the gathering), and (b) the main incentive for bringing attendees together is to further their knowledge on the topic(s) being presented. An appropriate disclosure of financial support or conflict of interest should be made
4) Subsidies to underwrite the costs of continuing medical education conferences or professional meetings can contribute to the improvement of patient care and therefore are permissible. Since the giving of a subsidy directly to a physician by a company’s representative may create a relationship that could influence the use of the company’s products, any subsidy should be accepted by the conference’s sponsor who in turn can use the money to reduce the conference’s registration fee. Payments to defray the costs of a conference should not be accepted directly from the company by the physicians attending the conference
5) Subsidies from industry should not be acccepted directly or indirectly to pay for the costs of travel, lodging, or other personal expenses of physicians attending conferences or meetings, nor should subsidies be accepted to compensate for the physicians’ time. Subsidies for hospitality should not be accepted outside of modest meals or social events held as part of a conference or meeting. It is appropriate for faculty at conferences or meetings to accept reimbursment for reasonable travel, lodging, and meal expenses. Token consulting or advisory arrangements cannot be used to justify the compensation of physicians for their time or their travel, lodging, and other out-of-pocket expenses
6) Scholarship or otherf special funds to permit medical students, residents, and fellow to attend carefully selected educational conferences may be permissible as long as the selection of students, residents, or fellows who will receive the funds is made by the academic or training instritution. Careful selected educational conferences are generally defined as the major educational, scientific or policy-making meetings of national, regional, or specialty medical associations
7) No gifts should be accepted if there are strings attached. For example, physicians should not accept gifts if they are given in relation to the physician’s prescribing practices. In addition, when companies underwrite medical conferences or lectures other than their own, responsibility for and control over the selection of content, faculty, educational methods, and materials should belong to the organizers of the conferences or lectures

Question 65

What is domestic violence?

Answer 65

1) Pattern of behavior in any relationship that is used to gain or maintain power and control over an intimate partner
2) Physical, sexual, emotional, economic, or psychological actions or threats of actions
3) Includes behaviors that frighten, intimidate, terrorize, manipulate, hurt, humiliate, blame, injure, or wound someone or influence another person

Question 66

What are statistics about domestic violence that are important to know?

Answer 66

1) Violence against women predominately intimate partner violence
2) Annual prevalence ranges from 8-22%
3) Abuse by partner is number one cause of injury for women in 15-44 age group
4) 1500-2000 women per year murdered by current or ex-partner
5) NJ Crime report:
a) 75,000 offenses reported to police annually
b) Most frequent day is Sunday
c) Most occur between 8PM and 12AM
d) Alcohol and/or drugs involved in 29% of DV offenses

Question 67

What is RADAR when speaking about domestic violence?

Answer 67

1) Routinely screen patients: Recognize clues of DV, improvement of patient-doctor relationship; learn more about patient’s relationships over time; develop personal approach to discussing domestic violence; studies show most woman, including victims, want physicians to ask about abuse; many studies show that most physicians do not ask about abuse
a) Screening tips: Interview patient alone in confidential setting; ask simple direction questions in nonjudgmental way; refrain from blaming patient; maintain advocacy; leave door open for future disclosure; HITS
2) Ask direct questions: “Do you feel safe at home?”, “Do you feel safe in your intimate relationship?”, Ask with state of awareness, & develop your own style
3) Document your findings:
a) Medical documentation can be used as independent third party evidence for obtaining range of protective relief
b) Can also be used in less formal legal contexts to support assertions of abuse for special status or exemptions in obtaining public housing, welfare, health and life insurance, victim compensation, or immigration relief related to domestic violence
c) Record details of the abuse and its relationship to the presenting problem
d) Document any concurrent medical problems related to the abuse
e) Document a summary of past and current abuse
f) Patient’s statement about what happened, not what lead up to the abuse
g) Include the date, time, and location of incidents where possible
h) Patients appearance and demeanor (e.g. “teaful, shirt ripped” not “distraught”)
i) Any objects or weapons used in an assault (e.g. knife, iron, closed or open fist)
j) Patients accounts of any threats made or other psychological abuse
k) Names or descriptions of any witnesses to the abuse
l) Take photographs of injuries
m) Write legibly
n) Set off the patient’s own words in quotation marks or use such phrases as “patient states” or “patient reports”
o) Avoid such phrases as “patient claims” or “patient alleges”
p) Avoid summarizing a patient’s report of abuse in conclusive terms; For example: “patient is a battered woman,” “assault and battery,” or “rape”
q) Use a body map to document injuries (some Electronic Health Records contain body maps)
r) Describe the patient’s demeanor, indicating, for example, whether she is crying or shaking or seems angry, agitated, upset, calm, or happy
s) Record the time of day the patient is examined and, if possible, indicate how much
4) Assess patient safety:
a) Is the patient afraid to go home?
b) “Has there been an increase in frequency or severity of violence?”
c) “Have there been threats of homicide or suicide?”
d) “Have there been threats to children?”
e) “Is there a weapon present?”
5) Review options and referrals:
a) Know your community resources
b) You can always call local, state or national hotlines with questions
c) Provide patients with referrals to local or state 24 hour hotline, domestic violence resources, centers, or shelters
d) Make follow-up appointments
e) Written material can pose a danger to patient/victim

Question 68

What are physician barriers to domestic violence screening?

Answer 68

1) Lack of time
2) Lack of education in domestic violence
3) “Not my job” - competing demands
4) Frustration if patient does not follow advice (e.g. “why don’t they just leave”)
5) “Opening Pandora’s Box”
6) Vicarious traumatization
7) Concern for personal safety
8) Physician’s previous abuse

Question 69

What three points summarize domestic violence?

Answer 69

1) Domestic violence rates during women’s lifetimes remains high and has long-term health effects
2) As physicians we should appreciate the prevalence of violence experience by our patients
3) We should incorporate domestic violence screening as a routine part of our clinical practice

Question 70

What are the 8 important factors from the power and control wheel?

Answer 70

1) Intimidation: making afraid, destroying property, abusing pets, weapon display
2) Emotional abuse: mind games, putting her down, humiliation, etc.
3) Isolation: Controlling every aspect of her social life. Justified with jealousy
4) Minimizing, denying, and blaming: saying it didn’t happen, shift of responsibility of the behavior, blaming the victim
5) Using children: threatening to take the children away
6) Economic abuse: preventing from keeping a job, giving an allowance, taking money away, not allowing her to have access to the family income
7) Male privilege: treating like a servant, defining men’s and women’s roles. Making all the big decisions
8) Coercion and threats: threats to hurt, threatening to leave, commit suicide, report to welfare. Making her do illegal things

Question 71

What are 6 important aspects of the advocacy empowerment wheels?

Answer 71

1) Respect confidentiality
2) Believe her and validate her experiences
3) Acknowledge the injustice
4) Respect her autonomy
5) Help her plan for future safety: what does she do to be safe, does she have any place to go if she needs to escape?
6) Promote access to services

Question 72

How do you screen for alcohol abuse?

Answer 72

1) Two or more affirmative answers to the CAGE questions ONLY SUGGESTS alcholism and the need to probe further
2) Have you felt you should Cut down on your drinking?
3) Have people Annoyed you by criticizing your drinking?
4) Have you ever felt bad or Guilty about your drinking?
5) Have you ever had an Eye-opener (a drink first ting in the morning) to steady your nerves or to get rid of a hang-over?

Question 73

How is confidentiality of medical information ethically justified?

Answer 73

1) Principles of autonomy

2) Privacy of the patient

Question 74

What should you know about medical information confidentiality?

Answer 74

1) Medical information is ethically and legally guarded (federal and state laws) by confidentiality, yet ethically valid claims can be made by third parties
2) Confidentiality is mentioned in the Hippocratic Oath: ancient practice

Question 75

What are risks to confidentiality?

Answer 75

1) Speaking in public places about patients
2) Cell phone conversations
3) Records not being secure
4) Electronic medical records pose significant risks: information storage, retrieval, and access to records
a) Employers, insurers, and relatives of the patient may want access to this information

Question 76

What are two grounds for exception of confidentiality?

Answer 76

1) Concern for the safety of other specific persons

2) Concern for public health