The document summarizes key principles regarding professional behavior and ethics for physicians. It discusses appropriate boundaries in physician-patient relationships, informed consent, medical errors and liability, and obligations to report issues like abuse or impaired colleagues. Physicians must prioritize patient welfare, maintain open communication, and follow standards of care to practice ethically and avoid legal issues.

1. Professional Behavior
Tom Heston, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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