What areas of professionalism should be the responsibility of medical students when engaging in patient contact?
- Confidentiality.
- Professional Persona.
- Respecting and maintaining boundaries.
Give 5 examples of the duties of a doctor.
- Recognise and work within the limits of your own competence.
- Maintain confidentiality, unless you feel that as a result of this the health/safety of the patient or the public is compromised.
- Listen to patients and respond to their concerns and preferences.
- Work with colleagues in a way that best serves patients interests.
- Never discriminate against patients or colleagues.
Explain the three types of ethics, and use this to attach a definition to ‘medical ethics’.
Ethics is the study of what makes an action right or wrong. There is:
- Meta-ethics: study of the meaning of moral concepts (i.e. what does right mean)
- Normative ethics (moral theory): the study of the means of deciding what is right or wrong.
- Applied ethics: The application of moral theory to real world cases.
- Medical ethics is concerned with the application of moral theory to medical cases. It is therefore mostly concerned with normative ethics and applied ethics.
In ‘Moral Theory’, what is: Consequentialism?
Consequentialism is which the rightness is judged by the desirability of the consequences of that action.
In ‘Moral Theory’ what is: Duty-based (deontology)
Actions are right if they conform to a system of rules or regulations - not necessarily if they result in the most desirable consequence.
In ‘Moral Theory’ what is: Virtue Ethics.
Virtue Ethics states that the right act is the one which a virtuous person would perform in the circumstances. The virtues are those character traits and dispositions needed for ‘human flourishing’.
Provide an overview of the four principle approach to medical ethics.
Beneficence - A practitioner should act in the best interests of the patient.
Non-maleficience: ‘Primum non nocere’, a practitioner should ensure that no further harm comes to the patient as a result of his/her actions.
Autonomy - the competent patient has a right to make his/her own decisions regarding their own healthcare, and should be guided by the practitioner into making a well informed choice.
Justice - concerns resource management and ‘who gets what treatment’.
What do proponents of the four principles approach state?
That the four principles pose prima facie, not absolute, obligations: This means that each one of the four principles should be followed unless it conflicts with an equal or stronger moral obligation.
Define patient-centred care.
Patient-centred care is health care that is closely congruent with and responsive to patients’ wants, needs and preferences.
This enhances prevention and health promotion and enhances the continuing relationship between the patient and the doctor.
It leads to more accurate diagnoses, increased adherence with treatment regimes, more effective patient-doctor relationship and increased patient (and doctor) satisfaction. Recognising the patient’s anxieties can help to reduce them, leading to a better mental and physical health (the immune system is dampened when stressed as cortisol is released).
What are the main criteria, or objectives, in patient centred care?
- To explore the patients’ main reason for the visit, concerns and need for information.
- Seek an integrated understanding of the patients’ world – their whole person, emotional needs, and life issues.
- Finds common ground on what the problem is and mutually agrees on management.
- Enhances prevention and health promotion.
- Enhances the continuing relationship between the patient and the doctor
- Is realistic
The Sick Role.
The Patient’s obligations should be to:
- Get well as quickly as possible.
- Should seek professional and medical advice and co-operate with the doctor.
- Allowed (and may be expected) to shed some normal activities and responsibilities. (i.e. employment, household tasks etc).
- Regarded as being in need of care and unable to get better by his or her own decisions and will.
The Sick role - the doctor’s obligations are:
- Apply a high degree of skill and knowledge to the problems of illness.
- Act for welfare of patient and community rather than for own self-interest, desire for money, advancement etc.
- Be objective and emotionally detached (i.e. should not judge patients behaviour in terms of personal value system or become emotionally involved with them).
- Be guided by rules of professional practice.
The Sick role - the doctor’s rights are:
- Granted right to examine patients physically and to enquire into intimate areas of physical and personal life.
- Granted considerable autonomy in professional practice.
- Occupies position of authority in relation to patient.
What is the fundamental concept in terms of resource management?
The fundamental concept in economics is the scarcity of resources. Resources are scarce for everyone. Economics is the process of making decisions about how to allocate these resources amongst competing activities.
Define ‘Opportunity Cost’
Opportunity cost is the value of what you give up when you make a treatment decision.
Every time a clinician treats a patient, another patient is deprived of care from which they benefit.
This can be measured in terms of cost (i.e. the administered treatment costs £2000 so this is £2000 that could have been used elsewhere) or the foregone health of other patients (i.e. because of that, we cannot do this for this other patient).
How is good medical practice linked to opportunity cost?
As well as having a duty of care to the patient (beneficence) we also have a duty of care to society, and we must ensure that we balance cost appropriately so that the opportunity cost is minimised.
Thus, good medical practice requires us to be aware of the cost of the care delivered. This includes the cost of the clinician, the treatment etc. We must also be aware of the evidence base for a treatment. Will it work better than other, cheaper treatments? The evidence base is often poor, only in about 15% of cases can one be sure that a treatment will be beneficial.
Briefly explain the structure of the ‘NHS Market”
A market is a network of buyers and sellers. In the NHS, the buyers or commissioners, are the 210 clinical commissioning groups (CCGs). The sellers (providers) are primary and secondary care institutions.
Explain the increase in the demand for healthcare.
- Technological change - new drugs, treatments, diagnostic techniques.
- Multiple morbidities - increasing numbers of people suffering from more than one illness.
The variation is better explained by the number of conditions as opposed to age.
This increasing demand leads to rationing i.e. denying or simply not offering an intervention which everyone agrees would do some good for the patient.
How is the NHS budget distributed?
The NHS budget is decided by Whitehall and then divided amongst England, Scotland, Wales, NI using the Barnett formula.
It is then further divided into CCGs. The NHS is funded by general taxation and national insurance contributions, as well as some user charges (prescription costs, car parking etc.).
In cases of conditions where treatment is necessary, it is examined on a clinical effectiveness basis. Otherwise, it is examined on a cost effectiveness basis. As Maynard said, ‘What is clinically effective may not be cost effective. But that which is cost effective is always clinically effective’.
Summarise the four clinical realities when examining cost effectiveness.
- What is clinically effective may not always be cost effective. Difficult choices are unavoidable.
- What is cost effective is always clinically effective.
- If the goal of the NHS is to maximise health gain for the population, clinicians must practice cost effectively; not be merely clinically effective.
- Failure to be cost effective creates inefficient resource use, deprives patients waiting for care from which they could benefit from and is unethical.
Describe how resource management is affected by variations in practice.
- Doctors deliver very different types of care to patients with similar conditions and similar personal characteristics.
- There are many clinical guidelines: will NICE guidelines lead to greater conformity in clinical practice?
- Waste of resources inherent in these variations has been well documented for decades.
- Is clinical autonomy unethical? If ‘autonomy’ leads to inefficiency it deprives potential patients of care from which they could benefit.
How do markets operate?
Through supply & demand.
Demand is inversely related to price. Other things being equal, the higher the price, the lower the level of consumer demand e.g. user charges.
Supply is positively related to price. Other things being equal, the higher the price, the higher the level of supply from providers e.g. the GP contract.
When demand equals supply, the market will be in equilibrium.
Markets are means to social ends. Markets rely on self-interest of buyers and sellers (including doctors) to achieve individual and social goals. Individual and social goals may conflict e.g. clash of clinical and employer goals. Markets are ubiquitous in medicine and health care. Payment systems affect their efficiency.
