Determining medical fitness to drive: physicians' responsibilities in Canada.

Current legislation indicates that physicians in Canada have a legal responsibility to know which medical conditions may impede driving ability, to detect these conditions in their patients and to discuss with their patients the implications of these conditions. The requirements to report unfit drivers vary among the provinces, and the interpretations of the law vary among the courts; therefore, physicians'' risks of liability are unclear. Physicians may be sued by their patients if they fail to counsel the patients on the dangers of driving associated with certain medications or medical conditions. Physicians may also face legal action by victims of motor vehicle accidents caused by their patients if the court decides that the physicians could have foreseen the danger of their patients'' continuing to drive. Physicians'' legal responsibilities to report patients with certain medical conditions override their ethical responsibilities to keep patients'' medical histories confidential.     

Annonce des résultats en médecine nucléaire : enjeux et réflexions. «: Informer le patient,ce n’est pas l’obliger à entendre,mais le préparer à comprendre » - Article 7 de la charte du GT Ethique de la SFMN

Announcing ant delivering results to patients from nuclear medicine tests, and particularly with PET imaging, can vary profoundly from a department to another, even from a physician to another. French regulation regarding patients’ information and access to their health data as well as the National Cancer Institute's (Institut national du cancer–INCa) most recent recommendations concerning cancer announcement ask all medical imaging specialists (nuclear medicine physicians and radiologists) to be more implicated in the announcement process. Moreover, and above all legal considerations, it is ethically difficult to refuse any kind of medical communication to a demanding patient and let that patient, sometimes alone, discover the results without any kind of medical comments from the specialist who wrote the report. Such heterogeneity is real and must therefore be understood and explored. The arguments given by physicians who do not give results or who are not implicated in cancer announcement are analyzed in a non-dogmatic fashion to find concrete answers to patients’ legitimate expectancies.     

Infidelity,jealousy, and wife abuse among Tsimane forager–farmers: testing evolutionary hypotheses of marital conflict

The role of men's jealousy over a wife's infidelity in precipitating marital conflict and wife abuse is well documented. The role of women's jealousy over a husband's infidelity has received little attention, which is puzzling given high potential costs to women of withdrawal of paternal investment. We address this gap by investigating marital conflict and wife abuse among Tsimane forager–farmers of Bolivia. We test predictions derived from male jealousy and paternal disinvestment hypotheses, which consider threats and consequences of infidelity by women (male jealousy hypothesis) and men (paternal disinvestment hypothesis). The paternal disinvestment hypothesis proposes that wife abuse is employed by husbands to limit wives' mate retention effort and maintain men's opportunities to pursue extrapair sexual relationships. Interviews were conducted among husbands and wives in the same marriages using a combination of open-ended and structured items. Spouses agree that the most frequently reported type of marital argument is women's jealousy over a husband's infidelity (N=266 arguments). Roughly 60% of abusive events occurred during arguments over men's diversion of household resources (N=124 abusive events). In multivariate analyses, likelihood of wife abuse is greater in marriages where husbands have affairs, where wives are younger, and where spouses spend more time apart (N=60 husbands, 71 wives). While we find strong support for both male jealousy and paternal disinvestment hypotheses, it is men's infidelity, not women's, that precipitates most instances of marital conflict and wife abuse. We conclude that men's aggression towards their wives facilitates men's diversion of family resources for their selfish interests.     

Informed consent and nudging

In order to avoid patient abuse, under normal situations before performing a medical intervention on a patient, a physician must obtain informed consent from that patient, where to give genuine informed consent a patient must be competent, understand her condition, her options and their expected risks and benefits, and must expressly consent to one of those options. However, many patients refrain from the option that their physician believes to be best, and many physicians worry that their patients make irrational healthcare decisions, hindering their ability to provide efficient healthcare for their patients. Some philosophers have proposed a solution to this problem: they advocate that physicians nudge their patients to steer them towards their physician's preferred option. A nudge is any influence designed to predictably alter a person's behavior without limiting their options or giving them reasons to act. Proponents of nudging contend that nudges are consistent with obtaining informed consent. Here I argue that nudging is incompatible with genuine informed consent, as it violates a physician's obligation to tell their patients the truth, the whole truth, and nothing but the truth during adequate disclosure.     

Do physicians assess lifestyle health risks during general medical examinations? A survey of general practitioners and obstetrician-gynecologists in Quebec

BACKGROUND: In Canada several guidelines have been published for the screening of lifestyle health risks during general medical examinations. The authors sought to examine the extent to which such screening practices have been integrated into medical practice, to measure physicians'' perceived level of difficulty in assessing these risks and to document physicians'' evaluation of their formal medical training in lifestyle risk assessment. METHODS: An anonymous mail survey was conducted in 1995 in Quebec with a stratified random sample of 1086 general practitioners (GPs) and with all 241 obstetrician-gynecologists (Ob-Gyns). The authors evaluated the proportion of physicians who reported routine assessment (with 90% or more of their patients) of substance use, family violence and sexual history during general medical examinations of adult and adolescent patients; the proportion of those who find inquiring about these issues difficult; and the proportion of those who evaluated their medical training in lifestyle risk assessment as adequate or excellent. RESULTS: The overall response rate was 72.6%. Among adult patients, 82.2% of the GPs reported routinely assessing tobacco use, 67.2% alcohol consumption, 34.2% illicit drug use and 3.2% family violence; the corresponding proportions for assessment among adolescent patients were 77.1%, 61.8%, 52.9% and 5.6%. Comparatively fewer Ob-Gyns reported routinely assessing these issues (56.1%, 28.6%, 20.4% and 1.3% respectively among adults and 62.7%, 35.2%, 26.8% and 2.8% respectively among adolescents). In the area of sexual history, condom use was routinely assessed by more Ob-Gyns than GPs (47.0% v. 28.2%); however, the proportion of Ob-Gyns and GPs was equally low for assessing number of partners (24.8% and 23.1%), sexual orientation (18.8% and 16.9%) and STD risk (26.2% and 21.2%). The vast majority of GPs and Ob-Gyns reported finding it difficult to assess family violence (86.5% and 93.0%) and sexual abuse (92.7% and 92.4% respectively). Over 80% of the physicians felt that they had had adequate or excellent medical training in assessing risk behaviours for heart disease and STD risk. The proportion who felt this way about their training in screening for illicit drug use, family violence and sexual abuse ranged between 12.7% and 31.6%. INTERPRETATION: Although morbidity and mortality associated with smoking, alcohol consumption, illicit drug use, unsafe sexual practices, family violence and sexual abuse have been well documented, routine screening for these risk factors during general medical examinations has yet to be integrated into medical practice.     

Battered wife syndrome.

Battered wife syndrome is a symptom complex of physical and psychologic abuse of a woman by her husband. Although it may occur in up to 10% of Canadian women, it largely goes unrecognized. Such women often present with vague somatic complaints, such as headache, insomnia and abdominal pain. Thus, the diagnosis can usually only be made by asking nonthreatening open-ended questions. Most women remain with their husbands because they are afraid of them. Hence, successful treatment usually depends on the woman''s leaving her husband and obtaining help in the development of a new self-concept.     

Burn injuries inflicted on children or the elderly: a framework for clinical and forensic assessment

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the difference between battery and assault in U.S. law and the concepts of the phrase "child abuse" and "elder abuse." 2. Understand that state statutes vary and can define abuse narrowly or with great specificity, and that either definition has inherent problems for physicians treating victims of abuse and neglect. 3. Know where to find the state-specific legal criteria for child or elder abuse and neglect, along with the corresponding standards for mandatory reporting and physician accountability. 4. Understand the relevant law regarding physician-patient privilege and the repercussions of incorrect but good faith reporting and of failing to report suspected abuse or neglect of children or the elderly. 5. Understand that there are no pathognomic signs for inflicted burn injury. 6. Clinically assess burned pediatric or elderly patients within a framework that will minimize the risk of missing or inappropriately suspecting injuries that stem from abuse or neglect. SUMMARY: This article deals with burns inflicted on children and the elderly, two particularly vulnerable societal groups. Though inflicted burning is a relatively rare method of inflicting physical abuse, failure to diagnose it has far-reaching ramifications. These injuries pose both medical and forensic problems for physicians, along with unique ethical dilemmas. This article is a collaboration between surgeons and lawyers providing a holistic, workable approach to the management of inflicted burn injury. The authors first describe the legal considerations that must be appreciated by U.S. physicians, then they suggest a rational and balanced clinical approach to the assessment of burn injuries that may have been inflicted intentionally or negligently on children and the elderly.     

Detecting and managing elder abuse: challenges in primary care

OBJECTIVE: To determine family physicians'' perceptions of barriers and strategies in the effective detection and appropriate management of abused elderly people. DESIGN: Questionnaire survey; the protocol included an advance notification letter and 3 follow-up mailings. SETTING: Regional Municipality of Hamilton-Wentworth, Ont. PARTICIPANTS: All active nonspecialist physicians who reported seeing elderly patients in their practices were eligible for inclusion. Fifty health service organization (HSO) physicians were randomly selected from among those listed with the HSO Mental Health Program, and 200 fee-for-service physicians were randomly selected from the Canadian Medical Directory. Of the 189 eligible physicians 122 returned completed questionnaires, a response rate of 65%. OUTCOME MEASURES: Physicians'' ratings of the importance of potential barriers in assisting older people experiencing abuse and of the usefulness of strategies for dealing with elder abuse. RESULTS: Physicians identified the following barriers as fairly or very important: denial of abuse, resistance to intervention, not knowing where to call for help, lack of protocols to assess and respond to abuse, lack of guidelines about confidentiality, fear of reprisal, and lack of knowledge of the prevalence and definition of elder abuse. Strategies deemed to be helpful included a single agency to call, a directory of services, a list of resource people, an educational package, guidelines for detection and management, reimbursement for time spent on legal matters, continuing education, revision of fee structure and a central library of resources on elder abuse. CONCLUSION: Although the physicians perceived numerous barriers to their detection and management of elder abuse, they identified many strategies that could be implemented at a local level. Preparation of an algorithm to help physicians is the next phase of this work.     

The treatment of perinatal addiction. Identification,intervention, and advocacy.

Women of reproductive age who use and abuse psychoactive drugs and alcohol present a special challenge to primary care physicians. There are compelling medical reasons for identifying and intervening with pregnant women who are addicted or have alcoholism. The teratogenicity of all drugs of abuse and alcohol, the risk of infection with the acquired immunodeficiency syndrome (AIDS), and the potential for full recovery of a pregnant woman from addiction are some of the reasons that identification and intervention in the problem are indicated. Whether encountered in the clinic setting or in private practice, chemically dependent pregnant or postpartum women are usually responsive to appropriate physician interventions that include a detailed and caring confrontation- and advocacy-oriented support. Complex legal and ethical issues surround perinatal addiction including the role of toxicologic screening, reports to child welfare services, issues in noncompliance, and interdisciplinary case management.     

The Ethical and Legal Framework for the Decision Not to Resuscitate

Practicing physicians are frequently faced with the question of whether or not to institute cardiopulmonary resuscitation in case of cardiac or respiratory arrest in a patient in hospital. Medical training has usually not included any systematic analysis of this issue from either an ethical or a legal standpoint. Many physicians may be unaware that ethical and legal principles, as well as professional guidelines, exist to guide such decision making. In practice, physicians make this decision without the benefit of training in ethical analysis. The problem is especially acute in teaching hospitals when young physicians unacquainted with formal ethics or the law must often make decisions emergently. Studies show some discrepancy between ethical and legal principles and the actual decision making by physicians. For this reason, we recommend an approach that will enable physicians to make and implement decisions not to resuscitate that are consistent with current ethical and legal standards.     

Medical Ghostwriting and Informed Consent

Ghostwriting in its various forms has received critical scrutiny from medical ethicists, journal editors, and science studies scholars trying to explain where ghostwriting goes wrong and ascertain how to counter it. Recent analyses have characterized ghostwriting as plagiarism or fraud, and have urged that it be deterred through stricter compliance with journal submission requirements, conflict of interest disclosures, author‐institutional censure, legal remedies, and journals' refusal to publish commercially sponsored articles. As a supplement to such efforts, this paper offers a critical assessment of medical ghostwriting as contrary to good patient care, on the grounds that it contradicts established general principles guiding clinical ethics. Specifically, I argue that ghostwriting undermines trust relationships between authors and their readers, and between these readers and their trusting patients, and in so doing contradicts the duty of respect for patient autonomy by obstructing informed consent. For this reason, complicity in ghostwriting practices should be understood as a violation of the professional ethical duties of physicians and other healthcare workers.     

Patient-physician sexual involvement: a Canadian survey of obstetrician-gynecologists.

OBJECTIVE: To determine obstetrician-gynecologists'' (ob-gyns'') awareness of and experience with sexual abuse of patients and former patients and their opinions about appropriate consequences. DESIGN: Mailed survey. SETTING: Canada. PARTICIPANTS: All 792 members of the Society of Obstetricians and Gynaecologists of Canada (SOGC); 618 (78%) responded. Approximately half of all ob-gyns in Canada belong to the SOGC. MAIN OUTCOME MEASURES: Knowledge of sexual involvement by an ob-gyn colleague with a patient or former patient (as defined by the respondents and by the College of Physicians and Surgeons of Ontario [CPSO]), self-report of such involvement, attitudes toward physician sexual abuse, desirable length of time a physician should wait before seeing a former patient in a situation that could lead to a sexual encounter, suggested consequences of sexual abuse. RESULTS: Overall, 10% of the respondents indicated that they knew about another ob-gyn who at some time had been sexually involved with a patient. In all, 3% of the male respondents and 1% of the female respondents reported sexual involvement with a patient; the corresponding proportions of those who reported having been accused of sexual abuse by a patient were 4% and 2%. Significantly more of the female ob-gyns than of their male counterparts (37% v. 19%) reported awareness of a colleague''s sexual involvement with a patient that would meet the CPSO''s definition of sexual impropriety, transgression or violation. Most of the respondents felt that the consequence of proven sexual impropriety should be reprimand and fine (chosen by 33%) or rehabilitation without loss of licence (28%). Most of the physicians supported loss of licence for proven sexual transgression (57%) or proven sexual violation (74%), but fewer felt that loss of licence should be permanent for these types of abuse (4% and 24% respectively). The female ob-gyns supported stronger sanctions against sexual transgression and sexual violation than the male ob-gyns. A wide range of opinion was seen regarding the propriety of sexual relationships with former patients. CONCLUSIONS: Ob-gyns have varied opinions about how sexual abuse of patients should be defined and how it should be sanctioned. There is a discrepancy between proposed public policy and the beliefs of physicians to whom the policy is to be applied.     

Emergency physicians and sexual involvement with patients: an Ontario survey

OBJECTIVE: To describe Ontario emergency physicians'' knowledge of colleagues'' sexual involvement with patients and former patients, their own personal experience of such involvement, and their attitudes toward postvisit relationships. DESIGN: Mailed survey. SETTING: Ontario. PARTICIPANTS: Emergency physicians practising in Ontario. RESULTS: Of 974 eligible mailed surveys, 599 (61.5%) were returned. Of these respondents, 52 (8.7%) reported being aware of a colleague in emergency practice who had been sexually involved with a patient or former patient. When describing their own behaviour, 37 respondents (6.2%) reported sexual involvement with a former patient. However, of this group, only 9 (25.0%) had met the patient in an emergency department. Thus, of the total number of respondents, only 1.5% (9/599) reported sexual involvement arising out of an emergency department visit. Most respondents (82.4%) agreed that it is inappropriate behaviour to ask a patient for a date after an emergency assessment and before the patient''s departure, and 66.4% felt that it is inappropriate to contact the patient after discharge. However, only 10.6% believed it to be unacceptable to request a social meeting after encountering a patient previously cared for in the emergency department in a nonprofessional setting. Most respondents (96.5%) did not believe that sexual involvement could ever be therapeutic for the patient. However, only 66% felt that it was always an abuse of power and 62.4% supported zero tolerance of all sexual involvement between physicians and patients. CONCLUSIONS: Vague regulatory guidelines currently in place have failed to dispel confusion regarding what is acceptable social behaviour for physicians providing emergency care. Our results support the need for clarification, and suggest a basis for guidelines that would be acceptable to the emergency medical community: that an emergency visit should not form the basis for the initiation of personal or sexual relationships, yet neither should it preclude their development in nonmedical settings.     

Differences in abuse reported by female and male Canadian medical students.

OBJECTIVE: To assess differences between male and female medical students concerning their experiences of abuse during training in a large Canadian medical school. DESIGN: Voluntary, anonymous cross-sectional survey of first- and fourth-year medical students during February 1991. SETTING: University of Toronto School of Medicine. PARTICIPANTS: Of 396 first- and fourth-year students surveyed after one of their regular classes, 347 (117 women, 230 men) completed the questionnaire. INTERVENTION: A 165-item, multiple-choice questionnaire concerning experiences of verbal or emotional abuse, sexual harassment and physical abuse, completed within 30 minutes. MAIN OUTCOME MEASURES: Differences between male and female respondents in abuse experiences before and during medical training, the relation between abuse before and during training, and the psychologic and behavioural effects of abuse during training. RESULTS: The experiences of the male and female respondents differed mainly in regard to sexual harassment: 42% (49/117) of the women and 11% (25/230) of the men reported sexual harassment before entering medical school (p < 0.0001); 46% (54/117) and 19% (43/230) respectively reported sexual harassment during medical training (p < 0.0001); and women who reported sexual harassment were the only respondents for whom a significant relation was found between abuse before and during training (p < 0.043). The women were more distressed than the men by all forms of abuse. A significant relation was shown between male students who reported experiencing abuse during medical training and mistreating patients (p < 0.0001). CONCLUSION: Female students'' experiences of sexual harassment differed from those of their male counterparts. As well, the female students'' reactions to and ways of coping with all types of abuse differed from those of the male students.     

Alberta euthanasia survey: 2. Physicians' opinions about the acceptance of active euthanasia as a medical act and the reporting of such practice.

OBJECTIVE: To ascertain the opinions of Alberta physicians about the acceptance of active euthanasia as a medical act (the "medicalization" of active euthanasia) and the reporting of colleagues practising active euthanasia, as well as the sociodemographic correlates. DESIGN: Cross-sectional survey of a random sample of Alberta physicians, grouped by site and type of practice. SETTING: Alberta. PARTICIPANTS: A total of 2002 (46%) of the licensed physicians in Alberta were mailed a 38-item questionnaire in May through July 1991; usable responses were returned by 1391 (69%). RESULTS: Although only 44% of the respondents considered active euthanasia morally "right" at least 70% opted to medicalize the practice if it were legal by restricting it to be performed by physicians and to be taught at medical sites. Even though active euthanasia is criminal homicide in Canada, 33% of the physicians stated that they would not report a colleague participating in the act of anyone, and 40% and 60% stated that they would not report a colleague to medical or legal authorities respectively. Acceptance or rejection of active euthanasia as a medical act was strongly related to religious affiliation and activity (p < 0.01). CONCLUSIONS: This survey about active euthanasia revealed profound incongruities in the opinions of the sample of Alberta physicians concerning their ethical and social duties in the practice of medicine. These data highlight the need for relevant modifications of health education policies concerning biomedical ethics and physicians'' obligations to society.     

Physical abuse during pregnancy: prevalence and risk factors

BACKGROUND: Violence during pregnancy is a health and social problem that poses particular risks to the woman and her fetus. To address the lack of Canadian information on this issue, the authors studied the prevalence and predictors of physical abuse in a sample of pregnant women in Saskatoon. METHODS: Of 728 women receiving prenatal services through the Saskatoon District public health system between Apr. 1, 1993, and Mar. 31, 1994, 605 gave informed consent to participate in the study and were interviewed in the second trimester. Of these, 543 were interviewed again late in the third trimester. During the initial interview, information was collected on the women''s sociodemographic characteristics, the current pregnancy, health practices and psychosocial variables. The second interview focused on the women''s experience of physical abuse during the pregnancy and during the preceding year, the demographic characteristics and the use of alcohol or illicit drugs by their male partner. RESULTS: In all, 31 (5.7%) of the women reported experiencing physical abuse during pregnancy; 46 (8.5%) reported experiencing it within the 12 months preceding the second interview. Of the 31 women 20 (63.3%) reported that the perpetrator was her husband, boyfriend or ex-husband. Although all ethnic groups of women suffered abuse, aboriginal women were at greater risk than nonaboriginal women (adjusted odds ratio 2.8, 95% confidence interval [CI] 1.0-7.8). Women whose partner had a drinking problem were 3.4 times (95% CI 1.2-9.9) more likely to have been abused than women whose partner did not have a drinking problem. Perceived stress and number of negative life events in the preceding year were also predictors of abuse. Abused women tended to report having fewer people with whom they could talk about personal issues or get together; however, they reported socializing with a larger number of people in the month before the second interview than did the women who were not abused. INTERPRETATION: Physical abuse affects a significant minority of pregnant women and is associated with stress, lack of perceived support and a partner with a drinking problem.     

Physicians' attitudes toward the legalization of marijuana use.

We asked 303 practicing physicians in general internal medicine, family medicine, gastroenterology, or psychiatry to indicate whether possessing or using marijuana should be considered a felony, a misdemeanor, warrant the issuance of a citation, or be legalized. The position physicians advocated was unrelated to their specialty, experience diagnosing or treating substance abuse problems, their attitudes toward the efficacy of the treatment of drug abuse, or any other work role or habit we measured. Legalization or citation as compared with harsher penalties, however, was more likely favored by physicians who were younger, less religious, politically more liberal, and those less likely to perceive a serious drug problem in society. Legalization was also more likely favored by physicians who themselves had used marijuana, cocaine, and amphetamines but was unrelated to the use of alcohol, cigarettes, or tranquilizers. Although physician opinion should be sought as society deals with the drug problem, this study suggests how physicians'' characteristics may influence the opinions that are rendered.     

Whom do dying patients tell?

Eighty married patients dying of cancer were assessed for their overt awareness of their condition. Of the 62 who discussed the possibility of dying, 22 had spoken of this to hospital staff, 43 to their husband or wife, and 53 to the interviewer. Those more certain of dying were more likely to speak about it. Patients previously considered "nervous" people more often showed their awareness, but current anxiety had no consistent effect. More overt sharing of awareness tended to happen in marriages considered average or poor by the spouse than in some closer marital partnerships. The patients'' communication of awareness to wife or husband was consistently better when the spouse favoured telling the patient. Patients also tended to disclose their awareness of dying more frequently to those staff prepared to discuss the matter. The findings have implications for the care of the dying.