Not telling the truth in the patient-physician relationship

The presence of truth and honesty is a permanent demand, and becomes vital the more committed and intimate a relationship is. Medical practice is relevant to this discussion when one questions whether or not a physician should always tell their patient the truth in the face of a progressive or potentially fatal disease, regarding their diagnosis, outcome, therapy and evolution of the specific disease. From this discussion we aim, with the present report, to look at the truth applicable to the patient-physician relationship, and its ethical and moral implications; and also to look at where the Brazilian Code of Medical Ethics (BCME) and the medical literature stand regarding this issue. One concludes that there are only two moments not to tell a patient the truth: when the patient does not want to be informed, and when the truth could be iatrogenic. The question now is, when would the truth be iatrogenic? Physicians, in our opinion, would not be able to judge solitarily when the truth might be deleterious to their patient. Alternatively, we proposed the appointment of a multidisciplinary commission to help the doctor with such a decision.     

Truth in Reconciliation

To what extent is truth required for reconciliation of peoples in conflict? What kind of truth? Objective truth, subjective truth? Maybe reconciliation require that the pursuit of truth be limited? The trial of the former “Khmer Rouge” leaders in Cambodia for crimes against humanity provides a case where these issues are examined.     

Improvisation and authority in illness meaning

Using the example of psychosomatic diagnosis, I argue that the clinical context has unique epistemological constraints that limit the certainty of diagnosis and so make meaning indeterminate for sufferer and healer. As a result, forms of clinical truth are borrowed from the therapeutic context to create and authorize meanings for ambiguous or ill-defined conditions and inchoate suffering. Diagnostic interpretation is concerned with classification and legitimation through the production of authoritative truth. In contrast, therapeutic interpretation is fundamentally concerned with the pragmatic problem of how to continue and hence, with the improvisation of meaning. These different ends give rise to tensions and contradictions in psychosomatic theory and practice. While authority is necessary to provide a structure on which variations of meaning can be improvised, authoritative meanings may also restrict the possibilities for invention by clinician and patient. The goal of patient and physician is to create enough certainty to diminish the threat of the inchoate while preserving enough ambiguity to allow for fresh improvisation. Accounts of illness meaning must recognize the interdependence of normative rigidity and metaphoric invention.A RUMBLING: truth itself has appeared among humankind in the very thick of their flurrying metaphors.     

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.     

Manson's triple error

The author discusses the significance, implications and limitations of Manson's work. How did Patrick Manson resolve some of the major problems raised by the filarial worm life cycle? The Amoy physician showed that circulating embryos could only leave the blood via the percutaneous route, thereby requiring a bloodsucking insect. The discovery of a new autonomous, airborne, active host undoubtedly had a considerable impact on the history of parasitology, but the way in which Manson formulated and solved the problem of the transfer of filarial worms from the body of the mosquito to man resulted in failure. This article shows how the epistemological transformation operated by Manson was indissociably related to a series of errors and how a major breakthrough can be the result of a series of false proposals and, consequently, that the history of truth often involves a history of error.     

The Accuracy and Truth of Knowledge and a "Technological Intention" in Psychology

The dilemma of true and untrue knowledge is not simply ancient, though it has not found any generally acknowledged understanding even today: it is also not merely logical or especially philosophical, but in its many particular manifestations (truth—untruth, truth and error, truth and falsehood; "the bitter truth" and "good intentions"; "base truths" and "edifying deception"; the search for the path to "divine truth" and the immersion of mankind in "golden" sleep; probity and dishonesty) decidedly pervades all forms of social consciousness, and is posed continually and acutely to every person in the course of his life, particularly in the professional activity of a psychologist in any area of specialization.     

Authorizing Knowledge in Science and Anthropology

An analogy exists between today's "defenders" of science in the "science/culture wars" and 19th-century "defenders" of euclidean geometry. Current critics have appointed themselves as arbiters of truth in a manner analogous to that of 19th-century mathematicians and theologians who argued against noneuclidean geometry that challenge Euclid's mathematically, philosophically, and theologically entrenched fifth postulate. The science wars then and now are not about science versus antiscience, objectivity versus subjectivity, but about authority in science: what kind of science should be practiced, and who gets to define it?     

Factors predicting patient use of the emergency department: a retrospective cohort study

Background:

Many studies have shown the tendency for people without a regular care provider or primary physician to make greater use of emergency departments. We sought to determine the effects of three aspects of care provided by primary physicians (physician specialty, continuity of care and comprehensiveness of care) on their patients’ use of the emergency department.

Methods:

Using provincial administrative databases, we created a cohort of 367 315 adults aged 18 years and older. Participants were residents of urban areas of Quebec. Affiliation with a primary physician, the specialty of this physician (i.e., family physician v. specialist), continuity of care (as measured using the Usual Provider Continuity index) and comprehensiveness of care (i.e., number of complete annual examinations) were measured among participants (n = 311 701) who had visited a physician three or more times during a two-year baseline period. We used multivariable negative binomial regression to investigate the relationships between measures of care and the number of visits to emergency departments during a 12-month follow-up period.

Results:

Among participants under 65 years of age, emergency department use was higher for those not affiliated than for those affiliated with a family physician (incidence rate ratio [IRR] 1.11, 95% confidence interval [CI] 1.05–1.16) or a specialist (IRR 1.10, 95% CI 1.04–1.17). Among patients aged 65 years and older, having a specialist primary physician, as opposed to a family physician, predicted increased use of the emergency department (IRR 1.13, 95% CI 1.09–1.17). Greater continuity of care with a family physician predicted less use of the emergency department only among participants who made 25 or more visits to a physician during the baseline period. Greater continuity of care with a specialist predicted less use of the emergency department overall, particularly among participants with intermediate numbers of multimorbidities and admissions to hospital. Greater comprehensiveness of care by family physicians predicted less use of the emergency department.

Interpretation:

Efforts to increase the proportion of adults affiliated with a family physician should target older adults, people who visit physicians more frequently and people with multiple comorbidities and admissions to hospital.Reforming primary care in Canada has been stimulated in part by increased crowding of emergency departments and evidence that their use, particularly for nonurgent care, may be related to inadequate primary care in the community.^1,2 Restructuring efforts, such as encouraging family physicians to work in multidisciplinary group practices with 24-hour access, are challenged by a relative shortage of family physicians.³ These issues are of particular importance in Quebec; despite relatively high numbers of family physicians per capita, in comparison with other provinces, residents of Quebec have the lowest rates of affiliation with a family physician and have one of the highest rates of seeing specialists.^4,5 In addition, residents of Quebec have among the highest rates of visits to emergency departments in international comparative studies.^6–8Research is needed into the effect that affiliation with a specialist rather than a family physician has on patients’ use of the emergency department, as is research into the continuity and comprehensiveness of care provided by the primary physician, regardless of specialty.Many studies have shown the tendency for people without a regular care provider to use the emergency department more often than people who have a primary physician.^1,9,10 Greater continuity of care with a primary physician has also been associated with fewer visits to the emergency department, but much of this research is cross-sectional, making causal interpretation difficult.¹¹ Furthermore, the distinction between continuity with a family physician versus a specialist primary physician has not been made, although one American study reported that having a specialist primary physician was associated with increased use of emergency departments.⁹We sought to determine whether certain factors predicted patients’ subsequent use of emergency departments, such as the specialty of their primary physician, the continuity of care with that physician and the comprehensiveness of care provided by that physician. To determine whether certain subgroups of the population may derive greater benefit from a particular type of care, we examined the potentially modifying effects of demographic factors, health status and previous use of health services. We restricted our study to residents of urban areas of Quebec for three reasons: rural residents visit the emergency department for primary care more often than residents of urban areas;¹² most specialist care is provided in urban areas; and primary care services in rural areas are more likely to be provided by salaried physicians, whose information is not available in the billing database.     

Bioethics for clinicians: 12. Ethical dilemmas that arise in the care of pregnant women: rethinking "maternal-fetal conflicts".

When a pregnant woman makes a decision or acts in a manner that may be detrimental to the health and well-being of her fetus, her physician may be faced with an ethical dilemma. Is the physician''s primary duty to respect the woman''s autonomy, or to promote behaviour that may be in the best interest of the fetus? The controversial concept of "fetal rights" or the "fetus as a patient" contributes to the notion that the pregnant woman and her fetus are potential adversaries. However, Canadian law has upheld women''s right to life, liberty and security of the person and has not recognized fetal rights. If a woman is competent and refuses medical advice, her decision must be respected even if the physician believes that her fetus will suffer as a result. Coercion of the woman is not permissible no matter what appears to be in the best interest of the fetus.     

Teaching bioethics as a new paradigm for health professionals

In The Clouds by Aristophanes, Strepsiades brings his son before Socrates so that he could learn Philosophy for he has heard that this science teaches how to overcome the most difficult causes with reasons. And Strepsiades wants his son to learn the art of failing to pay debts. Regarding medical education in our time, Edmund Pellegrino has noted that the educational philosophy of medical schools determines what a "good" physician is. Thus, teaching bioethics to future health professionals makes us face old problems now: What teaching method to choose among all the possible various ones? What should teaching aim at? Which will be our educational philosophy? Therefore I shall introduce here the epistemological basis of our Bioethics teaching program in Argentina and its implementing strategies in the undergraduate curriculum and the post-graduate level.     

Truth and fancy in the management of the solitary thyroid nodule.

Although there is considerable controversy about the proper management of the solitary nodule, certain information may be useful in reaching this decision. Age, sex, and a previous history of external irradiation to the head and neck are helpful as are the clinical characteristics of the thyroid gland. Whether the nodule is functioning or "cold" on thyroid scan, and cystic or solid on thyroid ultrasound is also helpful. Based on these findings, the physician must decide whether to recommend surgery or thyroid hormone suppressive therapy.     

The DIAMOND initiative: implementing collaborative care for depression in 75 primary care clinics

Background

The many randomized trials of the collaborative care model for improving depression in primary care have not described the implementation and maintenance of this model. This paper reports how and the degree to which collaborative care process changes were implemented and maintained for the 75 primary care clinics participating in the DIAMOND Initiative (Depression Improvement Across Minnesota–Offering a New Direction).

Methods

Each clinic was trained to implement seven components of the model and participated in ongoing evaluation and facilitation activities. For this study, assessment of clinical process implementation was accomplished via completion of surveys by the physician leader and clinic manager of each clinic site at three points in time. The physician leader of each clinic completed a survey measure of the presence of various practice systems prior to and one and two years after implementation. Clinic managers also completed a survey of organizational readiness and the strategies used for implementation.

Results

Survey response rates were 96% to 100%. The systems survey confirmed a very high degree of implementation (with large variation) of DIAMOND depression practice systems (mean of 24.4?±?14.6%) present at baseline, 57.0?±?21.0% at one year (P?=?<0.0001), and 55.9?±?21.3% at two years. There was a similarly large increase (and variation) in the use of various quality improvement strategies for depression (mean of 29.6?±?28.1% at baseline, 75.1?±?22.3% at one year (P?=?<0.0001), and 74.6?±?23.0% at two years.

Conclusions

This study demonstrates that under the right circumstances, primary care clinics that are prepared to implement evidence-based care can do so if financial barriers are reduced, effective training and facilitation are provided, and the new design introduces the specific mental models, new care processes, and workers and expertise that are needed. Implementation was associated with a marked increase in the number of improvement strategies used, but actual care and outcomes data are needed to associate these changes with patient outcomes and patient-reported care.

     

No correlation between lunar and menstrual cycle - an early report by the french physician J. A. Murat in 1806-

Jean Arnaud Murat was a physician at the Medical School of Montpellier in France. In 1806 he published his outstanding book “De L’Influence de la Nuit sur les Maladies ou Traité des Maladies Nocturne”. In his book he concentrated on the following questions:

- Does the night has an influence on a disease?

- Are there diseases in which this is more or less obvious?

- What is the physical background of this influence?

Murat described in detail certain diseases which dominate at night and he concluded that the most evident motivation for his observations is the constant and periodic movement of the earth around its axis, resulting in a period of about 24 h, and the elliptic rotation around the sun. Most important Murat presented for the first time data that the menstrual cycle is not governed by the lunar cycle.     

Listening to the Call of Dance: Re‐thinking Authenticity and ‘Essentialism’

A sustained and devastating critique has been aimed in recent years at a metaphysics of truth which understands truth and authenticity as essence, as fixed, self‐identical and persistent over time. So successful has this critique been that it is now possible to speak of authenticity only in terms of a certain ‘strategic’ or politically necessary engagement, on the part of subaltern groups, with an essentialist metaphysics. While the critique is a necessary one, taken on its own it has resulted in a reductionist presumption that we are only ever going to encounter versions of truth that we have already understood, for purposes of critique, as so many versions of ‘essentialism’. By contrast, in the ceremonial performances of dance described in this issue of TAJA, across a broad spectrum of cultures, we witness the striking persistence and centrality of references to virtuosity, appropriate ‘feeling’ and to the experience of a kind of integrity, coherence and ‘truth’ in a good performance. The commentary argues that these distinctions rest on traditions that move us quite far from an essentialism both of the spirit and of the body, requiring instead a fresh effort of understanding on our part. Utilising other traditions to develop a better, less reified understanding of truth criteria can help arrest a certain hyper‐expansion of ‘the political’ that threatens to leave no other terms alive with which to inform its own vision of the relation between past, present and future.     

Models for truth‐telling in physician‐patient encounters: What can we learn from Yoruba concept of Ooto?

Empirical studies have now established that many patients make clinical decisions based on models other than Anglo American model of truth‐telling and patient autonomy. Some scholars also add that current medical ethics frameworks and recent proposals for enhancing communication in health professional‐patient relationship have not adequately accommodated these models. In certain clinical contexts where health professional and patients are motivated by significant cultural and religious values, these current frameworks cannot prevent communication breakdown, which can, in turn, jeopardize patient care, cause undue distress to a patient in certain clinical contexts or negatively impact his/her relationship with the community. These empirical studies have now recommended that additional frameworks developed around other models of truth‐telling; and which take very seriously significant value‐differences which sometimes exist between health professional and patients, as well as patient's cultural/religious values or relational capacities, must be developed. This paper contributes towards the development of one. Specifically, this study proposes a framework for truth‐telling developed around African model of truth‐telling by drawing insights from the communitarian concept of oot?? amongst the Yoruba people of south west Nigeria. I am optimistic that if this model is incorporated into current medical ethics codes and curricula, it will significantly enhance health professional‐patient communication.     

Deceptive Intentions: Can Cues to Deception Be Measured before a Lie Is Even Stated?

Can deceitful intentions be discriminated from truthful ones? Previous work consistently demonstrated that deceiving others is accompanied by nervousness/stress and cognitive load. Both are related to increased sympathetic nervous system (SNS) activity. We hypothesized that SNS activity already rises during intentions to lie and, consequently, cues to deception can be detected before stating an actual lie. In two experiments, controlling for prospective memory, we monitored SNS activity during lying, truth telling, and truth telling with the aim of lying at a later instance. Electrodermal activity (EDA) was used as an indicator of SNS. EDA was highest during lying, and compared to the truth condition, EDA was also raised during the intention to deceive. Moreover, the switch from truth telling toward lying in the intention condition evoked higher EDA than switching toward non-deception related tasks in the lie or truth condition. These results provide first empirical evidence that increased SNS activity related to deception can be monitored before a lie is stated. This implies that cues to deception are already present during the mere intention to lie.     

Analysis of Your Professional Liability Insurance Policy

The most important lessons for the physician to learn in regard to his professional liability insurance coverage are the following:1. The physician should carefully read his professional liability policy and should secure the educated aid of his attorney and his insurance broker, if they are conversant with this field.2. He should particularly read the definition of coverage and carefully survey the exclusion clauses which may deny him coverage under certain circumstances.3. If the physician is in partnership or in a group, he should be certain that he has contingent partnership coverage.4. The physician should accept coverage only from an insurance carrier of sufficient size and stability that he can be sure his coverage will be guaranteed for “latent liability” claims as the years go along—certainly for his lifetime.5. The insurance carrier offering the professional liability policy should be prepared to offer coverages up to at least $100,000/$300,000.6. The physician should be assured that the insurance carrier has claims-handling personnel and legal counsel who are experienced and expert in the professional liability field and who are locally available for service.7. The physician is best protected by a local or state group program, next best by a national group program, and last, by individual coverage.8. The physician should look with suspicion on a cancellation clause in which his policy may be summarily cancelled on brief notice.9. The physician should not buy professional liability insurance on the basis of price alone; adequacy of coverage and service and a good insurance company for his protection should be the deciding factors.     

Impact of physician continuity on death or urgent readmission after discharge among patients with heart failure

Background:

Early physician follow-up after discharge is associated with lower rates of death and readmission among patients with heart failure. We explored whether physician continuity further influences outcomes after discharge.

Methods:

We used data from linked administrative databases for all adults aged 20 years or more in the province of Alberta who were discharged alive from hospital between January 1999 and June 2009 with a first-time diagnosis of heart failure. We used Cox proportional hazard models with time-dependent covariates to analyze the effect of follow-up with a familiar physician within the first month after discharge on the primary outcome of death or urgent all-cause readmission over 6 months. A familiar physician was defined as one who had seen the patient at least twice in the year before the index admission or once during the index admission.

Results:

In the first month after discharge, 5336 (21.9%) of the 24 373 identified patients had no follow-up visits, 16 855 (69.2%) saw a familiar physician, and 2182 (9.0%) saw unfamiliar physician(s) exclusively. The risk of death or unplanned readmission during the 6-month observation period was lower among patients who saw a familiar physician (43.6%; adjusted hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.83–0.91) or an unfamiliar physician (43.6%; adjusted HR 0.90, 95% CI 0.83–0.97) for early follow-up visits, as compared with patients who had no follow-up visits (62.9%). Taking into account all follow-up visits over the 6-month period, we found that the risk of death or urgent readmission was lower among patients who had all of their visits with a familiar physician than among those followed by unfamiliar physicians (adjusted HR 0.91, 95% CI 0.85–0.98).

Interpretation:

Early physician follow-up after discharge and physician continuity were both associated with better outcomes among patients with heart failure. Research is needed to explore whether physician continuity is important for other conditions and in settings other than recent hospital discharge.Hospital care accounts for almost one-third of health care spending, and unplanned readmissions within 30 days after discharge cost more than $20 billion each year in the United States and Canada.¹ Heart failure is one of the most common reasons for admission to hospital and is associated with a high risk of readmission.¹ Although the prognosis for patients with heart failure has improved over the past decade, the risk of early death or readmission after discharge is still high and is increasing.² Prompt follow-up of patients with heart failure has been associated with lower rates of death and readmission,^3,4 and 30-day follow-up has been included as a quality-of-care indicator in Canada.⁵It is unclear, however, whether the postdischarge visits should be with the physician who previously saw the patient or with any physician. Results of studies exploring the association between provider continuity and postdischarge outcomes have been inconclusive and the studies have included few patients with heart failure.^6–9 Intuitively, one might consider physician continuity important for patients with heart failure discharged from hospital, given their age, high comorbidity burdens and complex treatment regimens. However, a robust evidence base and multiple guidelines with consistent messaging on key management principles have made physician continuity potentially less important.We designed this study to determine whether physician continuity influenced postdischarge outcomes among patients with heart failure beyond the influence of early physician follow-up.