Clinical Skills – Ethics/Humanities/Health Law
Tutorial
Notes for
10-10:50
Physician as Clinical Decision Maker
Ethical Decision Making with the Difficult Patient
This is a stand-alone discussion session. It doesn’t follow on from any particular Clinical Skills case nor is there a follow-up lecture like last week. Instead, what we’re out to do is have a discussion of issues surrounding ‘difficult patients’.
This topic covers a lot of ground and we’re unlikely to cover all of it. We’ve provided the students with a few brief readings that raise a number of issues. These should give you plenty to talk about, but don’t feel like you have to get through all the points the readings raise. I’ve included a copy of the package that was sent out to the students. I’ve also included a longer article the students didn’t get, although they were supplied with a few case from the article.
The following are the main issues I’d suggest raising, but add or subtract from this list as you see fit:
· What are the moral limits of obligation on a physician? In other words, to what length should a doctor be prepared to go in order to properly treat a ‘difficult patient’? (This issue is raised by a number of the readings, but perhaps best by the piece on ‘dismissing’ patients. When, if ever, is it okay for a physician to do this?)
· What makes for a difficult patient? Is the piece by C. Fee right in saying that “… the patient is not difficult. The illness is.”?
· To what extent is it a doctors’ job to detect malingering? For example, suppose a doctor suspects, but cannot prove, that a patient is faking some problem in an effort to avoid some task at work. If treatment for the supposed condition poses no significant risk to the patient, to what extent is the doctor obliged to investigate whether the patient actually has the condition? (Here, the brief review of the book Patient or Pretender is most relevant.)
· To what extent is it a doctor’s job to ensure that patients only receive that treatment the doctor sees as medically necessary, even if the patient wants more than this? (Here, case descriptions 2 and 3 in the student package or the article The Difficult Patient are most relevant.)
Thanks for doing this. If you have any questions or concerns, you can reach me at 777-6720 or alatus@mun.ca
Andrew