DIP Episode 276 - USMLE Nov 2020 Changes Series 6: Professionalism/Ethics

Okay, welcome. My name is Divine. This is episode 276 of the Divine Intervention Podcast. And in this podcast, I'll be continuing the series on the November 11, 2020 USMLE Step 2 CK changes that essentially began a few days ago. I mean, not a few days, not December, whoops, began about three weeks ago on the USML Es. And this is series 6. Again, as I said, I've already made five podcasts. And I'm trying to follow the content outline put up by the USMLE pretty closely on this. So we've already talked about medication errors, we've talked about transition of care errors, we've talked about diagnostic errors, we've talked about palliative care, we've talked about ethics. We've talked about palliative care, actually, there are two podcasts just on palliative care. So today I'm going to be spending a lot of time on professionalism and ethics. And this may be a multi-part series or maybe a one-part series, but let me just try and cover. Because these things when you're making, when you're playing these podcasts, you're like, oh, this will only take 30 minutes. And then you say, like, well, this thing, I haven't even scratched half the surface. I'll go for as long as I can and call it if I can feel everything into one podcast that I will. If I can't, then I will just have to make another podcast or other podcasts. So let's go ahead and jump into it.

So ultimately, we know that with ethics and professionalism, the first thing you want to know is, you want to know your four ethical principles. This is something that even before the USMLE meet these changes is something you need to know. These are things you need to know. So remember that the four main ethical principles, the first one is benefits. So you always need to act in the best interests of your patient. You always need to act in the best interests of your patient, in the best interests of society. That's one important thing. The second one is non-malificent. So you don't want to do any harm. The thing is, whenever you're doing ethics questions, if you think about ethics questions in these contexts, you usually end up picking out the right answer. Although I'll also give you a few more tips so that you don't make such, such a, you know, you don't make errors with these ethics questions. Ethics questions, again, I know they sound very difficult, but most of them are pretty straightforward. If you know what you're doing. So non-malificent, again, you don't want to do any harm to the patient. And then the third one is autonomy. You always, always want to make the, respect the patient's autonomy. And then the next one is, final one is justice. So you're treating everyone equitably. Regardless of their access to care or the socio-economic status, things of that nature.

Although they're exceptions to these roles and your friends at the end being the love to test those exceptions. Right? So essentially, again, if a patient makes a choice, you are bound to respect that choice. You're bound to respect that choice. You cannot be a paternalistic physician where you're like, oh, you know what? I know my patients have made these choices, but I'm going to override their preferences. I'm going to ignore their preferences. Even if it's beneficial to them, that is beyond your, you're not the patient's dad. So that is beyond your purview as a, as a physician, as a physician. There are some exceptions to that role though. Obviously, if a patient has like some kind of mental illness that clouds your judgment. Or if it's an emergency situation, right? Where the patient is like more responsive, cannot communicate what they want. Then obviously, in those circumstances, you can take over as a physician and make choices that are beneficial to them. But if the patient is lucid, if the patient is completely with it, then you have no right as a physician to override the autonomy with regards to decision-making. So again, as much as possible, you always want to give your patients informed consent. Open the floor for them, give them everything they need, right? Tell them about their current and the thing is, it's actually important when you're giving informed consent to know the different things that are factoring to a prepreet informed consent.

So obviously, right, you want to tell the patient, okay, this is what's going on. This is your status right now, right? So let's see before you do a procedure and you need to explain to them, okay, this is, this is your status. This is your healthcare status. This is your healthcare status. And then you need to explain why you're doing the intervention you're doing. Like, is it indicated to be really need the medical intervention that you're doing? Then you also need to communicate what are the risks with that medical intervention. Again, all these things, I know like people in healthcare sometimes they want to be in a hurry to get going with the procedure. But if you don't do these things and drink correctly, then a lawyer can always find holes to try to come after you in the future, right? So you need to explain the risks and the benefits of the procedure. You need to explain the other alternatives that are available, right? And then you also need to then give the patient your recommendations based on your best judgment, based on your knowledge of the appropriate clinical guidelines. And really a lot of today's discussion to be honest with you is just me. I'll be throwing out a bunch of classic NV Me scenarios, right? And what to do in those circumstances. Some of them will be quite unusual, but just kind of follow along and you'll get something from this podcast, right? So say, for example, let's say they give you a question about a patient and this patient has a COVID-19.

And there's PPA available. There's N95 masks. There's everything that the physician needs to have. I probably take care of the patient. And then the patient, the physician says that know that he doesn't want to be, he doesn't want to place himself at risk to his family or his significant other or whatever and says because of that, even in the presence of PPE that he cannot take care of the patient. That's ethically wrong, right? So the thing is they love to do and give this mantra with infectious disease. This is a great way to come through in COVID on your test. In fact, to be honest with you, there are some other ways they can test COVID on your exam. They can make it a PTSD question like a first responder or an ICU nurse with a COVID unit. They can make a PTSD question from COVID. They can make a hydroxychloroquine question from COVID, right? Remember, Plaquenio causes a lot of problems, right? It can cause like cardiac problems and all that, all that fun stuff. So those are always they can test COVID, but yes, they love, love, love, love, love. Infectious diseases, right? And they love to set up these questions where the physician is like worried about contracting the disease, yada, yada, yada, yada. It's not ethically appropriate for a physician to say, I'm not going to care for a patient because they have a particular kind of infectious disease.

Obviously, if the appropriate infectious disease control measures or precautions are not available, so let's see, there is no PPO, whatever. Yes, the physician absolutely has the right to refuse caring for the patient. But if that equipment is available, the physician really has no rights, right? To deny, so like they love to do this with like people that have again like COVID-19, or they can give it like a patient that has HIV-8s, or a person that has like some kind of hepatitis virus like HB or HFC, or they can make it a question about a person that has like the flu, or a question about a person that has like a multi-drug resistant organism like cover-peninem resistant interococcus, or like multi-drug resistant TB. Again, it is, as long as you're taking the appropriate infection control of precautions and procedures, you're ethically bound to treat, to treat said, a treat said patient, right? And then on that classic ethical center that we're popular on an exam is, let me give you a question about like having a close family member or close friend that needs care and you're caring for, and they're wondering if you can care for them in the hospital. In general, on MBN exams, avoid caring for family members, right? The reason why you should not do that is, you may not do things impassioned if you're caring for a family member. You may get an incomplete history, you may get an incomplete physical exam, let's say the person has something where you need to do a rectal exam.

You'll be kind of awkward for you to do a rectal exam on a family member, right? So you don't want to do that in those circumstances, and the thing is, you may also like things you would ordinarily not do for other people, you'd then begin to do for them, right? So let's say it's like a viral thing, and then you're like, all right, a family member, this drug is pretty harmless, let's go ahead and give antibiotics, right? So the thing is, it's just really hard to give objective care when you're dealing with a family member. So that's why in general, on MBN exams, caring for close family members, caring for close friends, is probably not the most prudent thing to do in those circumstances, right? And then, should you ever have sexual relations with a patient? Absolutely not, you should not, right? So if you have a patient, especially if you have a current therapeutic relationship with a patient, do not have sex with those patients, right? You absolutely, absolutely, absolutely should not have sex with those patients. The thing is, there are some extreme situations, but again, these extreme situations are very few and far between where, let's say a physician really loves a patient, and the patient really loves the physician.

In some jurisdictions, in some circumstances, the appropriate thing you may want to do in those circumstances, is first, like speak with some colleague, speak with some other professional, break the therapeutic relationship with a patient first, and then wait for six months before you can start dealing with the patient. But again, I will encourage you to only choose that option if the option of just not engaging any kind of personal relationships is not an answer, right? So in general, you should, it's very unethical, super, super unethical, super, super unethical for a physician to have sexual relationships with current patients, right? And to be honest with you, even for, even for, like, cousins or like relatives of a patient you have, again, having sexual relationships with those people is not ethical, right? So again, the NBM maybe, very good. Again, that's the thing that, you know, seems to be freaking a lot of people out, with these newer examples, it's just some very bizarre ethics scenarios that pop up. So it can just something to be mindful of, right? Just something to be mindful of. Even if it's not just the patient themselves, but they are relatives, you cannot have sexual relations with the relatives of patients that you currently have, okay? You cannot have sexual relations with those people. Another classic ethics scenario in an NBM exam is they may give you a question about a patient.

And they may tell you that, you know, some guy, he comes in, you were chosen by some insurance company or whatever, to do a disability evaluation, right? And the patient is trying to essentially coach you on how to fill out the disability clean forms. You need to do what is medically appropriate. So you cannot throw in something that the patient does not have so that he can get more claims. Again, you're legally culpable if you do stuff like that, right? So you should never assist the patient in getting disability benefits fraudulently. That is absolutely unethical. That is super, super unprofessional for you as a physician. And then, what if they give you a question about a patient and, you know, let's say this patient, and they'll usually make this a cultural question if you may, right? So they give you a question about some patient. And they tell you that, oh, this patient is from some country that is not the US. And, you know, it's some, like, cultural thing. And it's, let's say, like an 80-mile-year-old female and she has some kind of really bad serosiness, like long cancer that has metastasized everywhere, where there's no treatment option. And then, let's say the family members of that patient say, oh, please, we would really want you to not tell grandma or whatever that she has ex-wisey condition.

So whenever you get that kind of question on an in-miming exam, typically the right answer to go with, I'll say like your first line answer in these circumstances is, you need to, in front of the patient and the family members, ask the patient, how much do they want to know? Does she wish to know the diagnosis or does he wish to know the diagnosis? Right? You need to ask the patient, because you can just pick a blanket answer that says, don't disclose information to the patient. No, you absolutely cannot do that. So you need to first clarify, like many times on in-miming exams, ethics questions have right answers where you're just gathering more information or you're encouraging more conversation between the patient and the physician. Right? So the thing is, you need to ask the patient, if she, you can't just say, no, I'm going to disobey the family and burr, go and tell the patient the diagnosis, no, no, no, no, no, no. Right? Always be as open-ended as possible as the patient. Do you want to know the diagnosis? How much do you want to know? Right? And whatever the patient states is what you're supposed to do. Right? So if the patient says, I want to know the diagnosis, then it doesn't matter what the family members say. They need to tell the patient what's going on. But if the patient says, you know what? I don't want to know the diagnosis, but you know, like my family members know, let them be the ones making decisions concerning my care.

That's something that's known as authorized delegation. Okay? That is something known as authorized delegation. Authorized delegation. In those circumstances, yes, that's absolutely fine. You can then communicate the diagnosis to family members and have they make decisions concerning the patients care. Now, what if they give you a question about a patient? And let's say it's a patient where this patient has just been in lots and lots and lots of disagreement with you. The patient, you tell the patient to do XYZ, they don't do it. The patient is having like significant quarrels with you and all that fun stuff. Right? I guess that's not fun for the physician. If you see all those kinds of things, is it appropriate for you to severe or break your relationship with those patients? So the thing is, this question is not simple, but there are certain things you should keep in mind as you answer these questions. First things first, if the patient has a serious illness and they are not medically stable, you cannot chalk the patient off. You can't severe your relationship with that patient. No. If there is one thing you want to remember from all my discussion with concerning the specific scenarios this, the patient has to immediately stable before you can then begin to severe relationships with them. That's one. So essentially because this goes with this whole thing of non-maleficence, right? Doing no harm.

If you break the patient-physician relationship, when the patient is like super, super sick and is at a pending risk of death, that's actually something known as physician abandonment. And you could be sued. You are legally capable in those circumstances. So the thing is, you know, if a patient is just not aggrieved to your care and things are not working out between yourself and your patient, always try to pick the answer first that tries to repair that relationship. But if you've tried multiple times to repair the relationship and nothing is going super well, then in those circumstances, one is yourself and the patient should mutually agree to severe the relationship. That's one. And two, you need to give them written notice. You literally need to give them written notice, like I think sometimes the manager's addiction say up to 60 days, right? You need to give the patient a written notice. And then if the patient is going, and you also need to provide some information on other physicians that may be able to take care of the patient, right? You need to provide information on other physicians that may be able to take care of the patient. And before you transfer the medical information to the other physician, like the patient's medical records, to the other physician, you need to definitely, definitely, definitely make sure that you get some approval of the patient. You need to get patient approval before you can transfer any kind of medical record.

Again, if you notice to this, this question is just a lot of scenarios, scenarios, scenarios. Well, these scenarios are very high yield, very important scenarios to know for the purposes of your exam. And then what if they give you a question about your physician, like a resident or something like that? And I'll go ahead and put this. You see another physician, and usually they will try to make it something where the power balance is kind of off. So let's say it's a resident, and then you notice this is an attending physician that is impaired, right? That where there is like clear, obvious evidence in a question that this person is impaired, this person is not with it, and they are trying to take care of patients. The right answer to pick on your exam, first and first, is to pick an answer where the physician involved is immediately removed from patient care. If they are currently in the ongoing process of, let's say they are doing a procedure like a surgery or something, you need to pick the answer where you are essentially removing that physician from patient care. And then you need to absolutely, absolutely report to the appropriate authorities. So if it's like the division chief, if it's like the head of the department, if it's the chair of the department, if it's the medical board, you absolutely need to report. If you do not report and you've noticed, then guess what, you are legally culpable.

Now, one thing I would say is, you should not make these reports on any of my exams based on something you heard through the Grieb Van. Oh, you know, I heard from someone that XYZ physician was impaired doing XYZ doing this and that. No, you cannot make reports on Grieb Van information on hearsay. No, you only make reports on solid information, something that you directly observe yourself. That is absolutely important to know for purposes of exams. And then obviously, if you commit, if you make an error as a physician, you need to disclose the error. So you cannot just say, you cannot just try to brush over things or maybe start an intervention. Like, let's say you give a person like tons and tons and tons and tons of insulin. And then, you know, the patient's glucose did not tank. But you're like, you know what, let's just hang D5 and leave it at that without telling the patient anything. You absolutely cannot do not pick that answer in a test, right? So, you need to do the exam. What you need to do is you need to disclose the error to the patient. That's the first thing you need to do. Two, you need to apologize for making the error. And then three, you need to tell the patient what you plan to do. So that similar errors would not be made in the future, right? That's what you need to do on an in-beam exam when you get those kinds of circumstances, right? When you get those kinds of circumstances.

Even if it's something that does not harm the patient, you still need to disclose errors that you have meeting and caring for the patient. And then, what if they give you a question about a patient and this patient came to see a physician, got some blood draws, and then the patient does not pay for the service. The patient does not present any insurance. Let's say, you know, the results of the tests are out. And the patient is like, oh, I'm sorry, I'm not going to pay. I can't people are blah, blah. But I need to know my medical information. What's going on? Do I have an XYZ disease or whatever? And then you'll say, what is the best physician response in this scenario? The thing is, you need to tell the patient the results of their tests. Okay? You need to tell the patient the results of their tests. You cannot say, oh, you know what? Since you've not paid, I'm not going to give you the information on what we found out from your patient. If we found out from your blood work or from your chest texture or some kind of image, you cannot. The medical records, especially the information in the medical record, is absolutely the information of the patient. They have four rights, so bad that information. Even if they've not paid for care. I know it kind of sounds bizarre. I know it kind of sounds unfair. But that's the right thing to do. That's the right thing to do on an in-blig mix.

And then what if, you know, in terms of patient confidentiality, what are some maybe key principles to keep in mind? So some key principles to keep in mind with patient confidentiality. Again, as much as possible, you want to maintain patient confidentiality. But there are just some specific situations on in-blig mix exams where maintaining patient confidentiality is superseded. You can do those kinds of things. So what are some of these classic scenarios? For example, they can give you a question about a healthcare worker. This healthcare worker has something that can be a healthcare worker, it can be a food worker. That has something that is transmittable and infectious is transmittable. So let's say the person has like a beat. And again, they have to give you objective information in the question that the person, you know, does in fact have a beat. When you see something that is communicable and the person is working in a career where like again, like a healthcare worker, it can be a medical student, it can be a food care worker. So like an employee at some fast food restaurant, you need to disclose. You need to disclose the patients employer. In that circumstance, pick the answer choice that involves disclosing to the employer of the patient. Another classic one is if a person has like a really bad infectious disease, right? Something like TB for example, or a person has like really bad meningitis and they are wondering, oh, you know what? I don't want to get care.

I want to return to work. I want to be able to care for my family. They will make it like a situation where you'll be like, oh, I got to take care of the patient. I mean, the patient has to take care of their family like, oh, you know, let this person go back to work. I won't tell anyone. No, no, no, no, no, don't pick those answers. Right? If a person has a really bad, super infectious disease like TB, like meningitis, then you need to disclose that information. You should not allow the patient to infect other people. In fact, many times on an MBM exam, the right answer to go with in those circumstances is to hold the patient against their will if need be. Right? You can hold the patient in the hospital. Right? You can think slip the patient. Well, it can depends on what part of the country you are. But, you know, hold the patient against their will in those specific circumstances. Right? Another classic one is an STI. Right? So if a person has like a sexually transmitted infection, like trachomoniasis, for example, or HIV and you're like, you know what? Please don't tell my partner. No, no, no, no, no, no, no, no, you need to tell the partner. The thing is, in general, you want to pick the answer that encourages the patient to tell the partner. Right? But the thing is, even if the patient says they will tell their partner, they need to provide objective evidence in the question that the patient has actually been treated. If not, usually the right thing to do.

Regardless of what the patient says or not, is to actually inform the health department. You need to let the health department know and then the health department, they will then be tasked with reaching out to the patient's partner or any close contacts of the patient that could potentially get infected. Another classic confidentiality scenario that you love to bring on exams is if a person has, if a person has like some thing that can impair the ability to do certain things, like drive, right? So it can be a person that has like really bad seizures or a person that has like really bad arrhythmias. Arhythmias is something that for some reason, best students don't consider when preparing for these exams with something you kind of need to watch out for. So if a person has like very severe arrhythmias, has really bad seizures, right? Those people should probably not be allowed to drive. So you need to report this information to the DMV, for example, in the department of motor vehicles, so that these patients are not giving licenses or their licenses are suspended. So that they are not able to drive because again, if you knew and then you didn't communicate information, the patient drove and then killed someone in an accident, guess what? Or the patient even dies, guess what? Well, let's say like the patient is in an accident or the patient killed someone in an accident, guess what? You are legally culpable in those circumstances, right?

You are super, super legally culpable in those circumstances, right? Now, looking at things from the on end of the curtain, remember if a person is under age, if they are less than 18 years old, most times you need to tell the appearance what's going on with their health. You are absolutely need to tell the parents what's going on with their health. So for example, let's say the child says, oh, I don't want to disclose this information to the child is under 18. Well, I don't want to disclose this information to my parents. You can't. You need to disclose that information. And here's the thing on the flip side, if the parents say, you know what? Wow, we know that our child has this. We don't want our child to notice diagnosis. In general, the right thing to do in those circumstances is to encourage the parents to tell the child the information or you can even ask the child a question like, what have your parents said about this? Again, gathering more information answers, usually the correct answer on MBM exams with regards to ethical circumstances. But if the parents say they don't want the child to know, then the child does not need to know. But again, usually they don't provide an answer where you encourage the parents to tell the child or you are asking the child what have your parents mentioned to you. So that's those are usually good answers to be in those circumstances.

Now, one thing is to be careful about though, if something concerns a mental health or reproductive health and the child that's under 18 says, please I don't want my parents to know. You don't you should not tell the parents on an MBM exam. So things like birth control or the, let's see, the child has like some mental health thing and the child doesn't want to disclose to the parents. Yes, you're allowed on an MBM exam to not disclose to not disclose those things to the parents, right? To not disclose those things to the parents. Now, another thing I want to say, another classic scenario, and again, I'll be into wrap the supper pretty quickly here is they can give you an ethical scenario where a physician is trying to refer patients to like a facility where the physician actually like owns the facility or is like a partner in the facility. Basically, like in general on an MBM exam, it should not pick answer choices that allow you to that like, okay, let me tell you this, essentially on an MBM exam, don't refer patients to facilities where you have some kind of financial interest in that facility that is ethically inappropriate on an MBM exam. And then obviously as a physician, right, you shouldn't pay some other physician to give your referrals, right? So let's say they love to make the situation where it's like they can give you like a gastroenterologist and some colorectal surgeon.

And then the colorectal surgeon is paying the gastroenterologist to refer patients that have like polyps in the in the colon or colon cancer to all refer them to this hospital. No, that is ethically, that's ethically inappropriate. You shouldn't do that on an MBM exam. And then in terms of like getting stuff from pharmaceutical companies, right, so that you can recommend your products. Again, that's ethically inappropriate, right? So as a physician, as a resident, you should not accept payments from insurance companies or gifts from insurance companies or from like pharmaceutical companies to recommend a specific product to your patients. Again, that's ethically inappropriate. A lot of people unfortunately do that in healthcare, but again, it is not ethically appropriate on an MBM exams. Again, remember, we're taking an MBM exams here. So it won't do those things, right? And then one very challenging situation that pops up quite a bit on exams, they want to be wary of is a physician selling things out of their own practice, right? So let's say for example, a physician is like selling stuff in their office, like selling like cosmetics, herbal supplements and all those things. Again, those things are ethically inappropriate on an MBM exam. You cannot sell herbal supplements as a physician.

The only or like these are like rejoining creams or whatever stuff, especially and again, usually in the question, they'll make it pretty obvious that these things have not been medically proven or anything like that. You absolutely cannot sell those things out of your office. The only time you can sell stuff out of your office as a physician is if for example, you live in a rural area and it's something that the community really needs and is not available anywhere else, right? So usually those things are like durable medical equipment, right? So like a DME, so stuff like like what are some classic things I can think about right off the cuff, like those CPAP machines, for example, or crutches, things like that, or those motorized things that motorized walkers that are pressing me, like an old person me use. Yes, you know, if you have the only gaming town, rural area, you can sell those things out of your office. But again, all these like fountain of youth creams and all that stuff, you absolutely absolutely absolutely cannot sell that stuff as a physician, right? And the thing is you also cannot as a physician make claims on in a public space, right? On things that have not been medically proven, right? So it's almost like some company pays you to be like the face of your product and all use some show you've watched TV again. I'm not going to mention anyone's name. I'm not going to mention his specific program because I like to protect myself as well.

And you know, I don't like trashing people or resources, but basically right like you can't comment be advertising like some supplement that has not been medically proven has not been approved by the FDA nothing, right? And then you're saying you make all these wild bizarre claims, right? If you do those things again, that is ethically inappropriate on an MBM exam, right? The thing is to be honest with you actually really supports the MBME. In these most towards more ethics questions, because these are things that pop up on lot in clinical practice, right? These are things that actually a lot more useful to clinical practice than some question on some esoteric pathway that you probably will never use in anything in anything that you're doing in real life. Right? So again, just something you need to be into your mind full of. And then another thing I should also mention is it's actually perfectly fine for a physician to be an expert witness in a legal case, right? A physician can be an expert witness. But again, you you shouldn't like if they give you a situation on the exam with a vision is an expert witness and physicians making like tons and tons and tons of money from it, right? Then that is not ethically appropriate, right? Basically, you should compensate the physician only for what is like reasonable, right? They're just coming to give you on bias testimony and that's it, right?

And obviously as a physician, you should not accept payments to come and testify on a person's behalf so that they can get off for for a clinical case. I mean, for a criminal case where obviously they've done wrong, right? You absolutely cannot do those things. You absolutely cannot do those things on an MBM exam. And then another thing that you love to also throw on examples is the me give you situations where you're doing some kind of research study and it's for like a super, super expensive drug, right? And let's say you're the physician and you're the one administering the study. You cannot deny people access to the study. Like if a person wants to enroll and they're poor and you're like, this person probably won't be able to afford this medication in the future or this person has a low social status. So they shouldn't be allowed to enroll in this study. You absolutely cannot do that again. That's not ethically appropriate. Or let's say it's some study where just basically like it's like a justice principle. You cannot deny people access to research study based on their social economic status or the amount of wealth that they have on an MBM exam. Again, that is just not not not appropriate. That is super, super not appropriate on on an MBM exam, right? And then just kind of to recap here as I as I wrap up, right? There are some situations I've talked about in my earlier thick podcasts, right?

Again, if a patient has a living well, whatever I mean in the palliative care podcast, if a patient has a living well, right? You need to you need to do what's the patient has already said in the living well, right? And classically, one thing they all love to do is they all love to, you know, the patient has a living well and then the family members are like, no, we're not going to be able to do this. We don't want you to do this. We don't want to do in that. We don't want to do in this. And many times on MBM exams, they will make the family members lawyers just to see they can get you emotionally like shaking on the test. Once a patient has a living well, it's literally a contract between the patient and the physician. There's nothing that the family member can do. And I'm telling you this, the living well will always hold on. They can threaten you all the want, sue all the ones who they will usually not win those cases. Well, depends on the lawyer, I guess. That's a different conversation, right? But basically, we need to respect a need to respect a need to respect the living well, right? We need to respect the living well. Now, the thing is if a patient does not have a living well, right? And let's say for example, the family members say, because they love to throw in these corollary cases on exams, right? I mean, the MBM, they're very smart, right? With many of these things.

So let's say they give you a question about some patient and you know, the patient has no living well. Patient is brought to the emergency room, blah, blah, blah, blah, blah. And you know, the chances of them not making it are very high. And then the patient's families are like, you know what? Let's let our loved one go in peace and all that stuff, right? The temptation will prevent, present two kinds of answers to you on the exam, right? One will be like respect the family members wishes and do XYZ. And then the answer may say that you should try to gather more information from the family members or from close friends and colleagues, but what the patients wishes are. You definitely want to go with the second answer. You absolutely, absolutely, absolutely want to go for the second answer, right? Where your gathering more information don't just acquiesce to whatever wishes the patient's family members have. No, no, no, you need to gather more information. Basically, the only situation where you should pick an answer where the patient's family members say, you know, just let our loved one go in peace is when like they give you clear objective evidence in the question. That even if the patient has no living will, they already voiced that, you know, if they were in these really bad emergency circumstances where like the chance of survival is pretty much zero. That you know, you should go ahead and do XYZ, right? Like all like communicated decisions.

So if they've communicated a decision to like someone else or something, you know, you can go ahead and pull the plug, right? But you need to be careful. You need to usually try to pick the answer that involves gathering some more gathering some more gathering some more information, right? And then another classif in the doing exams, right? They can give you like a situation where a patient has like something that is really bad where it's going to kill them, right? But the patient does not want to be admitted to the hospital. The patient does not want to care. So they can make this like the patient has like a PE and the patient says, you know what? I don't want to be admitted. I want to go home and the patient is completely lucid. In those circumstances, guess what? You need to respect the wishes of the patient. You need to respect the patients autonomy. Yes, they're essentially doing themselves harm. But if the patient is lucid and they clearly communicate the decision to you, that's a clearly communicated decision to you that you know what? I don't want to get treated. I don't want to blah blah blah. And essentially what's going to happen is typically, especially in the railroad, you want to send an AMA for right? So they're leaving against medical advice. They have it signed. We explain the typically on the exam, you want to pick the answer where you explain the risks of them leaving against medical advice was the sign it. You can have them go home, right?

You can have them go home. But again, if the patient is impaired for any reason. So let's say you're worried that this patient probably is not going to be able to drive home safely. So they may affect other people. Basically, once the patient's decision is affecting other people, you typically can override what the patient wants in those circumstances. So you typically can override what the patient wants in those circumstances. So again, these are just all things. I'm just trying to think of some other circumstance where like some weird circumstance in me throwing just based on my experience. Well, another one they can give is they can give you a question about a patient that is on a ventilator. Right? And this patient is, you know, the patient is lucid, the patient is with it. The patient says, I want to be disconnected from this ventilator. And we tell you the question that, oh, if this patient is disconnected from the ventilator, patient is going to die. If the patient is completely with it, the patient is completely lucid. And the patient says, yes, I absolutely, absolutely do not want to be on this ventilator anymore. Then again, don't pick the answer choice that involves boom, acquires to what the patient wants. No, again, try to pick that is almost like you are picking that. Let me let this things to over kind of situation before you pick an answer answer. So what do I mean by that?

So typically, right, what you want to do is you want to maybe try to gather more information from the patient. Like, why do you want to do this? Maybe gather more information from family members, because again, if you pull the plumber, the patient is going to die. So what if you've done all those things and the patient is like, no, I want to be off the vent thing. You take them off the vent. And that's it. But again, usually that take them off the vent and that's it is usually not the right thing to do an endemic exam. You're almost always I'm telling you this. I need to be like divine. These answers you're giving us are not very straightforward. Well, I'm trying to be as straightforward as possible, right? But the key key key thing I'll just tell you is again, when you see those situations, try to gather more information, try to put some time between when the patient requested and when you're actually undergoing that. And then on that going that intervention, right, on the going that intervention. And then, if for example, yeah, actually, this is this, this, this would be a great example. Let's say they give you a question about a patient and the patient has. Let's say a patient has. So patient comes into the office and their diagnosis with like some really bad disease, right? So let's say the diagnosis something like. Trying to think of a really bad circumstance. Let's say like content tense, for example, right, content tense, right? And the patient is married, right?

And the patient says, please don't tell my wife that I have content tense. And then they say, what is the best physician response in this circumstance? Let me tell you this right now. The right thing to do in those circumstances is to try to encourage the patient to tell the spouse. But if the patient does not want to tell the spouse, then unfortunately, you need to, you need to tell the patient spouse. You need to find a way to tell the patient spouse because guess what, right? The patient spouse needs to understand that if she has kids with said patient, they'll probably have kids that are going to die like for sure in the future, right? And they will for sure get said genetic illness. So again, these just weird bizarre 10 was circumstances. These are things you want to be very fully well prepared for, especially if you're taking step one or you're taking step two CK for sure for sure, if you're taking step two CK and for sure for sure, if you're taking step one and also step three, right? I mean, step three, like the first day of step three is just a ton of bizarre ethical situations, a bizarre ethical situations like this. So since this is going to get it on for you means I'm going to go ahead and stop now. So thank you for listening. Please subscribe to the if you're interested. I guess let me talk about the step to CK course. If you're interested, I have us an MV me test against strategy scores taking place next next Thursday from 2 to 4 30 PM Mountain standard time.

And a comprehensive step to CK class, it's a 10 hour class, but it's five hours on Friday, the 11th of December and Saturday, the 12th of December. So if you're interested in any of those and it's from 11 PM to 4 PM Mountain standard time on both days. So if you're interested in any of those things, feel free to reach out to me. And if you're interested in any of those things, feel free to reach out to me. And if you're interested in any of those things, feel free to reach out to me. And if you're interested in any of those things, feel free to reach out to me. And if you're interested in any of those things, feel free to reach out to me. And if you're interested in any of those things, feel free to reach out to me. And if you're interested in any of those things, feel free to reach out to me. And if you're interested in any of those things, feel free to reach out to me. And if you're interested in any of those things, feel free to reach out to me. And if you're interested in any of those things, feel free to reach out to me. And if you're interested in any of those things, feel free to reach out to me. And if you're interested in any of those things, feel free to reach out to me. And if you're interested in any of those things, feel free to reach out to me. And if you're interested in any of those things, feel free to reach out to me. And if you're interested in any of those things, feel free to reach out to me.

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Beneficence (act in best interest), Non-maleficence (do no harm), Autonomy (respect patient choice), and Justice (treat everyone equitably).

Only if the patient is impaired, unable to communicate their wishes, or if the situation involves immediate public safety risk.

The current status/diagnosis, why the intervention is needed (indication), potential risks and benefits, and available alternative treatments.

1) Immediately remove the impaired physician from patient care. 2) Report the impairment to appropriate authorities (e.g., department chair, medical board).

It is ethically inappropriate and constitutes a conflict of interest; referrals must be made based solely on objective medical need.

The physician is ethically bound to treat the patient, as lack of equipment is the only justifiable reason for refusal of care.

1) Disclose the error to the patient immediately. 2) Apologize for the error. 3) Explain the plan to prevent recurrence.

Autonomy.

Only when appropriate infection control measures (PPE, isolation) are completely unavailable.

It is absolutely unethical; maintain professional boundaries at all times.

If a patient has a condition (e.g., severe arrhythmias, seizures) that impairs their ability to safely drive.

1) Disclosure/telling the patient. 2) Apologizing for the error. 3) Explaining corrective action plan.

Mental health or reproductive health issues are exceptions; otherwise, you should encourage the parents to tell the child.

It is unethical and inappropriate; compensation must be limited to reasonable fees for services rendered (e.g., expert witness testimony).

Autonomy.

Only when appropriate infection control measures (PPE, isolation) are completely unavailable.

It is absolutely unethical; maintain professional boundaries at all times.

If a patient has a condition (e.g., severe arrhythmias, seizures) that impairs their ability to safely drive.

1) Disclosure/telling the patient. 2) Apologizing for the error. 3) Explaining corrective action plan.

Mental health or reproductive health issues are exceptions; otherwise, you should encourage the parents to tell the child.

It is unethical and inappropriate; compensation must be limited to reasonable fees for services rendered (e.g., expert witness testimony).