Tuesday, March 27, 2012

Bioethics and Professionalism

I've just been reading a paper "Toward a Practical Definition of Professional Behaviour" by Wendy Rogers and Angela Ballantyne, Journal of Medical Ethics, 2010, 36 -250-254.  The first thing I notice is that this journal has adopted the convention of not designating what Wendy or Angela's professional association is.  When I dig further I learn that Wendy is from the Department of Philosophy and Angela is a doctor from the Department of Primary Health Care.  I don't know if Wendy is a student or if Dr. Angela Ballantyne is a medical doctor or just a doctor of grasshopper research.  I'm biased against journals that 'hide' the professional status of the writers and make it difficult for me to place the information in a context which has 'traditionally' helped me. I think journals like this are a bit 'flaky' and 'academic'.  I equate them with bellbottom minds and dope smoking for some reason.  Both are from New Zealand and I can't help but remember that WikiLeaks just exposed senior United States officials as saying that the geopolitical significance of New Zealand was less than irrelevant.
I'm not off to a good start.
I'm a front line worker. I have no resources.  All my experience is that of being lied to by politicians and their appointees.  I am in the lowest paid speciality despite the overwhelming evidence that it is central to health care. I left family medicine, public health and community medicine to become first a psychiatrist and then an addiction medicine consultant because this was where the area of greatest need and greatest challenge was.
When I taught at the university it was a wonderful ivory tower as far removed from the front lines as could possibly occur.  At the university there was a strict heirarchy dating back to the middle ages.  It was the most sexist organization I have ever been a part of.  Old male dogs were pampered by young female bitches. A new order of old female dogs was pampered by young female and young male dogs. There was tenure and privileges of an aristocracy.  I could 'select' my cases and I had so much time to consult and form committees. I was a first world nation and the private practice of medicine was the third world.  There was equipment I could access without any real effort. There was next to no oversight.  I liken it to a garden of eden where I walked and talked with God then one day found myself outside in the real world.
The real world is unselected patients who have multiplicity of problems with no resources.  My interests have been sick people. Half my patients are drug addicts. I learned early that almost all the 'research' by 'academics' excludes my patients because they are by nature non compliant, non adherent to medical regimen, contrary, often times threatening, routinely kill themselves, and use a variety of drugs and behaviours which make their management difficult to say the least.  Because of their difficulties they haven't resources so can't pay for the extras which are part of the modern Canadian medical practice where a physician gets only a little bit of money and is expected to collect the rest of his income through "administrative charges".
Three young female physicians amused me to no end when they opened their slick new Canadian practice by requiring every new member to pay an annual 'retainer' for 'administrative costs' of $5000 a head.  God I'd love to start my year with that much booty in the bank but my outdated ethics have never allowed me to do that. Only this week the court of Ontario struck down the laws against brothels and bawdy houses.  The Canadian Broadcasting Corporation reported people saying this was progressive.  I'm a progressive conservative but the new opposition party, NEW Democratic Party has been stealing the term 'progressive' to describe their own ideas.
The mixed economy of our present Canadian health care system which ignores and lies about the despicable and nauseating abuse of the poor and sick by the very agencies that  promised to be there for them. Having worked and lived in the United States I never was bothered by financially driven medical system. The patients knew the rich had better health care and that the rich were special.  The patients mostly wanted to  be rich themselves.  Yet in Canada the 'lie' of the medical care system is that everyone gets 'equal' care. In the frontline patients are grossly ignorant of what 'health care' they are 'entitled' to and daily surprised that they no longer can have the kind of care that some third world countries take for granted.
There was increasingly  a 'two tier' medical system in Canada with  the rich going to the United States for extra and special care but now the rich simply go to a practice like the one mentioned.  My patients have a waitlist for an MRI for 6 months whereas my colleague working in the private medical care system in Canada with the rich has an MRI yesterday.
Interestingly the licensing bodies apparently specializing in professionalism do not hold the different doctors to different standards. If I miss a brain tumor and my patient sues before he dies because I ordered an MRI and it took 6 months, my colleague working with the rich doesn't make that 'mistake' because he has resources. Further his patients already at the top of the class are likely to be compliant and follow through with instructions and return for further care doing all those wonderful things the academic doctors take for granted. My patients meanwhile are sometimes scheming to see how ill they can be to see if they can get a law suit against a doctor if they manage their symptons right.
It's always awkward to talk about patients this way since half of mine are of stirling character whereas a significant portion have had the ethics of a snake with their crack addictions and their education in jails and institutions.  Ironically I'll see a cabinet minister, priest, lawyer and doctor in the afternoon and a murderer, pedophile and drug trafficer in the morning.  The two groups overlap too.
The institutions are like great air craft carriers of personnel and resources, all of who are masters of complaining and getting collectively a lions share of the resources available for health care even though the majority of real work in the system is done out on the front lines. My colleagues alone on the wilderness are likely carrying a stethescope and a prescription pad for defence against everything that comes out of the darkness. My colleague at the university has a couple of clinics and sees about 20 people a week. She has a nurse full time assigned to her and that nurse is paid by some other intitutional body. There's administrative assistants and all manner of warm bodies called students.  All these happy hands can be delegated work.
In the real world at the centre of disease doctors work alone with often only an administrative assistant that they pay out of their earnings. Any other person is paid for by them.  Anything done by them, such as writing a requisition for an MRI or having an argument, an increasingly hourly business, to get a patient what they are 'entitled to' but the health care system is 'passive aggressively' denying knowing that only the 'rich' and 'wise' continue to demand to get their 'entitlement' in the end , whereas the defeated and hopeless will simply walk away from further rejection and abuse. My colleagues have all the time in the world too, along with resources and their 'ideas' about care never seem to take into account full waiting rooms, waitlists of sometimes a year and patients who aging are coming back into practices while more and more front line doctors are closing their practices and young doctors are too smart to do such things as see patients.  They're in medicine for easy street and gravy train. As one assistant registrar for the College is fond of saying, "it's just a job".  Meanwhile the Canadian Code of Ethics still calls it a 'calling' and no one in the ethereal heights has bothered to address this gross unprofessional discrepancy.
So when I pick up an academic article these days I remember that the budget is like a pie and health care is a fixed pie with increasing numbers of people taking a slice that was originally negotiated for doctors and nurses and an administration which worked for them doctors, nurses and patients rather than today's reality where the doctors, nurses and patients serve the whims of the administrators who have dachaus at Whistler.  
There are all these other players also who never come close to actual disease, never get touched by blood, piss, shit or spit and I envy them as the rich fat cats far removed from the real world of medicine, another layer of ivory tower dilletantes, whose arrogance and defensiveness are impecable.
So I approach this paper on Medical Ethics and know that I have not got a nurse at my side, someone clinically trained, another warm body, or a good pair of hands, or a junior doctor which would be the best but instead I've got another fat cat never been in the front line opinionated theoretician philosopher, like the world doesn't have enough philosophers and arm chair quarter backs and second guessers, and judges, and just generally people who don't know but want to be taken seriously and usually are married to some power broker or have some power button that makes the infantry snap to attention rather than facing further punishment for now kowtowing to the brass.  The brass are really touchy these days and don't realize that it's not all about them but they're increasingly selecting their inbred groupings and joining only with those who agree and think like them. And they're getting the very best of salaries and pensions and whenever you go to the places where the brass are they have clean things and no one is sick because sick people are sent home and they don't touch people.
I'm remembering all the aids biters I was spat on by when I worked with the dements and psychotics when we didn't know how the disease was spread and my friends were dying and we were wondering if they were needle users or gay and people backed away from me in the cafeteria when I talked about my fears.  I laughed at the Chinese colleague who wore a face mask when there was the SARS scares. She only came onto the 'battlefield' from upper management and the patients didn't see her face.  She's such an opinionated fat cat full of herself and painful but it was amusing for us to see her rank fear when she came near patients in the clinic.
They didn't have a sink where I worked.  I noticed they have these cleaners this last couple of years. I couldn't wait to get home and shower after work. I thanked my lucky stars for the hot shower.  Just this week I was examining an unusual rash and abscess, touching the edges, feeling for fluctuance. There weren't any gloves handy. I supposed I could have found them.  There was a waiting room of angry threatening to boil over patients irritated they had to wait for a doctor, demanding the doctor hurry up.
My patient doesn't wash. They can't afford the money for water or soap.  The smell was fierce.  Reminded me of the fungating breast cancer on that woman who I insisted take off her bra years ago who'd been to a dozen doctors in the weeks and months before me. None had got her to undress fully because they thought her 'modest' or feared what radical feminists would say, but she was ashamed of the stinking disgusting mass that she had growing out of her chest.  She died a while later.
This paper says that "Medical Ethics remains a topic that is difficult to define teach or assess."  But that doesn't stop this courageous daring pair from down under.
They say that the reason is that medical ethics gets mixed up with clinical competency and argues that "teachers and students require a medical professionalism curriculum that is clear, accessible, and  where possible, evidence based."
Well, it's decidedly 'unprofessional' of me to say this but Wendy and Angela are space cadets.  It's politically correct to treat even our mentally retarded administrators who are routinely high on some drug with the respect that they believe they deserve or perhaps their position as brass monkeys entitles them to but never as their behaviour deserves.  No matter how many deaths they cause you'd damn well better respect and pay hommage to these new lords and masters because they live by the beaurocratic code of revenge, revenge, revenge.  Angela and Wendy think 'clinical competency' isn't all that it's cut up to be.  Yet clinical competency is what decides whether a person is alive or dead at the end of the day.  And since I haven't a clue if either Wendy or Angela have been near a sick person in their lofty careers I can't guess what is going to be taken out of the existing 'medical school curriculum' to teach the students 'philosophy'.
And note this 'philosophy' is supposed to be 'evidence based', not because 'evidence based' is the new beaurocratic buzz word, politically correct where 'scientific' is not but somehow 'evidence based' is a truly necessary term to be used with the world 'philosphy'.  Isn't 'evidence based philosopy' an oxymoron?
This paper didn't bode well at the start and it's getting very sketchy about here and I'm sure that sweet Wendy and Angela would think me rude to talk like this but generally speaking any idea I suggest to a patient is met with as much if not worse skepticism. Yet in the hallowed halls everyone is bending over congratulating each other on their little 'publication' which they're paid to do ,as academics in the 'publish or perish realm where no one reads them with the scrutiny my editor read me asking if really I wanted this 'rubbish' published. But those were all the bad old days and everyone today is better and nice and we don't talk down to people or question their 'conflicts of interests' or ask' whose paying them' and why did they write this drivel because it's just not nice to call anything 'drivel' these days , even 'drivel."  One is called 'offensive' and 'confrontative' and 'difficult' because only those who 'agree' are nice people.  Ethical people are 'agreeable' people but agreeableness doesn't cut it in the trenches and these agreeable nice people go to any length to be in the softest seats and stay as far away as possible from the trenches.  That's where the black humor and the gallows humor reside.  People who are easily offended haven't lived long enough to get the joke let alone take themselves humorusly.
So the American specialists assessment find that the beaurocrats and licensing 'brass' have the amazingly unrealistic expectation that a full 90 minutes of activity is 'required' by the 'powers that be' before the specialist actually has the 15 minute visit with the patient who hasn't as yet stated what they want. Increasingly the patient wants a 'letter' because some third party is denying them some 'entitlement' and they want the doctor to write a letter or fill in a form to validate their illness which makes their illness an object of 'secondary gain' whereas the doctor was taught that his job was to 'cure' the disease.  Increasingly in our society there are soldiers in the field of life who are shooting themselves in the thighs to get a way out.  My patients are smoking crack too.
And Angela and Wendy think all that dirty messy clinical stuff shouldn't be intermingled with 'medical ethics'.  Philosophizing is just so much more difficult when you have to contend with the aberrations of patients and doctors.  And please, don't consider that real chaos maker disease. That's just too 'yucky'!
When they get right down to it, these girls (forgive my age, women, or should I say, ladies, cause I frankly I don't know if they are colleagues, clinicians or just busybodies) trying desperately to redefine medicine in their own image and create a role for themselves as "coffee clutch girls" chatting and judging and coming up with what others should have done and what 'we would have done' if we were there.
No wonder everyone wants to philosophize rather than actually touch and talk to patients who are so painfully human.
Where's the money coming from and what gets hacked in the medical school and how come no one is telling me how I can get easier access to an MRI or how I can't have a lawyer accompany  me 24 hours a day because that's what this is really all about isn't it, 'defensive medicine."  Give me a lawyer over a medical ethicists any day. I know lawyers are professional.
Oops.  Ethics is a means whereby people can develop responses of 'deniability'.  That's what this is about too.  Medical students are supposed to be taught more ethics. Yet I'm no doubt ,in the top 1% of my clinical colleagues as I  have read many medical ethics and bioethics texts and I haven't really to date seen how they help me in the office where I'm constantly faced with lack of resources and unrealistic expectations and a thousand chiefs to every Indian.  And having read these texts going back for 25 years today I wish I'd read more immunology because I am fascinated by how the body deals with intruders but can't figure how the medical system has been unable to deal with every carpet bagger who wants a piece of the 'evidence based' pie. People are coming to doctors and wanting doctors more and more. Science is on the rise the world over  whereas philosophy, traditionally based,  is on the decline.
The 'bioethics' of decision making clinically was done in a post mortem discussion. Yet the professional licensing bodies failed patients and doctors alike by not protecting the principal form of clinical learning and ethical development of clinicians from the carpet baggers. When my patient killed himself at Winnipeg General Hospital we gathered as staff and had a frank discussion of what we could have done or should have done or might have done.  There were 20 voices and for 2 hours we hashed it out.  It was brilliant and sad and tragic and we were all grieving this man's death. He'd been suicidal for years and after dozens of tries we hadn't stopped the latest one.  And he died.  What nurses said, what orderlies said, what doctors said, etc all came together to help me decide and reflect on what I would do in any future sessions. We could have been more aggressive with medications.  We could have been more careful with body checks. We could have explored better the patients attitudes to life and death. We could have done a thousand things and most of them came up in that 2 hour session. No one was blaming or fault finding.  It was beautiful. it was clinical learning at it's finest and why I became a doctor.
When my patient suicided at Vancouver General Hospital a year later, it was covered up. There was no psychological post mortem. I was told we couldn't do that as it could be leaked to the media. We couldn't talk about the death as it might lead to medical legal consequences.  There was alot of finger pointing. The doctor who had been covering for me and whose decision was directly related to the death was doing all that beaurocratic stuff of shifting blame and passing the buck and confusing matters. They were so different from the doctor who was covering for me in Winnipeg.  In my early years I seemed to always have a suicide to come home to from holidays since I was treating predominatly suicidals and when I was away a colleague would cover my practice and doing double the work as a result with decreasing hospital beds there was greater risk. Each patient had come to the doctor and said they were suicidal and in both cases the doctors hadn't done what I might have done, my being like an arm chair philosopher, never wrong, but what was most significant to me was we learned from tthe suicide in Winnipeg and in Vancouver we learned to lie and be deceitful because that the was the new ethical norm.  The Pickton Serial Murders have been and interesting study in the failure of beurocratic ethics and the corruption in the system rather than the failure of any one individual .
And the Colleges and Universities and their heads and probably all the way up to the Minister of Health had failed patients collectively because doctors couldn't talk about their mistakes.  The doctors who make the most mistakes are the best politicians.  And increasingly the worst clinical doctors are getting into administration becuase their errors don't show up like dead bodies the surgeons and psychiatrists have to deal with.It's easy to slip 'bad ideas' under the rug. We're still dealing with the philosophy of Marx which lead to 50 million deaths when it was 'applied' by Stalin and the Pol Pot and others.  Philosophy is rarely accountable.
So Wendy and Angela would have a pleasant round circle discussion of what we should and shouldn't do because the spineless doctors in charge of health care sold the farm and today doctors can only talk in back rooms with lawyers about what went wrong.  And our lawyers and insurance people tell us to avoid seeing really sick people. Stay back from the real fight. Let some other guy take on the tanks and machine guns. When the real fighting is over get in their and get your picture taken.
I heard a sergeant tell me that his role in Afghanistan was driving around and protecting Ottawa officers who needed a 'combat' badge on their boy scout and girl scout shirts so they could get advanced in the ivory tower defence beaurocracy. These sergeants orders were to keep the brass away from any real dangers, to entertain them, the wine, and parties and prostitutes or cabana boys or whatever, let them mix with some of the real fighters and then get them home safe after their 2 or 3 weeks 'in combat' because these were the guys who were going to 'philosophise' about war.
Wendy and Angela think that "ethics is distinct from professionalism" They disagree with Wynia et al, who define patient and public health advocacy and activism as a core component of medical professionalism.
I like Wynia and have got in the most trouble in my career for patient and public health advocacy and activism.  I've been repeatedly told by authorities, 'there's nothing more we can do' only to refuse to accept this "ethical decision' on the part of the 'authorities' and instead through 'advocacy' and 'activism' get what my patient needed to keep them alive.  I am annoyed because I don't like fighting the authorities for things as basic as penicillin but a week now doesn't go by with some highly unethical and unprofessional body above accountability within the system interfering with what I believe, know and prove to be necessary for the health of my patient or community. No matter how many times I'm right and these budget cutters, ass lickers, are proven wrong the more they come back and insist that I give them more time than my patients. I am not paid to talk to these salaried accessories and minions. I'm paid for time with the patient but I have less and less time for the patient because increasingly their are battalions of folk gathered to deny the patient life or right to health care.  They are all politically correct and trained in complaints departments ethics.  A month doesn't go by now that I'm not getting a politician involved with getting patients care that was once available but now is only dangled as a carrot for those who go through all the forms and dance steps of the fat and flush beaurocracy.
Fundamentally there is no discussion of bioethics evidence based or not without discussing 'neglect' and 'sins of omission'.
So Wynia et al, now my heros are panned by Wendy and Angela. :They say "we agree with Wynia et al that topics such as conflicts of intererest, whistelblowing, patient advocacy and health care values are important components of medical school curriculum but are more appropriately situated as part of the ethical legal components of health care course;"
The absolute atrocity of my career has been dealing with colleagues, hospitals and administration that have turned out to have 'conflicts of interests'. I have repeatedly followed the money trail leading from the death of my patient to someone on the take, getting kick backs or shines or some such cudo which I wasn't getting and which didn't cloud my judgement when it came to patient care. But suddenly I'm off sleeping and I return to a dead patient becuase I find out that the person who was supposed to be watching my patient was off getting laid by someone. That was one death.  The administrator was screwing the head nurse and my patient died alone becuase there was no one at the bed side because they were off having nooky.
I came across a patient with rigor mortis on the ward.  It takes hours for rigor mortis to set in.  There was a shortage of staff that night. The administration had mismanaged their budget and short changed the nursing staff so that there was none.
I'm a whistle blower and it killed my career. I caught and brought down the medical head of a hospital, a drunk who killed people and lied and cheated.  I found out later that whistle blowers are universally hated in the Canadian health care system, especially in the British Columbia health care system. The people who were supposed to protect me and patients from the idiot didn't do their job. They were off studying ethics and I took the tyrant out so everyone was scared of me and his friends all uniformly thought  I was bad. No patient got to know what I'd done either. There was no democratic discussion where I was carried on the shoulders of patients through the champs elysee. People just pulled back from me and though it was terrible that such an august man, even though he was killing people, could be brought down. There's an anthropological thing that philosophers don't talk about.it's evidence based though. People don't want to be around people who get things done. Peopled would rather a few patients die than the whole apple cart get turned over. The collective guilt of those who did nothing while the killing occured too is best handled by turning away from the person who sacrificed their career for patients. The Code of Ethics for phsyicians is 'patient first'  .  I've rarely seen this in the institutions I've worked in except at the bed side where doctors and nurses are accountable. The further back from the frontline the more cover your ass and concern about pensions and perks takes over.
But I like Wynia et al whereas Wendy and Angela would use up student time for their own bugbears and ideas about what is important. I think Wynia et al are right on the mark.  I can't get a patient seen by a specialist for months unless I pull favours and grease palms but the minister of health when he had a heart attack had the whole floor of a hospital shut down.  20 beds were taken over for his care.  This is Canada. In the US we pay for such privilege but in Canada, a dying bastion of the old british system, status is worth more than dollars and sense.  The new aristocracy is in the beurocracy.  A retired MLA comes to the office and demands dozens of medical travel pink slips which she wants signed. Her tone and body language are threat and harrassment.  She is breaking the law. There is nothing anyone can do about it because of who she is. She knows and she is a bully and she probably would bring legislation against bullies becuase that's what is done. So many of the laws that legilators put through simply don't apply to themselves.
A single law that required politicians to use the health care resources the people use in Canada and not get their private American Ottawa clinic to treat them or their front of the line priviledge would do immense good for the medical system and result in far fewer lower level ethical delimenas for doctors and medical students but we can't talk about this. The oldest law is the Chinese law of the fish. There are big fish and there are little fish. The little fish must be fast and numerous.
In then end Wendy and Angela propose
Six domains of "Medical Professionalsim"
1) Responsiblity (eg conscientiousness, record keeping)
2)  Relationships with and respect for patients
3) Probity and honesty
4)Self awareness and capacity for reflection
5) Collaboration and working with colleagues
6) Care of colleagues

Now I must say if I asked a hundred clinicians to define "medical professionalism' I really don't think any of them would come up with such a list.  Really.
So we're back at the problem of definition that they stated they had a problem with initially.  And remember the 'devil is in the details'.  If we accept these 6 'domains' then we're going down the slippery slidy slope to an absurdity Angela and Wendy may only dwell in alone.
Remember these gals don't want 'clinical competence' messing up what they think 'medical professionalism' should be.  Further they are the same ones who have some idea that there is such a thing as 'evidence based philosophy'.  And we don't know where they got their fine arts degrees if they have degrees as everyone is a doctor today and here we advertise 'rug doctors' and everyone is a 'professional' because the 'professional bodies' association just included a whole collection of people who I never thought were particularly professional.
And how did 'record keeping' get tied in with 'responsibility'.
By the way I was a top medical student. They go on in their paper to associated medical students with bad table manners with those who they find later have problems with the authorities.  Yet fundamentally they don't address the simple concern summed up by the universal statement "one step a head of the crowd, you're a leader, two steps ahead of the crowd you're a martyr.'
They show no capacity themselves or for the bodies they study in the area of 'self awareness or 'reflection'.  I was asked to study trouble makers in a Canadian school system. I found much to the horror of the authorities that  some third of the  'trouble makers' were  geniuses, a third mentally disabled and third bad asses.  The key which no one wanted to admit was the trouble makers were the geniuses.  Indeed many of my patients were smarter than their teachers and the administrators but neither the schools , teachers or administration had any capacity for considering this obvious concern.
A bioethics course I attended by a rather entertaining australian philosopher focused on the recurrent failure of licensing bodies and administrations to maximize the use of the 'difficult doctor' and the tendency for administrative doctors who had by leaving essentially 'failed' in some other field of medicine to think that those who stay in that endeavour should be like themselves.  The narcissism in administration is rarely acknowledged. The delightful philosopher was never invited back. Australians are notoriously 'inadvertently offensive'.  The Americans take Australia very serious.  Julian Assange is an Australian and one could never imagine such a character coming from New Zealand, notorious for it's irrelevance.
In psychiatry we long ago recognised that the same person who had a narcisstic personality disorder and went on to be a top criminal lawyer could just as easily become the antisocial perosnality disorder who became the rich gang leader.  The key was getting beyond good and bad , recognising the value of traits and utilizing resources wisely.
Yet increasingly regulatory bodies are selected from that group of students who are 'goody goody two shoes' and self perpetuate the inherent flaws of yesterdays structures.
I'm a goody goody two shoes. I am fascinated today by the geniuses who didn't go into medical school and won't today because of the unethical and unprofessional controlling of doctors by beaurocrats and tyrants.
As physicians we 'attracted' patients. Patients came to us individually and collectively based on our 'clinical competency'.  Increasingly the incompetent and clinically inept and indeed those who literally hate patient contact and fear disease are getting the reigns of the health care system. In defence terms, we'd say there are alot of cowards in the fields of the new management.  The greatest problems in the sytem are now at the top but there is no capacity for self reflection there.
Record keeping - this is an institutional fascination for clinicians.  Doctors who get behind in their charts will instantly lose thier privilede with the hospital but another doctor can kill several patients and no immediate such reaction occurs.  The institution is more interested in the institutions needs than it is in patient needs. That's the nature of cancerous growths as well.
When I worked in a country hospital recently I dictated all my notes. I'm a noted taker. My favourite clinicians, the very best doctors I ever worked with, weren't note takers like me. One fellow in paricular had the healing touch. Touched patients and they came alive. Genius of a diagnostician, too but a really bad dictator and really bad note taker. Loved the bed side. Loved healing but got kicked out of that hospital. They loved me until a typist I refused the sexual advances from just happened to lose my dictation. So I dictated everything again and that went missing too.  I've had strange women pull me into filing rooms and put my hand on their breasts so I'm not imagining this and no I didn't invite. I treat sex addicts and this is what they do. The ugly don't know about it because the ugly aren't typical sexual prey.  I told her no and extracted my hand and made an escape.  After that I had problems with getting my dictation done.  My colleague told me she'd have just fucked her. She said she got into no amount of trouble refusing sex too so just had sex with one staff.  You're damned if you do and damned if you don't with women, she said.  We laugh together. It helps but I don't have time to deal with unethical staff but the hospital doesn't pay their typist pool well. There's further very little screening and yet all manner of confidential information goes through the typist pool. Another girl didn't speak English and I was supposed to 'correct' my dictation.  it was all errors.  I found out she was sleeping with the guy in charge of the administration pool.
I type at 120 wpm sometimes so I just took to typing my own notes. I've always got my notes in everywhere I go. I'm a typist and a dictator and worked once as a dictaphone typist.  Yet the hassle this has been in different facilities is unbelievable. The last country hospital I worked in was in the news because of all the corruption problems in the hospital. Not surprisingly I had a nightmare of a time getting my notes typed. I worked in another country hospital for two years and never had one problem.  Yet here is this ethicist saying doctors need to be responsible for note taking without realizing that there are amazing factors in volved in such a simple statement that are beyond the knowledge and capacity of a philosopher to grasp. The devil is in the details.  Administration don't have nurses and they don't have typists and they don't want to put money into clinical care and they don't want to put money into typists so the doctor is dependent on the equipment, charts and record keeping and all manner of people who don't have patient care uppermost in their minds.  And increasingly any doctor who objects is now called a 'difficult doctor'.
The whole area of 'chart keeping' today is about lawyers and administratiors.  Charts have less and less to do with patients daily yet doctors are expected to use these tombs which increasingly record beaurocratically what 'should' be said and done rather than 'what actually is said and done'.  I once wrote my notes for my own clinical work, especially caring for the patient, and keeping notes as a journal. It helped us in our clinical work and journey together. Now I keep all notes for third party viewing and their value for clinical work is halved or useless because I can't really put down what I am concerned about.  Repeatedly in courts I've seen judges use clinical notes in ways they weren't meant to. I've seen one judge 'cherry pick' notes to serve his a priori judgement and claiming the 'medical notes' were 'the way he perceived them."  I'd never trust him with a comic book because he would be at severe risk of reading it as a holy book.
This is because of the 'culture' of the institutions.  The new 'culture'  is dictated by the administration and the administration has been favouring goose stepping synchronous look like me and act like me behaviours to the detriment of a once diverse and creative community.
People live in fear in hospitals except at the top. Years ago I wrote a humorous article about the lack of joy and pleasure for doctors and patients in hospitals pointing out that the administrative offices are the only place where there's a party anymore.  It was really well received.  All kinds of doctors called me up and thanked me for saying what wasn't being said.  Up the Doctor , the British Comedy did a series on the hospital administration not wanting patients in general as they interfereed with the smooth running of the facilty.
Last time I was in hospital I felt like I was loathed and hated and causing no end of difficulty being sick. Another time , I waited with my 89 year old father for 8 hours after a car accident just to be seen.  He's a pace maker and arthritis and was subjected to a whiplash and yet there we were not seen by a doctor for 8 hours.
Romes burning and there's an ethicist discussing whether the children should pee standing up or sitting down. Please, piss in the direction of the fires for Gods sake.

I had to look up "probity'. English is my first language.  I was straight A's in Arts and Science.  If I have to look up a word I know that 99% of my clinical colleagues will look it up.  Typical academic, choosing an obscure word to state a simpler said thing using 'common english'.  Obfuscation is what our hospital medical ethicist impressed me with. I listened to him discuss a case and he was like the movie Doubt. Everything was okay and he wasn't going to get himself into a position where he had to support anyone position. He was a glorious pantheist and bent over backwards showing how much he liked every aspect of a decision making except the decision making part itself.  Idiot. Like we don't have our own random thoughts and wandering ideas but when the rubber hits the road we who are 'doing' things know we have to be responsible. W e also don't have time to Mary away our time when we've got 60 people in the waiting room and on average 7 minutes to Martha each.
In the psychiatry office I've got a dozen a day at least, every half hour to 45 minutes and when I started I saw people once or twice a week but today am lucky if I can book someone in next in 3 to 6 months.  I had a complaint last year because a person threatened to complain if I wouldn't see them. That's how the telephone call began after the patient had badgered my assistant. I told them I wouldn't see them. The cost of that refusal to see a threatening individual was roughly $10,000 in loss of time and work that had to be done.
The licensing bodies deny their own destructiveness of the profession and the horrendous cost of their involvement in the system. They are like the police who in rush hour traffic on the freeway pull over a person going 5 miles over the speed limit and while ticketting them cause  a dozen accidents upstream,  Tyrrany is above self reflection. The administration demands 'self awareness' from all others because like big babies they haven't the capacity themselves but they love to talk about it. They talk about it because they lack it.  Those who have it don't talk about it.
Like my favourite doctor who wasn't good at note taking. I told a young genius to avoid medicine. He'd suicide with his desire to 'fix' people's illness. I encouraged him to go and work in engineering building mines or something.  He'd burn out in weeks as a doctor these days.
I was told by the leading government rock star that I wanted my addicted patients to abstain from drugs and alcohol whereas she saw her role as assisting patients in the culture of addiction getting food, shelter, drugs , money and everything that was harming their health. She thought I was wrong to interfere with their 'culture of addiction ' that my patients subscribed too. I envied her her  million dollar budget and went back to treating my patient feeling like a dinosaur among robots.
Probity means 'the quality of having strong morals and principles.'
I was raised Christian and as a Christian studied morality to no end. I'm also cross culturally trained and worked with the finest. I'm a student of comparative religion too. My favourite ethics book was by Dr. Robert Hare. It's called Snakes in Suits. It discusses how sociopaths and psychopaths chameleon and get into positions of authority and destroy individuals and systems.  I wish I'd studied that in medical school becuase it described so many of the characters I'd had problems with.  My colleague who was arrested for theft was in there as was the hospital administrator who stole the money for the baby incubator and the nurse who was self inflicting wounds to get off work. Dr. Robert Hare is a brilliant clinician and his book rings of morality and truth.
Beverly McLaughlin is the head of the supreme court of Canada. She's a breath of fresh air. She campaigns for 'transparency' in law courts in Canada. She has whole lot of judges and lawyers against her. There is a great deal of dishonesty in the legal work and the administration world.
While I know the American authorities don't consider New Zealand even relevant don't Wendy and Angela know what's happened to Julian Assange. I've no interest in him personally but he and wikileaks are the greatest weathervane this world has had in the last 50 years on whether 'honesty' is really going to have any place in beaurocracy and government. Nothing has better exposed the lies and deceit that dominate the colleges, universities and hallowed halls of power than that the people who were students of the greatest universities in the world are acting like thugs and mafiosa making dirty sneaky decisions behind closed doors with little thought or care for the people they are supposed to be serving.
I work in a city where the Stock Exchange was so corrupt it was shut down and now only operates with adult supervision from another city in Canada. The principle agricultural product of my community is marijuana.  When I objected to the  Manitoba Medical Registrar that so many colleagues were smoking dope he actually said 'if we stopped every doctor doing drugs we'd not be able to man the ship" or some such words. Whether because he smoked dope himself or his circle smoked dope he believed wrongly that physicians collectively smoked dope.  I was concerned about a professor smoking dope and having sex with students.  At most 10% of doctors at the time had smoked dope once and very few indeed were regularly dope smokers. More frightening was the recent Canadian estimate that some 40% of judges had done cocaine.  Lawyers have a much worse track record for illicit drugs, something like 2 or 3 x as bad so it's not surprising that as lawyers become judges judges have a much higher risk.  Yet here was the senior licensing authority unaware of a tremendously critical ethical and moral problem.
All the evidence based research from addiction medicine and psychiatry shows that the first harm of chronic drug or alcohol abuse is morality. Drugs and alcohol and addiction in general is called the great eraser because it erases the layers of brain taking out the frontal lobes , then amygdalla and finally affecting the basal brain.  So people with drug and alcohol problems can readily have sociopathic tendencies and commonly make poor ethical decisions because increasingly they thnk less like humans and more like animals and lizards.
I'm frankly terrified of colleagues with addictions. I love people in recovery but I've seen the harm done by drug addicted doctors and fear drug addicted judges and administrators more. But the depth and seriousness of the problem is such that they refuse random drug screens and come up with all manner of arguments , probably put together by ethicists, on why they shouldn't have someone looking at their pee.  It certainly upset the supreme court judge nominee that investigators found evidence of sex addiction in the extensive pornography purchases disclosed by his garbage. If that's what you find outside the house, imagine what's concealed inside the bodies.
That's why Beverly McLaughlin is such a threat with her promoting transparency.  Yet aren't some 'secrets' justified.
Yesterday a government agency sent a man back to me who I said was a danger to society.  They wanted me to review my statement.  I was afraid of this man and I again said he was a threat to society.  The same thing happened when I recently said that I didn't think a dangerously insane person should have a gun. The police involved didn't have the confidentiality in place to protect me for my contribution to my community. One very angry fellow showed up in my office wanting me to be accountable for my decision in a way that wasn't something ethicists considered often. And I know the police can't get to me in the time it takes for me to die. Their promise to protect and servie is a lie. It needs a provisor these days, "sometimes in the future, if the budget cuts have left us with any indians and the chiefs haven't sent us out on soemthing that isn't police work so we can respond still to an emergency."
I looked up definitions of professionalism and they're very different from this list of 'domains'.
Dr. Jeff Schmidt in his book, Disciplined Minds (subtitled a critical look at salaried professionals and the soul battering System that shapes their lives) considers professionals as "the less creative and less diverse".  Professionalism then should begin with a study of 'lack of creativity' and 'lack of diversity'.
Alternatively professional refers to a person who has a specialized set of skills which they exchange for a set amount of money.  To this end a good study of professionals would consider the highest earners and study as Maslow might what traits they have in common.
Angela and Wendy wandered off talking about 'altruism' and airy fairy shit which I've not seen in the highest earners in my profession.  Also the issue of 'salaried' versus contract versus 'fee for service' affects 'professionalism' significantly .He who pays the piper calls the tune. So in truly private practice the patient pays for the services but increasingly in public services a third party with its own agenda plays the key role in defining the professional behaviour as it defines what will be paid.
There is little correlation today between what I am paid and what a positive outcome should be. Indeed with the increasing success of abortion and now talk of euthanasia as the new buzz there's a trend to health care being defined by what is 'least done' rather than what is most. Further there is a whole area of 'investigation' rather than 'therapy which is key to ethics.  Endless investigation can avoid ethically difficult treatment decisions.
The rest of Wendy and Angela's paper was heavy with the word 'innappropriate'. This is one of the great ' weasel words' of psychiatry and yet Wendy and Angela don't even enter that critical discussion because one assumes they assume that everyone knows as they know what is 'appropriate' yet 'appropriate' behaviour is the bouncing ball in multipcultural society and especially beurocratic societies where fashion rather than evidence based factors really sets the whole tone on any endeavor.  What is appropriate is increasingly best understood as what is fashionable yet this paper doesn't even address this.
It does say that students who had trouble completing their assignments often went on to having problems with record keeping. There's a subtle suggestion of 'badness' here but I couldn't help think of attention deficit disorder and obsessive compulsive disorders and wonder why the students weren't identified as such in medical school.
There is increasing 'tokenism' in beurocracy which has resulted in some ethnic, female and sexually oriented individuals getting preferential treatment in schools to allow them to access the professional 'status' which has historically been considered authoritarian.  Such matters as 'tokenism' and 'athoritarianism' seem more important than some of the discussion by Wendy and Angela.  Further, tokenism hurts the tokens in contrast to meritocracy which proves the invalidity of tokenism and unfair discrimination.
Their paper is pretty and fashionable but it's not left me thinking it has anything to do with what I'm going to do the next time someone threatens to kill me in my office or any of the other really interesting ethical and moral dilemnas doctors face . My favourite these days is the pathologically lying colleague. Another is the pathologically lying patient.  Another is the patient who says, "if you don't give me drugs I'm going to complain to the college of physicians and surgeons."  I'm really wondering too about ethically working with the incredibly wealthy pharmacists who were getting millions of dollars in kickbacks for only stocking a particular brand of generic drug after the government kicked the drug companies that actually do research out of the country. I think of issues on a lesser scale than the greater scale issues I just read in a treatise on the Vichy French.  I work with some of the senior pharmacists whose ship came home on the backs of the elderly and diseased.  I feel just a little unclean around them like they really should be dealing black jack in a casino somewhere and should never have been allowed anywhere near a patient as I understand them.
But according to Wendy and Angela 'clinical competence' indeed a whole lot of matters 'clinical' don't count nearly as much as "inadvertant offensiveness' in my world where some of my patients are fundamentally offended by anyone else but themselves.  These patients with severe personality disorders look for offense but in the Wendy and Angela scheme the doctor and medical student should be taught to only 'advertently offend' without consideration of the type of person who is always offended and has a monopoly on persecution.
It misses the mark but does tend to point to why medical students might be missing the major clinical issues I'm concerned about because theres no time in their curricula for the study of schizophrenia, heart disease or brain tumors.
Professionalism according to Wendy and Angela is more what I learned as a young man in a 'salesman' course.  So if you think of the doctor as a 'marketting agent' then surely this article is a good one. Certainly the best marketting agents are the richest and wealth and professionalism go hand in hand. Yes? No?


Anonymous said...

there are alot of sick people out there

the sick people are so sick that you can not help them

you can not agonize over everyone
and I have never seen a whistle blower ever win...ever

as thoughtful as you are you have to just do the best you can and move on...

Anonymous said...
This comment has been removed by a blog administrator.
haykind said...

The challenge is helping the sick. I've sometimes thought that Paul, Peter, Gandhi, Martin Luther and such are all waiting to enter heaven but are waiting for the last one, perhaps me to catch up.

As for 'jumps in logic', I studied logic and don't have the luxury of 'jumping' much outside a 'blog'. In my working world there is not the 'play' of the blog where I believe the instantaneous trumps the long pondered. The blog is part of the new genre of writing which captures the moment better. I prefer 'leaps of faith"
Your 'anonymous' reply came up on my 'spam' meter and I thought it was simply a self serving mechanism to get as many viewers looking at your page. I sometimes read these 'generic' sounding replies and suspect they are factory produced in an attempt to get around the spam people. In contrast the first note from anonymous is real and human and sounds like something written by someone who has read my blog. I'm truly not sure if rubbish removal isn't just a marketting strategy, but I chose to respond to this in hope that perhaps a human exists somewhere in the rubbish removal business.