Changing pre-med requirements and med school curricula

Ezekiel Emanuel, the University of Pennsylvania physician and ethicist, has written an opinion piece suggesting many changes in both pre-medical education and the medical school curriculum.

He would do away with many of our hallowed medical school prerequisites such as calculus, physics, and organic chemistry, feeling that those subjects are simply used to "weed out" certain students. I confess I once believed that such subjects were worthwhile. However, Emanuel makes a convincing argument that rigorous college courses in more relevant disciplines such as statistics, genetics, ethics, and psychology with a special focus on human behavior would suffice.

Regarding medical school, Emanuel points out he was taught the Krebs cycle on four different occasions in college and medical school and never used it once in practice or research. I have made a similar observation in a previous blog post.

He considers pathology, cytology, and pharmacology to be largely irrelevant to medical practice but concedes that some may disagree.

Ethics and uterus transplants

Guest post by @UtilityKnife1

It’s easy to be negative. Given that the return in clinical outcomes relative to cost is too often poor for any clinical innovation (e.g., robotic surgery, home uterine monitoring, bone marrow transplants for breast cancer, etc.), it is a reasonable bet anything new in medicine is lemon. Innovation and technology within health care account for significant portions of per capita growth in health spending among Americans over the last 50 years. In some cases this spending has resulted in real improvements in health outcomes but this is not the case in many settings. So what about spending to transplant a uterus?

Uterine transplant is not new. The procedure has been done in animals, has even resulted in live births among humans, and is not conceptually complicated. A donor uterus including the cervix is sutured to the top of the vagina, and the blood supply is hooked up. Since there is no nervous input into the transplant, it will not contract in any sort of coordinated way and delivery of any fetus must be via cesarean section. Similarly, fetal movements will not be felt in the same way. Any “experience” of pregnancy from a transplanted uterus is thus not totally natural (note the recent patient who underwent uterus transplantation at The Cleveland Clinic said “experiencing” pregnancy was an important reason behind her decision to pursue this surgery).

The reason to perform a uterine transplant is most easy to understand in those settings where a woman is born without a uterus (although in these cases they should have ovaries). Getting pregnant with a transplanted uterus requires in vitro fertilization. The organ recipient will have to take anti-rejection drugs, and when pregnancy is no longer desired, the uterus should be removed to avoid prolonged exposure to these drugs. None of this is an ordinary part of the pregnancy experience to say nothing of the implications for the fetus.

A HIPAA and ethical conundrum

Do you know anything about HIPAA?

Here’s a scenario for you.

Patient A comes in from the parking lot of a doctor’s office and said to the nurse, “I just saw a patient leave here and when she was backing out of her space, she hit another car. Then she just drove away.” Patient A was able to accurately describe the perpetrator and said she would sign a statement saying she witnessed the incident.

The nurse finds out that the car that was struck belonged to Patient B. Patient B then asks the nurse to tell him who was driving the car that struck his.

The nurse, knowing exactly who the hit-and-run driver was, said, “I can’t tell you that. It would be a HIPAA violation.”

Patient A and Patient B appeal to the doctor. What would you tell the doctor to do?

Major Ethical Breach at Bronx Trauma Center

Not to diminish the magnitude of the tragic bus accident that occurred in New York yesterday, but as a surgeon, I am compelled to mention the almost astonishing ethical and privacy violation committed by an unnamed surgeon at a Bronx trauma center.

According to a New York Times article published on March 13, 2011, the following took place:

“The wife of a Jacobi Medical Center surgeon said her husband called her from work and described a passenger with a crushed skull and others with hand and arm amputations. She showed an iPhone photo, texted from Jacobi, of a hand and forearm, severed just below the elbow, lying on an operating table.”

I have many concerns here.

One, why would you call your wife to discuss a victim’s injuries?
Two, why would you text a photo of a severed extremity to you wife?
Three, did the victim sign consent for photographs and did he agree to let the surgeon disseminate information about his condition to the wife or the New York Times?
Four, why would the wife discuss this case with a New York Times reporter and show him the picture?

In the next few days, I expect that heads will roll on this, and rightfully so.

Medicolegal Musings: Physician Posting on Social Media & the Internet

You are in the middle of a deposition. Plaintiff’s lawyer asks, “Do you blog or tweet?” Before you answer, consider this. If you blog or tweet and respond in the affirmative, I believe anything you have ever posted would be subject to discovery by the plaintiff. Oh, you post anonymously? Would you then lie under oath and say you do not blog or tweet? For many physicians, admitting that you blog or tweet might not be a problem. But in my short career as a blogger/tweeter, I have read some things that frankly would not enhance a malpractice defense if projected on a large screen in front of a jury.

I will allow that I am skeptical and sarcastic, but I do not think I have posted anything that is derogatory to a patient, either generally or specifically. There are some very popular anonymous doctor-tweeters who post some scathingly negative comments about patients. Even if a patient could not be identified, the tone of some of these posts implies a deep-seated resentment of patients and their problems, not to mention many are vulgar, sophomoric or both. OK, some of them are funny as well, but the humor would be lost in a courtroom. Some of these tweeters disseminate prodigious numbers of posts per day perhaps suggesting that they are not always focused on their work.

I have followed several medical bloggers who post clinical anecdotes, which are essentially case reports. Despite disclaimers stating they are not about real patients, it seems obvious that they are. If the subject of one of these case report blogs decides to sue, it might be difficult to convince a jury that the blog was about a fictitious case. And this type of publication might be considered a HIPAA violation especially because it is unlikely that a blogger would have obtained institutional review board permission to publish the case report.

By the way, if you blog or tweet anonymously and answer falsely that you don’t, you better never have told anyone that you do. A lie under oath that is discovered tends to undermine your credibility quite a bit. [Defense lawyer, “Your honor, may we have a short recess while I talk to my client.”]

As far as I know from an attempt to search for medicolegal references to Twitter and blogging, this perspective has not been brought up before. What do you think?