Material Summaries:

Hippocrates: The Physician summary

Hippocrates is discussing the preferred physical appearance of a physician. He must present himself as well-taken-care of. He must be fair, proper, and self-controlled, and he can’t be harsh or demeaning, or he will not establish rapport with the patient.

Hippocrates: The Oath summary

The oath is a statement of a physician that he will “do no harm” and always act in the best interest of the patient. A doctor must act dignified and respectful of all patients and must never speak of a patient’s confidential information to another. Interestingly, the oath mentions today’s controversial topics like abortion and physician-assisted suicide as completely prohibited.

Groopman: How Doctors Think Introduction summary

Throughout the introduction, Groopman tells the story of Anna Dodge, a 31-year-old woman who had seen doctor after doctor for years because they couldn’t figure out what was wrong with her. She had been diagnosed with anorexia and bulimia, and later irritable bowel syndrome, but even after increasing her daily calorie intake, she was getting worse. Finally, a new doctor named Dr. Falchuk came in and sat down with her, listening gently to her description of her condition in her words, and he diagnosed her with celiac disease.

Groopman believes the doctor-patient relationship to be created through trust. That trust is founded upon language, mannerisms, and actions. Groopman praised Dr. Falchuk for listening to Anna and letting her explain her symptoms herself with no judgment or wrongly constructed questions.

Groopman criticizes medical school teachings for making students learn the clinical decision tree, a closed, limited way of diagnosing patients’ conditions. He believes that doctors must learn to think outside the box more.

Discussion Questions:

• How much merit does the clinical decision tree have? How helpful is it in diagnosing patient conditions?
• Groopman’s book was published in 2007. Do you think there has been a change in the way doctors have been taught to interact with patients since then?
• Given the controversial medical topics discussed in today’s age, should the Hippocratic Oath be changed, or even done away with?
• In what ways could medical schools teach their students to think outside the box more?
• How much weight does physical appearance have in a patient’s first impression compared to mannerisms?
• What should be the most important step in establishing a trusting relationship between the doctor and the patient?

General Discussion in Response to Questions:

• How much merit does the clinical decision tree have? How helpful is it in diagnosing patient conditions?
  • Should be expounded upon
  • Discussion of topics in this class is binary, similar to the algorithm of the decision tree
  • Can become obsolete when effects on the patient aren’t necessarily biological
  • Helpful in some ways
    • Base understanding of diagnosing patients
    • Good building block to learn off of
    • Provide established method of structure to narrow down diseases
  • Only relying on the decision tree can miss things
    • Can be challenged by preconceptions and tunnel vision
  • Start with decision tree, then go from there
    • Definitely listen to the patient’s descriptions and experience
  • Decision tree must be continually reassessed throughout the patient questioning and treatment process
    • New information can render previous assumptions invalid
  • Decision tree can lead to confirmation bias
  • Decision tree helps administration, insurance cleanly categorize cases
  • Helps people who fit within the “normal” mold of a disease
  • Decision tree treats the condition rather than the patient
    • Makes the patient into a puzzle
    • Similar to a calculator with functions – inputs affect outputs
  • Should be expanded and changed to fit what the patient is saying
• Groopman’s book was published in 2007. Do you think there has been a change in the way doctors have been taught to interact with patients since then?
  • Med school is a classroom setting
    • Loses humanity
  • Primary care physician response has been pretty positive
    • Listen to patients
  • Specialists take the decision tree more into account
    • Natural, given that they are specialists and don’t know the patient as well as primary care
  • Bedside manner can’t always be taught
    • Experience can play a large factor in bedside manner
  • Today, people value quick, easy service instead of quality face-to-face that might take longer
    • Telehealth has exacerbated it
  • Physicians must be able to accept when they’re wrong and question their biases and judgment
    • Can be affected by stereotypes, implicit bias
  • Doctors need to trust the patient more
    • Cynicism is becoming more prevalent
    • Should be skeptic, not distrustful
• Given the controversial medical topics discussed in today’s age, should the Hippocratic Oath be changed, or even done away with?
  • Most medical students don’t actually say the original Oath
    • Have changed it to match today’s social values
    • Has become a list of things to do or not to do, not necessarily the original
  • Should be changed to fit the times
  • There are values in the Hippocratic Oath that are valuable, but not because they’re in the Hippocratic Oath
  • Medical schools should go back to lower tuition
    • Stipulated in the Hippocratic Oath
    • High tuition counter-incentivizes students so that they avoid medical school or accept programs of less prestige and learning
• In what ways could medical schools teach their students to think outside the box more?
  • Did not get to
• How much weight does physical appearance have in a patient’s first impression compared to mannerisms?
  • White Coat Syndrome
    • Patients’ blood pressure increases when they see people wear white coats

• • • • Authority figure makes them stressed out

• • Some people value white coats and suits more
    • Looks more professional
  • Every patient population is different and views doctors differently
    • Physical appearance matters for what type of patient they’re seeing
    • Know the audience
  • How you act is also important
    • Okay to have a personality and laugh, but always remain professional
    • Always take patients seriously
  • Must be conscious of the agenda people have
    • Emotion shouldn’t be ignored
• What should be the most important step in establishing a trusting relationship between the doctor and the patient?
  • Did not get to

Discussion Response:

What I took away from this discussion is that America as a whole is moving towards a quicker, more efficient society at the expense of personal relationships. This is a big problem; the core of medicine is to definitively help someone, and that cannot be completely accomplished without forming interpersonal connections with the patient. However, if bedside manner is falling out of curriculums in undergraduate and medical school, the only way to develop it is through years of experience. As the name suggests, it takes a long time to build that up, and a doctor could see countless patients before a satisfactory, successful bedside manner is developed.

That is why classes like IDMD 101 are so beneficial; not only does it encourage future physicians to think for themselves and create their own opinions, but it also teaches the value of viewing the patient as a person and not just an amalgamation of statistics. Medicine is neither linear nor clear-cut, and the efficiency that the medical field values tries to circumvent that by ignoring bedside manner and embracing concepts like the decision tree.

While such concepts are useful in many situations, there should never be one concept or process that is the end-all-be-all of a patient’s treatment plan. Just as a patient should never be construed as a simple statistic, or another tick on a list of “patients helped today,” physicians should remember that there is never a perfect way to examine and diagnose a patient. It is imperative that physicians learn to adapt to and account for outlying situations like Anna Dodge’s, because looking at a new problem from a conventional stance might not reveal everything that is happening with the patient, and therefore the physician can’t make the most informed estimates on the patient’s diagnosis and/or treatment.

Kaitlin Deans

Dr. Geoffrey Emerson

IDMD 101-004

6 Oct 2023

Physician-Assisted Suicide in Canada

       In 2016, Canada implemented a national law that prohibits physicians from suggesting Medical Assistance in Dying (MAID) to patients that only suffer from mental illness. Currently, the rule stipulates that the only patients eligible for MAID are those who are older than 18 and have a serious and incurable condition that will lead to death. However, a physician at a Vancouver hospital recently offered MAID to a patient suffering from chronic depression and suicidal thoughts. I was unable to find the original Canadian report, but there is no mention of the patient having any physical ailment.

This means that a physician in Vancouver broke Canadian law by offering assisted suicide to a patient who was suffering purely from a psychiatric diagnosis. This could set a precedent of physicians ignoring the law in order to give a treatment that may or may not be right morally or legally. Not only that, but it could even harm the patient further by giving them a sense of hopelessness that a professional believes it is futile to help cure them.

This touches on informed consent, because the law states that in Canada, patients who only have a psychological problem with no physical underlying condition are ineligible for physician-assisted suicide. Not only does offering the treatment to an ineligible patient make them think that they are eligible, but patients who are receiving this as an option (psychiatric patients with no terminal physical condition) are not generally considered mentally sound enough to make this kind of decision for themselves.

It also touches on medical futility, because only patients who have a terminal physical condition may be offered the treatment. This better defines what Canada believes is a medically futile case; patients with psychiatric disorders, even those that are severe, are not considered futile and therefore cannot receive the treatment.

A patient could misconstrue this as the physician thinking they are a medically futile patient, which could lead to a hopeless mindset due to the idea that a so-called expert in health does not believe they will get better. If a medical professional that society tends to idolize doesn’t believe a patient will get better, then why should they believe they will? I realize that isn’t the case with every patient, but there are those who would give up hope based on everyone around them giving up too. This could push them to attempt to end their own life through unsafe means, which is why many doctors discuss the option with the family first, before bringing it up to the patient.

This could also lead to misinformed consent because the patient is now considering a futile option rather than the viable options they actually have. Once someone in the hospital realizes the patient’s situation and that this is the treatment being offered for that situation, it will no longer be on the table. Not only is a doctor projecting their view of futility on a patient and thus affecting the outcome of their treatment considered paternalism, but it can also fall under lying to a patient because they are telling them of an option that they can’t actually use.

More often than not, those two seem to go hand in hand. If a doctor wants to override a patient’s free choice, whether they have a sound mind or not, it is very easy for the doctor to misrepresent statistics or even omit information altogether to influence a patient’s decision towards what the doctor wants them to do.

From a patient’s perspective, offering this treatment to a patient and their subsequent acceptance or denial of the treatment would depend largely on their personal beliefs, both surrounding the treatment itself and the law. Some would refuse to accept the treatment on religious grounds, or they would refuse the right of a doctor to give it in the first place. Some would accept the treatment, especially if they have planned it for a while (as in the case of someone with progressive illness). Finally, though it seems paradoxical and is likely very uncommon, I believe that it is possible for patients to refuse the notion that a doctor should offer it, but since they are offering it accept the treatment anyways. Overall, if they are of sound mind, the doctor must accept their beliefs and choice, otherwise they would be engaging in paternalism.

The average public reader’s response to this would be dependent on their beliefs. They could lose trust in the medical field for giving patients a treatment that they do not believe in, or they could be perfectly okay with the treatment because they agree with the practice. Furthermore, if a patient is aware of the law surrounding MAID, they might lose trust in their doctor because they would see the doctor ignoring the law to advise them in care that they can’t receive. If a patient is unaware of this law, depending on the severity of a patient’s psychological state, they still cannot make an informed decision on this, and this treatment could hurt them in the long run. This brings up a different legal issue in not gaining informed consent before treatment, which could lead to lawsuits and loss of license.

As I am discussing the average reader, I should clarify my opinion on the subject, and how my opinion and that of a reader might differ. As far as I am concerned, I believe that since there is little understanding of psychological disorders and how to truly cure them, Canada’s approach is logical, and I can understand it. For personal and religious reasons, I would never give MAID as a treatment, but I would still discuss it with the patient and refer them to a physician who would give it to them, assuming the patient is of sound mind and has discussed this at length with me and the other medical professionals involved in their care.

This article could help close the expertise gap between patients and doctors because it emphasizes how most patients know their own bodies better than a doctor does. This is instinctive to most mentally sound patients, and it has even been a cause of debate between doctors and individual patients in a wide variety of settings. In most cases, if a patient is mentally sound, they are the ones to make the ultimate decision about treatment, not the doctor. If the doctor believes the patient not to be of sound mind, then the patient cannot make an informed decision and it is decided that the doctor (in the absence of family and emergency contacts) is in a better position to make that decision for them. This, I believe, is Canada’s reasoning behind imposing such a law that only patients with futile physical ailments can even be considered for the treatment.

Works Cited

Kornick, Lindsay. “Vancouver hospital discusses ‘medical assistance in dying’ treatment to suicidal patient.” Fox News, https://www.foxnews.com/media/vancouver-hospital-discusses-medical-assistance-dying-treatment-suicidal-patient. Accessed 6 Oct 2023.