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* exam experience
  rdb - 02/21/06 14:32
  This forum helped me a lot to prepare for the exam . Now its time for me to help others.I prepared for a month,6 hours a day(I am pretty slow). Used UW for both mcqs and ccs. Took step 2 CK in 2004. I hadnt touched the books for more than a year. Tried to read Kaplan step 2 notes, but it was time consuming. Read only IM and half of OBGYN. First I did Fiscers Qs. It really made me to think and I liked it more than UW. then started UW and my average score was 58. I took notes from all the mcqs and read it twice before the exam. Two days before the exam I read Aster notes once(helped me answer 2-3 Qs). Went through for some derm pictures and Washington U website for ethics.
Did not do kaplan mcqs.
Did not do Fischers ethics.

Got 75% in USMLE CD a week before the exam.
Got 430 in NBME one month before the exam( did the free trial)
58% in UW

Read UW twice(all the cases) and read 100 CCS rules twice. Actually after reading UW, I was totally confused and kept on forgetting the orders. Thats when CCS rules gave me the helping hand. If you read that rules thoroughly, U can easily ace the CCS. But I strongly recommend to read UW also......As everybody says become familiar with the software.

As everybody says first day was more tiring than the second. MCQs were really lengthy and tougher than UW. UW helped to answer about 7-8 Qs. Very few mcqs were straight forward. Some were weird. most of them were about the common conditions, at the same time the most confusing one. Time management is very very imp. I had to rush through the last 3-4 Qs in almost all the blocks.I was guessing the answers most of the time(>80%).
please read a little how to interpret medical literature. the following scenario was repeaded so many times on my exam (at least 10-15 questions with almost identical scenario):
a person takes X measure (or a study was done to see the effects of X, something like this), he wants to know about Y measure, u have read table 1.1 (will be given).
there will be 2-3 questions from this table, such as:
what would u suggest the person
what is sensitivity/specificity of the measure Y or X
what kind of bias is possible, what does the p value mean there, and things like this.
It was totally confusing and I am sure I got all of them wrong. Towards the end I didnt even care to read those type questions, rather I spent time on other questions.
Day 2 mcqs were similar to day 1.

All the cases were from UW. But it depends, some of my friends got only 3-4 from UW. Thats were CCS rules comes to play a major role. It generally tells what to do in CCS. All my cases improved and ended well ahead of 25 minutes.

After the exam:
I was really depressed. Oh my god! How do usmle manage to write those type of Qs. Where can I find the answers for those Qs? CMDT? Harrisons? or may be AFTER doing residency for 1 year?? What I did in the exam was GUESSING. why the heck I studied for a month. Nothing was useful except UW ccs cases. Exam was more difficult than I expected and more difficult than UW. But the good thing was the CCs cases.
I was really worried about the scores and I just wanted to pass.......with gods grace I got 86.Now waiting for the match.

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* Re:exam experience
  mamu - 02/25/06 08:55
  Thanks man, you are the best........

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* Re:exam experience
  rdb - 02/24/06 15:53
  hi mamu,

This is the link:
BUT, its not working now??

Here are its content:

Advance care planning is a process aimed at extending the rights of competent adults to guide their medical care through periods of decisional incapacity. The process, when accomplished comprehensively, involves three steps: (1) thinking through one's values and preferences, (2) talking about one's values and preferences with others, and (3) documenting them. What follows is a discussion of commonly asked questions related to the process of advance care planning. (For related discussion, see also the topic pages on Advance Directives, DNR Orders and End of Life Issues.)
How is advance care planning different from advance directives?
Advance care planning is the process. Advance directives usually are the written documents that provide information about the patient's wishes and/or her designated spokesperson. Verbal directives may be ethically valid, but most patients and health care providers prefer written documentation in the form of official forms. If official forms are not used, health care providers should document the result of their advance care planning conversations in a medical record progress note.
What are the goals and expected outcomes of advance care planning?
The goals of advance care planning are four-fold. In the event of decisional incapacity, they are to:
maximize the likelihood that medical care serves the patients goals,
minimize the likelihood of over- or undertreatment,
reduce the likelihood of conflicts between family members (and close friends) and health care providers, and
minimize the burden of decision making on family members or close friends.
As a health care provider who engages her patient in advance care planning, you can expect to better understand your patient's views about the goals of medicine, his preferred approach to end of life care, what makes life worth living, as well as his fears about medical interventions and loss of dignity. In addition, you can expect to have a discussion that clarifies misunderstandings. For example, patients often think that cardiopulmonary resuscitation is successful 80% of the time, that mechanical ventilation is a fancy word for nasal prongs, and that coma patients still have the ability to enjoy life.
You can also expect to have better communication with the patient's family members or loved ones because there should be enhanced shared understanding of the patient's values and wishes. Thus, you can expect to have fewer conflicts with family members about the approach to end of life care.
Advance directives will not be the outcome of most advance care planning. At a minimum patients should become familiar with the concept and rationale for advance care planning. Some patients will want to mull things over, others will want to discuss the topic with their close friends or family and health care providers. Fewer will be ready to sign documents and even fewer will be interested in personalizing their advance directives so that they are clear and contain pertinent information with clinical relevance.
Who should I approach for advance care planning?
Unlike health promotional activities that are targeted to select populations based on cost-effectiveness research, advance directives and advance care planning have been recommended for everyone. This is a limitation to the policy as recommended by the Patient Self-Determination Act of 1991 and the Joint Accreditation of Health Care Organizations, as it has led to including a standard set of questions at hospital admission without much information or understanding.
We usually think of doing advance care planning with patients who are at higher risk for decisional incapacity. You should consider having a conversation about this with patients with the following conditions:
at risk for strokes (e.g., those with hypertension)
experiencing early dementia
engaging in risky behavior that is associated with head trauma and coma (e.g., motorcyclists, riding in cars without seat belts)
experiencing severe, recurrent psychiatric illnesses
terminal illness
When and where should I initiate advance care planning?
It is unknown when or where advance care planning should ideally occur. It is generally thought that this should occur initially in the outpatient setting, and then be reviewed upon admission to and discharge from inpatient settings. It is also recommended that whenever there is a significant change in a patient's social or health status, the patient's views about advance care planning should be reviewed.
How can I raise these issues without scaring patients?
You can raise advance care planning as one of many health promotion activities. These discussions are aimed at avoiding harms (over- and undertreatment), and promoting benefits (treatments tailored to the patient's goals). You should reassure the patient that raising this issue does not mean that there is something unspoken to worry about. You also may tell the patient that this topic is difficult for many patients and that you will understand if she does not want to come to any conclusions during this discussion.
Are there some questions that I could use for advance care planning?
When having a discussion about advance care planning, the following questions are recommended:
Who should speak on your behalf if you become so sick you can't speak for yourself?
Are there any circumstances that you've heard about through the news or TV where you've said to yourself, "I would never want to live like that?" If so, what are they and why do you feel this way about them?
Are there any life-sustaining treatments that you would not want to receive under any circumstances? If so, what are they and why do you feel this way about them?
Some people have more concerns about the way they will die or dying than death itself. Do you have any fears or concerns about this?
In the event that you are dying, where do you want to receive medical care?
Should your current preferences be strictly applied to future situations or serve as a general guide to your family (or loved ones)?
How should I advise a patient if she doesn't have anyone to name as a proxy?
You should inform the patient that the best course of action under these circumstances is to write down her wishes and give a copy to her health care providers. She should fill out a legal form, such as a living will, with as much detail as possible, and then include a personalized statement to provide a better understanding of her wishes.
How should I advise a patient if he believes that some family members will disagree with his wishes?
The patient should be informed that the best way to prevent disagreements is to communicate with everyone ahead of time to let them know who has been picked as a spokesperson and what kind of approach to medical care he wants.
As a trainee, should I do advance care planning with my patients?
In the ideal doctor-patient situation the primary care physician should initiate discussion when the patient is not acutely ill. However, this often is not the case and therefore these discussions frequently occur in the hospital setting. Regardless of the setting, good medical practice includes having these discussions. Thus, medical students and residents should engage the patients they are caring for in these discussions. If the patient has been recently diagnosed with a terminal or life changing condition, has severe depression, demonstrates paranoid ideation, or is suicidal, you should ask the responsible attending physician whether this is an appropriate time to raise these issues. Otherwise, you should initiate the discussions and request faculty support (such as role modeling or mentoring) if needed. You should review the framing of the discussion and the patient's views with the attending physician responsible for the patient's overall care
Case 1
An elderly woman told her daughters that if she ever ended up with dementia she wouldn't want to live like that. Years later she developed senile dementia and her daughters had her move into a nursing home. Although she did not recognize family or friends, she enjoyed the company of others and the nursing home's cat. When she stopped eating, her daughters were asked whether she should receive a feeding tube.
Should the daughters consider her previously stated wishes as an advance directive?
Case 1 Discussion
The daughters should consider her previously stated wishes as well as her current best interests. The daughters don't know how to proceed because they did not have the advance care planning conversation that clarified what their mother meant when she said that she wouldn't want to live with dementia. Was it the cognitive problems, the problems with self care, living in an institution, or the sense that living with dementia would not bring any joy? Without knowing this, the daughters are unprepared to step into her mothers shoes.
Without really knowing their mother's wishes, the decision about a feeding tube is difficult. The daughters may choose to approve the insertion of a feeding tube with the proviso that future triggers could lead to its removal or nonuse. For example, if her current quality of life deteriorates to the point where she is no longer experiencing joy, or if she physically tries to remove the tube and keeping the tube in means restraining her, it may be appropriate to remove the feeding tube at that time.
Case 2
A patient who has coronary artery disease and congestive heart failure shows his physician his advance directive that states he wants to receive cardiopulmonary resuscitation and other forms of life-sustaining treatment.
What should the doctor say to the patient in response to this?
Case 2 Discussion
The patient's expression of a preference should be explored to understand its origins. It is possible that the patient believes, based on television shows, that CPR is usually effective. If this is the case, the doctor should educate the patient about the near futility of CPR under these circumstances. However, the physician may learn that the patient has deeply held beliefs that suggest that not trying to live is tantamount to committing suicide which he perceives as morally wrong. In this situation, the doctor might want to ask the patient to explore this further with the chaplain.
Case 3
A patient tells his family that he would never want to be "kept alive like a vegetable".
What is meant by the term "vegetable"?
Case 3 Discussion
The use of this expression is as vague as saying, "I don't want any heroics or extraordinary treatments" or, "Pull the plug if I'm ever in ...." If these types of comments in advance care planning discussions are not clarified, they are not helpful. For some patients being a "vegetable" means being in a coma, for others it means not being able to read

Advance directives are usually written documents designed to allow competent patients the opportunity to guide future health care decisions in the event that they are unable to participate directly in medical decision making. (For related discussion, see Advance Care Planning and Termination of Life-Sustaining Treatment.)
What types of advance directives are currently available?
A 1991 federal law, the Patient Self-Determination Act, requires that patients are informed about their right to participate in health care decisions, including their right to have an advance directive. Advance directives fall into two broad categories: instructive and proxy. Instructive directives allow for preferences regarding the provision of particular therapies or classes of therapies. Living wills are the most common examples of instructive directives, but other types of instructive directives, such as no transfusion and no CPR directives are also employed. The proxy directive, generally a Durable Power of Attorney for Health Care (DPAHC), allows for the designation of a surrogate medical decision maker of the patient's choosing. This surrogate decision maker makes medical care decisions for the patient in the event she is incapacitated.
Why are advance directives important to medical care?
The major argument for the use of instructive directives, such as a living will, is that it allows an individual to participate indirectly in future medical care decisions even if they become decisionally incapacitated, i.e., unable to make informed decisions. Instructive directives may extend individual autonomy and help ensure that future care is consistent with previous desires. The living will was created to help prevent unwanted and ultimately futile invasive medical care at the end-of-life.
When patients becomes incapacitated someone else will be required to make medical decisions regarding their care. Generally a spouse is the legal surrogate. If no spouse is available, the state law designates the order of surrogate decision makers, usually other family members. By designating a DPAHC, the patient's choice of a surrogate decision maker supersedes that of the state. A legal surrogate is particularly valuable for persons in non-traditional relationships or without close family. The DPAHC need not be a relative of the patient, though this person should have close knowledge of the patient's wishes and views.
Are advance directives legally binding?
Advance directives are recognized in one form or another by legislative action in all 50 states (in Washington, see RCW 11.94). If the directive is constructed according to the outlines provided by pertinent state legislation, they can be considered legally binding. In questionable cases, the medical center's attorney or ethics advisory committee can provide guidance on how to proceed (see also the topics Law and Ethics and Ethics Committees).
When should I refer to a patient's advance directive?
It is best to ask a patient early on in his care if he has a living will, or other form of advance directives. Not only does this information get included in the patient's chart, but by raising the issue, the patient has an opportunity to clarify his wishes with the care providers and his family (see Advance Care Planning).
However, advance directives take effect only in situations where a patient is unable to participate directly in medical decision making. Appeals to living wills and surrogate decision makers are ethically and legally inappropriate when individuals remain competent to guide their own care. The assessment of decisional incapacity is often difficult and may involve a psychiatric evaluation and, at times, a legal determination.
Some directives are written to apply only in particular clinical situations, such as when the patient has a "terminal" condition or an "incurable" illness. These ambiguous terms mean that directives must be interpreted by caregivers. More recent forms of instructive directives have attempted to overcome this ambiguity by either addressing specific interventions (e.g. blood transfusions or CPR) that are to be prohibited in all clinical contexts.
What if a patient changes her mind?
As long as a patient remains competent to participate in medical decisions, both documents are revocable. Informed decisions by competent patients always supersede any written directive.
What if the family disagrees with a patient's living will?
If there is a disagreement about either the interpretation or the authority of a patient's living will, the medical team should meet with the family and clarify what is at issue. The team should explore the family's rationale for disagreeing with the living will. Do they have a different idea of what should be done? Do they have a different impression of what would be in the patient's best interests, given her values and commitments? Or does the family disagree with the physician's interpretation of the living will?
These are complex and sensitive situations and a careful dialogue can usually surface many other fears and concerns. However, if the family merely does not like what the patient has requested, they do not have much ethical power to sway the team. If the disagreement is based on new knowledge, substituted judgment, or recognition that the medical team has misinterpreted the living will, the family has much more say in the situation. If no agreement is reached, the hospital's Ethics Committee should be consulted.
How should I interpret a patient's advance directive?
Living wills generally are written in ambiguous terms and demand interpretation by providers. Terms like "extraordinary means" and "unnaturally prolonging my life" need to be placed in context of the present patient's values in order to be meaningfully understood. More recent forms of instructive directives have attempted to overcome this ambiguity by addressing specific interventions (e.g., blood transfusions or CPR) to be withheld. The DPAHC or a close family member often can help the care team reach an understanding about what the patient would have wanted. Of course, physician-patient dialogue is the best guide for developing a personalized advance directive.
What are the limitations of living wills?
Living wills cannot cover all conceivable end-of-life decisions. There is too much variability in clinical decisionmaking to make an all-encompassing living will possible. Persons who have written or are considering writing advance directives should be made aware of the fact that these documents are insufficient to ensure that all decisions regarding care at the end-of-life will be made in accordance with their written wishes. They should be strongly encouraged to communicate preferences and values to both their medical providers and family/surrogate decision makers.
Another potential limitation of advance directives is possible changes in the patient's preferences over time or circumstance. A living will may become inconsistent with the patient's revised views about quality of life or other outcomes. This is yet another reason to recommend that patients communicate with their physicians and family members about their end-of-life wishes.
Case 1
An elderly man with end-stage emphysema presents to the emergency room awake and alert and complaining of shortness of breath. An evaluation reveals that he has pneumonia. His condition deteriorates in the emergency room and he has impending respiratory failure, though he remains awake and alert. A copy of a signed and witnessed living will is in his chart stipulates that he wants no "invasive" medical procedures that would "serve only to prolong my death." No surrogate decision maker is available.
Should mechanical ventilation be instituted?
Case 1 Discussion
If the patient has remained awake and alert, his living will is irrelevant to medical decision making. The potential risks and benefits of mechanical ventilation need to be presented to the patient. If he refuses this therapy with an understanding of the consequences, his wishes should be honored. If he opts for mechanical ventilation, it should be instituted when it becomes medically necessary. The presence of a living will or other advance directive does not obviate the responsibility to involve a competent patient in medical decision making.
Case 2
The same patient described in Case 1 presents confused and somnolent.
Should mechanical ventilation be instituted?
Case 2 Discussion
If the man has deteriorated to the point that he can no longer communicate, his living will may be a helpful guide to decisionmaking. The language of the directive, however, is difficult to interpret in this case. Pneumonia represents a potentially reversible condition from which the patient may recover fully. Mechanical ventilation does not serve only to "prolong death" but offers a significant chance to return to his previous level of functioning. Most patients with even end-stage emphysema can be successfully weaned from mechanical ventilation. The intent of the directive, whether to avoid intubation and ventilation at all costs or simply to withhold such therapies when they are clearly futile, is not evident. In the absence of other information to aid the decision, mechanical ventilation should be instituted, with the plan that it be discontinued if it becomes evident that the patient cannot be weaned.
Breaking bad news is not something that most medical students are eager to try. Dilbert's advisor Dogbert says: "Never break bad will only get you in trouble." And stories abound about how unskilled physicians blundered their way through an important conversation, sometimes resulting in serious harm to the patient. Many patients with cancer, for example, can recall in detail how their diagnosis was disclosed, even if they remember little of the conversation that followed, and they report that physician competence in these situations is critical to establishing trust.
Some physicians contend that breaking bad news is an innate skill, like perfect pitch, that cannot be acquired otherwise. This is incorrect. Physicians who are good at discussing bad news with their patients usually report that breaking bad news is a skill that they have worked hard to learn. Furthermore, studies of physician education demonstrate that communication skills can be learned, and have effects that persist long after the training is finished.
Robert Buckman's Six Step Protocol for Breaking Bad News
Robert Buckman, in an excellent short manual, has outlined a six step protocol for breaking bad news. The steps are:
Getting started.
The physical setting ought to be private, with both physician and patient comfortably seated. You should ask the patient who else ought to be present, and let the patient decide--studies show that different patients have widely varying views on what they would want. It is helpful to start with a question like, "How are you feeling right now?" to indicate to the patient that this conversation will be a two-way affair.
Finding out how much the patient knows.
By asking a question such as, "What have you already been told about your illness?" you can begin to understand what the patient has already been told ("I have lung cancer, and I need surgery"), or how much the patient understood about what's been said ("the doctor said something about a spot on my chest x-ray"), the patients level of technical sophistication ("I've got a T2N0 adenocarcinoma"), and the patient's emotional state ("I've been so worried I might have cancer that I haven't slept for a week").
Finding out how much the patient wants to know.
It is useful to ask patients what level of detail you should cover. For instance, you can say, "Some patients want me to cover every medical detail, but other patients want only the big picture--what would you prefer now?" This establishes that there is no right answer, and that different patients have different styles. Also this question establishes that a patient may ask for something different during the next conversation.
Sharing the information.
Decide on the agenda before you sit down with the patient, so that you have the relevant information at hand. The topics to consider in planning an agenda are: diagnosis, treatment, prognosis, and support or coping. However, an appropriate agenda will usually focus on one or two topics. For a patient on a medicine service whose biopsy just showed lung cancer, the agenda might be: a) disclose diagnosis of lung cancer; b) discuss the process of workup and formulation of treatment options ("We will have the cancer doctors see you this afternoon to see whether other tests would be helpful to outline your treatment options"). Give the information in small chunks, and be sure to stop between each chunk to ask the patient if he or she understands ("I'm going to stop for a minute to see if you have questions"). Long lectures are overwhelming and confusing. Remember to translate medical terms into English, and don't try to teach pathophysiology.
Responding to the patients feelings.
If you don't understand the patient's reaction, you will leave a lot of unfinished business, and you will miss an opportunity to be a caring physician. Learning to identify and acknowledge a patient's reaction is something that definitely improves with experience, if you're attentive, but you can also simply ask ("Could you tell me a bit about what you are feeling?").
Planning and follow-through.
At this point you need to synthesize the patient's concerns and the medical issues into a concrete plan that can be carried out in the patient's system of health care. Outline a step-by-step plan, explain it to the patient, and contract about the next step. Be explicit about your next contact with the patient ("I'll see you in clinic in 2 weeks") or the fact that you won't see the patient ("I'm going to be rotating off service, so you will see Dr. Back in clinic"). Give the patient a phone number or a way to contact the relevant medical caregiver if something arises before the next planned contact.
What if the patient starts to cry while I am talking?
In general, it is better simply to wait for the person to stop crying. If it seems appropriate, you can acknowledge it ("Let's just take a break now until you're ready to start again") but do not assume you know the reason for the tears (you may want to explore the reasons now or later). Most patients are somewhat embarrassed if they begin to cry and will not continue for long. It is nice to offer kleenex if they are readily available (something to plan ahead); but try not to act as if tears are an emergency that must be stopped, and don't run out of the room--you want to show that you're willing to deal with anything that comes up.
I had a long talk with the patient yesterday, and today the nurse took me aside to say that the patient doesn't understand what's going on! What's the problem?
Sometimes patients ask the same question of different caregivers, sometimes they just didn't remember it all, and sometimes they need to go over something more than once because of their emotional distress, the technical nature of the medical interventions involved, or their concerns were not recognized and addressed.
I just saw another caregiver tell something to my patient in a really insensitive way. What should I do?
First, examine what happened and ask yourself why the encounter went badly. If you see the patient later, you might consider acknowledging it to the patient in a way that doesn't slander the insensitive caregiver ("I thought you looked upset when we were talking earlier and I just thought I should follow up on that--was something bothering you?")
Case 1
Jose is a 62-year-old man who just had a needle biopsy of the pancreas showing adenocarcinoma. You run into his brother in the hall, and he begs you not to tell Jose because the knowledge would kill him even faster. A family conference to discuss the prognosis is already scheduled for later that afternoon.
How should you handle this?
Case 1 Discussion
It is common for family members to want to protect their loved ones from bad news, but this is not always what the patient himself would want. It would be reasonable to tell Jose's brother that withholding information can be very bad because it creates a climate of dishonesty between the patient and family and medical caregivers; also, that the only way for Jose to have a voice in the decision making is for him to understand the medical situation. Ask Jose how he wants to handle the information in front of the rest of the family, and allow for some family discussion time for this matter.
In some cultures it is considered dangerous to talk about prognoses and to name illnesses (e.g., the Navajo). If you suspect a cultural issue it is better to find someone who knows how to handle the issue in a culturally sensitive way than to assume that you should simply refrain from providing medical information. For many invasive medical interventions which require a patient to critically weigh burdens and benefits, a patient will need to have some direct knowledge of their disease in Western terms in order to consider treatment options
Case 2
You are a 25-year-old female medical student doing a rotation in an HIV clinic. Sara is a 30-year-old woman with advanced HIV who dropped out of college after she found that she contracted HIV from her husband, who has hemophilia. In talking to Sara, it turns out you share a number of things--you are from the same part of Montana originally, also have young children, and like to cook. Later in the visit, when you suggest that she will need some blood tests, she gets very angry and says, "What would you know about this?"
What happened?
Case 2 Discussion
Although the protocol for breaking bad news is helpful, it doesn't cover everything. There are instances when you may provoke a reaction from a patient because you remind them of someone else--or, as in this case, themselves. In these instances it can be helpful to step back, get another perspective (perhaps from someone in clinic who has known Sara), and try not to take this reaction too personally--even though it is likely that Sara will know how to really bother you.
The term complementary medicine (also alternative medicine and integrative medicine) is applied to a broad range of therapies that are not commonly taught in medical schools or utilized by the medical profession. In recent years, the acronym CAM (Complimentary and Alternative Medicine) has come into wide use to identify unconventional approaches to healing.
What is the scope of complementary medicine?
Since anything outside mainstream medicine is alternative to it, the spectrum of alternative medicine spreads over a confusingly wide area. At one end are fully professionalized systems of practice that operate schools, publish journals and textbooks, have local, state, and national organizations, and subscribe to codes of ethical practice (chiropractic and naturopathic medicine are examples). Across the middle regions are any number of methods (aromatherapy, for example, or iridology) at a less systematized stage of development. There are also different versions of faith healing, Christian Science being the most extensive. Finally, at the darker end are the misguided notions and purely moneymaking schemes better classified as quackery, even though their proponents advertise themselves as practitioners of complementary healing.
How extensively used is complementary medicine?
Complementary therapies have been growing in public recognition and support since the 1970s. A 1993 survey determined that one-third of Americans use one or another alternative method (generally in conjunction with mainstream, or so-called "allopathic," measures, though the great majority do not inform their physicians of their use); and that the annual number of office visits to complementary practitioners is somewhat greater than the number of visits to all primary care MD and osteopathic (DO) physicians. Surveys conducted since then have determined that patronage of unconventional practitioners has been steadily growing and is well over fifty percent in some regions of this country.
What is the medical profession's understanding of complementary medicine?
Several studies have demonstrated that most allopathic practitioners have only a vague awareness of the practices and underlying principles of complementary medical systems. Many are prejudiced against alternative medicine, furthermore, by the profession's long history of opposition to "sectarian medicine" and "medical cultism." From the 1847 founding of the AMA until quite recently, conventional medicine has presumed alternative treatments to be ineffective, and has condemned any cooperation with alternative practitioners as unethical. Over the last quarter century, however, something of a rapprochement has been established between the two sides, and many physicians are now open to the possibility of alternative therapies being useful in particular situations, and some regularly refer patients to alternative providers.
What is known about the efficacy of complementary therapies?
Generally speaking, alternative methods have not been subjected to the orthodox gold standard of controlled clinical trials, though a few have. Chiropractic has been found effective for some forms of back pain, for example, and several investigations of homeopathic remedies have shown positive results. In 1992, Congress established the Office of Alternative Medicine at NIH precisely for the purpose of funding clinical evaluations of the efficacy of complementary therapies; in 1998, Congress upgraded the Office to The National Center for Complementary and Alternative Medicine (NCCAM), giving the Center more autonomy within the NIH. A number of studies funded by NCCAM are presently being conducted, but results thus far are largely inconclusive. Nevertheless, some of these studies have yielded positive results. A special issue of JAMA published in November, 1998 contained reports of trials demonstrating the efficacy of yoga and relaxation techniques, moxibustion, and Chinese herbal remedies in certain conditions. Acupuncture was found to have "promising results" in controlling postoperative pain and nausea, and to be possibly useful in a range of ailments that includes addiction, stroke rehabilitation, asthma and osteoarthritis. Alternative practitioners maintain many more of their methods are validated by clinical experience, and claim a high rate of successful outcomes. Physicians tend to dismiss these claims as anecdotal and attribute positive outcomes to the placebo effect and the self-limited nature of the ailments. Both sides agree on the need for more substantial evidence of efficacy, but there is much debate over whether or not randomized, placebo-controlled trials can be successfully applied to complementary therapies.
What ethical issues are associated with complementary medicine?
"Complementary medicine" implies cooperation between two or more approaches to treatment, each balancing and complementing the other(s). The recent appearance of "complementary medicine," to replace the older term "alternative," signifies the desire in the complementary community to integrate their services with allopathic methods. Simultaneously, patients are showing more interest in and requesting complementary therapies. Thus the referral of patients to complementary practitioners has emerged as a fundamental ethical question for physicians.
The normally straightforward duty to direct patients to treatments that are known to be effective, and to advise them against those that are useless or harmful is seriously confounded in the case of complementary medicine by physicians' scant knowledge (and negative preconceptions) of alternative therapies, the sheer number and bewildering variety of practices that fall under the complementary heading (no one can be familiar with them all), and the shortage of evidence for the efficacy of many complementary treatments. The decision to refer or not to refer should be based on sufficient information about the benefits and dangers of the treatment being considered, and too often in the case of complementary therapies the information either does not exist or is not known to the physician. This situation is certain to improve over the next few years, given the quantity of research now being done on the efficacy of complimentary medicine; for now, the physician may often find herself unsure whether to refer to an alternative practitioner or not. There is nevertheless an ethical obligation to attempt to stay current with evidence for effectiveness of complementary therapies, since presenting conventional treatment as the only option for a condition would in certain situations deny a patient the help of a useful CAM method. Physicians should apply a risk-benefit analysis to each case, weighing the evidence for efficacy and harm for both conventional and complementary therapies, while also taking into account the severity of the patient's illness and the degree to which the patient desires CAM treatment.
How is informed consent related to complementary medicine?
The principle of informed consent requires that the patient be adequately informed of therapeutic options and the benefits and risks associated with each. Historically, physicians have simply ignored alternative treatments when presenting options, or have summarily dismissed them as quackery. Given the current level of public interest in complementary treatments, though, many patients will expect or request information about unconventional therapies. Ideally, any complementary treatments that might be of benefit should be presented to the patient, and any that involve significant risk identified as dangers.
By now, many physicians accept the value (and safety) of some chiropractic adjustments for low back pain, and regularly refer patients to chiropractors. But in those situations where the physician does not feel he has adequate knowledge of a complementary option, he is not ethically obligated to inform the patient of that system. At most, a particular alternative method, or "complementary medicine" in general, might be mentioned as a possible adjunct, and the patient given the responsibility of investigating options and obtaining sufficient knowledge for a sound decision.
The potential interactions of various treatments present a further challenge to the practice of informed consent when using complementary medicine. The risk of harm is simply unknown when therapies are combined in new, as yet untested, ways, making truly informed consent impossible to achieve. It is essential that the physician make herself aware of whatever complementary treatments the patient pursues so as to advise on the risk of untoward interactions between the complementary medications and any conventional therapies also being used.
What is the proper approach when alternative medicine is used for children?
Parents of seriously ill children sometimes forego beneficial allopathic treatments in favor of an alternative method that is useless or injurious. One of the physician's ethical duties in this case is to find a way to work with the parents. However, if the physician believes the child is in danger, she should counsel the parents to abandon the therapy, or, if they refuse, attempt to obtain a court order to discontinue the treatment. This situation most frequently arises with the children of Christian Scientists, who rely on prayer for all healing, and there is ample legal precedent for assuming custody of the child and substituting conventional care. If the child is in the advanced stages of terminal illness, cannot be helped by allopathic treatment, and will not be further harmed by the complementary practice, then, of course, no action need be taken. There are also opportunities in these circumstances to turn an adversarial relationship into a collaborative one by frankly discussing concerns with the alternative practitioner and jointly working to support the child's healing.
What are the physician's professional obligations with respect to complementary medicine?
Offhand dismissal or ridicule of complementary medicine will only close off communication with patients, and perhaps encourage them to seek complementary options more aggressively. Rather, the allopathic practitioner must encourage patients to inform him of their use of complementary therapies, and should attempt both to learn more about the complementary methods his patients select, and to coordinate care with their complementary practitioners.
Case 1
A young mother has just been informed that her 2-year-old son has leukemia. The mother refuses permission to begin chemotherapy and informs the team that their family physician (a naturopath) will follow the child's illness.
What should you do?

Case 1 Discussion
Of utmost importance are the child's best interests, which include getting good medical care and maintaining a close connection with his mother. One way to achieve both is by requesting a care conference with both the mother and the family's naturopathic physician. If the mother refuses this meeting and you remain convinced that chemotherapy is the only hope this child has, you are professionally obligated to seek a court order to appoint a guardian for the child. If chemotherapy offers a clear and compelling survival benefit, the justification for seeking legal intervention increases.
Case 2
Your patient has been suffering from chronic low back pain for many years now. She voices her frustration with the various treatment modalities that you have been trying and says her friend had recommended a homeopath.
How do you respond?
Case 2 Discussion
In this case, there are few clearly effective treatments for the medical condition. Hence, complementary approaches may be a reasonable recommendation, assuming they are not harmful. While you may know little about homeopathy yourself, you may encourage your patient to consult with local experts or the library to find out more about what homeopathy can offer. It may be appropriate to seek alternative therapies, but they should be researched or recommended. Encourage your patient to stay in contact with you and explore opportunities.
Confidentiality is one of the core tenets of medical practice. Yet daily physicians face challenges to this long-standing obligation to keep all information between physician and patient private.
Where does the duty of confidentiality come from?
Patients share personal information with physicians. You have a duty as a physician to respect the patient's trust and keep this information private. This requires the physician to respect the patient's privacy by restricting access of others to that information. Furthermore, creating a trusting environment by respecting patient privacy can encourage the patient to be as honest as possible during the course of the visit. (See also Physician-Patient Relationship.)
What does the duty of confidentiality require?
The obligation of confidentiality both prohibits the physician from disclosing information about the patient's case to other interested parties and encourages the physician to take precautions with the information to ensure that only authorized access occurs. Yet the context of medical practice does constrain the physician's obligation to protect patient confidentiality. In the course of caring for patients, you will find yourself exchanging information about your patients with other physicians. These discussions are often critical for patient care and are an integral part of the learning experience in a teaching hospital. As such, they are justifiable so long as precautions are taken to limit the ability of others to hear or see confidential information. Computerized patient records pose new and unique challenges to confidentiality. You should follow prescribed procedures for computer access and security as an added measure to protect patient information.
What kinds of disclosure are inappropriate?
Inappropriate disclosure of information can occur in clinical settings. When pressed for time, the temptation to discuss a case in the elevator may be great, but in that setting it is very difficult to keep others from hearing the information exchanges. Similarly, extra copies of handouts from teaching conferences that contain identifiable patients should be removed at the conclusion of the session. The patient's right to privacy is not being respected in these sorts of cases.
When can confidentiality be breached?
Confidentiality is not an absolute obligation. Situations arise where the harm in maintaining confidentiality is greater than the harm brought about by disclosing confidential information. In general, two such situations that may give rise to exceptions exist. In each situation, you should ask - will lack of this specific information about this patient put a specific person you can identify at high risk of serious harm? Legal regulations exist that both protect and limit your patient's right to privacy, noting specific exceptions to that right. These exceptions follow.
Exception 1:
Concern for the safety of other specific persons
On the one hand, the 1974 Federal Privacy Act restricts access to medical information and records. On the other, clinicians have a duty to protect identifiable individuals from any serious threat of harm if they have information that could prevent the harm. As mentioned above, the determining factor in justifying breaking confidentiality is whether there is good reason to believe specific individuals (or groups) are placed in serious danger depending on the medical information at hand. The most famous case of this sort of exception is that of homicidal ideation, when the patient shares a specific plan with a physician or psychotherapist to harm a particular individual. The court has required that traditional patient confidentiality be breached in these sorts of cases.
Exception 2:
Concern for public welfare
In the most clear cut cases of limited confidentiality, you are required by state law to report certain communicable/infectious diseases to the public health authorities. In these cases, the duty to protect public health outweighs the duty to maintain a patient's confidence. From a legal perspective, the State has an interest in protecting public health that outweighs individual liberties in certain cases. In particular, reportable diseases in Washington State include (but are not limited to): AIDS and Class IV HIV, hepatitis A and B, measles, rabies, tetanus, and tuberculosis. Suspected cases of child, dependent adult, and elder abuse are reportable, as are gunshot wounds. Local municipal code and institutional policies can vary regarding what is reportable and standards of evidence required. It is best to clarify institutional policy when arriving at a new site.
What if a family member asks how the patient is doing?
While there may be cases where the physician feels compelled to share information regarding the patient's health and prognosis with, for instance, the patient's inquiring spouse, without explicit permission from the patient it is generally unjustifiable to do so. Except in cases where the spouse is at specific risk of harm directly related to the diagnosis, it remains the patient's, rather than the physician's, obligation to inform the spouse.
Case 1
Your 36-year-old patient has just tested positive for HIV. He asks that you not inform his wife of the results and claims he is not ready to tell her yet.
What is your role legally? What would you say to your patient?
Case 1 Discussion
Because the patient's wife is at serious risk for being infected with HIV, you have a duty to ensure thatshe knows of the risk. While public health law requires reporting both your patient and any known sexual partners to local health officers, it is generally advisable to encourage the patient to share this information with his wife on his own, giving him a bit more time if necessary.
Case 2
A 75-year-old woman shows signs of abuse that appears to be inflicted by her husband. As he is her primary caregiver, she feels dependent on him and pleads with you not to say anything to him about it.
How is this case different from Case 1? How would you handle this situation?
Case 2 Discussion
In this case, the required reporting laws can be interpreted in a number of justifiable ways. The laws supporting reporting elder abuse (and child abuse) allow you to break confidentiality and report suspected abuse. However, if you think it is possible to give this woman support and access to other services without reporting the case immediately, those alternatives will help her more in the long run. Either way, you have an obligation to address her abusive situation.
Case 3
A 60-year-old man has a heart attack and is admitted to the medical floor with a very poor prognosis. He asks that you not share any of his medical information with his wife as he does not think she will be able to take it. His wife catches you in the hall and asks about her husband's prognosis.
Would you tell his wife? What are you required to do legally?
Case 3 Discussion
The duty to maintain confidentiality remains strong in this case as information about the patient's health does not directly concern others' health, welfare, or safety. There is no imminent danger to others here. However, the wife is certainly affected by her husband's health and prognosis and every effort should be made to encourage an open dialogue between them. It remains his responsibility to do so.
Patients bring cultural, religious and ideological beliefs with them as they enter into a relationship with the physician. Occasionally, these beliefs may challenge or conflict with what the physician believes to be good medical care. Understanding and respecting the beliefs of the patient represents an important part of establishing and maintaining a therapeutic relationship.
Why is it important to respect what appear to me to be idiosyncratic beliefs?
Respecting the beliefs and values of your patient is an important part of establishing an effective therapeutic relationship. Failure to take those beliefs seriously can undermine the patient's ability to trust you as her physician. It may also encourage persons with non-mainstream cultural or religious beliefs to avoid seeking medical care when they need it.
What are some ways to discover well known sets of beliefs?
There are many groups, some religious, that share common sets of beliefs. Knowledge of these beliefs and the reasonable range of interpretation of doctrine can be very helpful in deciding if unusual beliefs should be respected. Good resources for guidance in this area include staff members with personal knowledge or experience, patients and family members themselves, hospital chaplains, social workers, and translators. Unusual beliefs that fall outside known belief systems should prompt more in-depth discussions to insure they are rational.
It is important to explore each individual's beliefs, as shared membership in a particular religious or cultural group does not necessarily entail identical belief systems.
What is my responsibility when a patient endangers her health by refusing a treatment?
Adults have a moral and legal right to make decisions about their own health care, including the right to refuse treatments that may be life-saving. The physician has a responsibility to make sure that the patient understands the possible and probable outcomes of refusing the proposed treatment. The physician should attempt to understand the basis for the patient's refusal and address those concerns and any misperceptions the patient may have. In some cases, enlisting the aid of a leader in the patient's cultural or religious community may be helpful.
Can parents refuse to provide their children with necessary medical treatment on the basis of their beliefs?
Parents have legal and moral authority to make health care decisions for their children, as long as those decisions do not pose a serious threat to the child's physical well-being. Parents should not be permitted to deny their children medical care when that medical care is likely to prevent substantial harm or suffering. If necessary, the physician may need to pursue a court order in order to provide treatment against the wishes of the parents. Nevertheless, the physician must always take care to show respect for the family's beliefs and a willingness to discuss reasonable alternatives with the family.
What kinds of treatment can parents choose not to provide to their children?
Parents have the right to refuse medical treatments when doing so does not place the child at significant risk of substantial harm or suffering. For example, parents have the right to refuse immunizations for their children on religious or cultural grounds.
Can a patient demand that I provide them with a form of treatment that I am uncomfortable providing?
A physician is not morally obligated to provide treatment modalities which they do not believe offer a benefit to the patient or which may harm the patient. However, it is important to take the patient's request seriously and attempt to formulate a plan that would be acceptable to both the physician and patient.
Case 1
A mother brings her 18-month-old daughter to your office for a routine physical examination. The child has had no immunizations. Her mother says that they believe in naturopathic medicine and prefer not to immunize their children.
What is your role in this situation? Can parents refuse to immunize their children?
Case 1 Discussion
The risk faced by unimmunized individuals is relatively low, and the mother's refusal to immunize does not pose a significant likelihood of harm to her child. The physician should be sure that the child's mother understands the risks of remaining unimmunized and attempt to correct any misconceptions about the degree of risk associated with getting immunized. If the mother persists in her request, the physician should respect her wishes.
Case 2
A 23-year-old Navajo man has injured his leg after a fall. He presents to the emergency room of the reservation hospital where he is complaining of pain. His leg appears to be broken. The man requests that you call a medicine man before doing anything further.
Should you find a medicine man? Should you proceed with treatment?
Case 2 Discussion
As a competent adult, this patient has the right to make decisions about his medical care. You must respect his wish not to be treated until he gives you permission to do so. Calling the local medicine man will show your respect for the patient and strengthen the patient's trust in you and your abilities.
Case 3
A 3-year-old child is brought to your clinic with a fever and stiff neck. You are quite certain the child has meningitis. When you discuss the need for a spinal tap and antibiotic treatment, the parents refuse permission, saying, " We'd prefer to take him home and have our minister pray over him."
Can the parents refuse treatment in this case? How should you handle this?
Case 3 Discussion
The physician has a duty to provide treatment to a child when denying that treatment would pose a significant risk of substantial harm. Failure to diagnose and treat bacterial meningitis would seriously threaten the health and even life of this child. The physician should share his view with the family and seek to elicit their cooperation through respectful discussion. Inviting their religious leader to the hospital while also providing standard medical therapy may prove to be an acceptable compromise. Should these efforts not result in parental permission, the physician is justified in seeking legal help so as to proceed with the procedure and treatment of the child. In most states a physician is legally authorized to provide emergency treatment to a child without a court order when delay would likely result in harm.
On the medicine wards, you will come across patients who have a "Do-Not-Resuscitate" order on their chart. You will also be in situations where you are asked to discuss with a patient whether they want to or should have resuscitation following a cardiac arrest or life-threatening arrhythmia. Like many other medical decisions, deciding whether or not to resuscitate a patient who suffers a cardiopulmonary arrest involves a careful consideration of the potential likelihood for clinical benefit with the patient's preferences for the intervention and its likely outcome. Decisions to forego cardiac resuscitation are often difficult because of real or perceived differences in these two considerations. (See also Do Not Resuscitate Orders during Anesthesia and Urgent Procedures.)
When should CPR be administered?
Cardiopulmonary resuscitation (CPR) is a set of specific medical procedures designed to establish circulation and breathing in a patient who's suffered an arrest of both. CPR is a supportive therapy, designed to maintain perfusion to vital organs while attempts are made to restore spontaneous breathing and cardiac rhythm.
If your patient stops breathing or their heart stops beating in the hospital, the standard of care is to perform CPR in the absence of a valid physician's order to withhold it. Similarly, paramedics responding to an arrest in the field are required to administer CPR. Since 1994 in Washington state, patients may wear a bracelet that allows a responding paramedic to honor a physician's order to withhold CPR.
When can CPR be withheld?
Virtually all hospitals have policies which describe circumstances under which CPR can be withheld. Two general situations arise which justify withholding CPR:
when CPR is judged to be of no medical benefit (also known as "medical futility"; see below), and
when the patient with intact decision making capacity (or when lacking such capacity, someone designated to make decisions for them) clearly indicates that he / she does not want CPR, should the need arise.
When is CPR "futile"?
CPR is "futile" when it offers the patient no clinical benefit. When CPR offers no benefit, you as a physician are ethically justified in withholding resuscitation. Clearly it is important to define what it means to "be of benefit." The distinction between merely providing measurable effects (e.g. normalizing the serum potassium) and providing benefits is helpful in this deliberation.
When is CPR not of benefit?
One approach to defining benefit examines the probability of an intervention leading to a desirable outcome. CPR has been prospectively evaluated in a wide variety of clinical situations. Knowledge of the probability of success with CPR could be used to determine its futility. For instance, CPR has been shown to be have a 0% probability of success in the following clinical circumstances:
Septic shock
Acute stroke
Metastatic cancer
Severe pneumonia
In other clinical situations, survival from CPR is extremely limited:
Hypotension (2% survival)
Renal failure (3%)
AIDS (2%)
Homebound lifestyle (4%)
Age greater than 70 (4% survival to discharge from hospital)
How should the patient's quality of life be considered?
CPR might also seem to lack benefit when the patient's quality of life is so poor that no meaningful survival is expected even if CPR were successful at restoring circulatory stability. Judging "quality of life" tempts prejudicial statements about patients with chronic illness or disability. There is substantial evidence that patients with such chronic conditions often rate their quality of life much higher than would healthy people. Nevertheless, there is probably consensus that patients in a permanent unconscious state possess a quality of life that few would accept. Therefore, CPR is usually considered "futile" for patients in a persistent vegetative state.
If CPR is deemed "futile," should a DNR order be written?
If CPR is judged to be medically futile, this means that you as the physician are under no obligation to provide it. Nevertheless, the patient and/or their family should still have a role in the decision about a Do-Not-Resuscitate (DNR) order. This involvement stems from respect for all people to take part in important life decisions, commonly referred to as respect for autonomy or respect for person.
In many cases, the patient/family, upon being given a caring but frank understanding of the clinical situation, will agree with the DNR order. In such cases a DNR order can be written. Each hospital has specific procedures for writing a valid DNR order. In all cases, the order must be written or cosigned by the Attending Physician.
What if CPR is not futile, but the patient wants a DNR order?
As mentioned above, a decision to withhold CPR may also arise from a patient's expressed wish that CPR not be performed on her. If the patient understands her condition and possesses intact decision making capacity, her request should be honored. This position stems from respect for autonomy, and is supported by law in many states that recognize a competent patient's right to refuse treatment.
What if the family disagrees with the DNR order?
Ethicists and physicians are divided over how to proceed if the family disagrees. At the UW, Harborview, and VA Medical Centers, the policy is to write a DNR order only with patient/family agreement.
If there is disagreement, every reasonable effort should be made to communicate with the patient or family. In many cases, this will lead to resolution of the conflict. In difficult cases, an ethics consultation can prove helpful. Nevertheless, CPR should generally be provided to such patients, even if judged futile.
What about "slow codes"?
It is the policy of the UWMC, Harborview and VA that so-called "slow-codes," in which a half-hearted effort at resuscitation is made, are not ethically justified. These undermine the right patients have to be involved in inpatient clinical decisions, and violates the trust patients have in us to give our full effort.
What if the patient is unable to say what his/her wishes are?
In some cases, the decision about CPR occurs at a time when the patient is unable to participate in decision making, and hence cannot voice a preference. There are two general approaches to this dilemma: Advance Directives and surrogate decision makers.
Advance Directive: This is a document which indicates with some specificity the kinds of decisions the patient would like made should he be unable to participate. In some cases, the document may spell out specific decisions (e.g. Living Will), while in others it will designate a specific person to make health care decisions for them (i.e. Durable Power of Attorney for Health Care). There is some controversy over how literally living wills should be interpreted. In some cases, the document may have been drafted in the distant past, and the patient's views may have changed. Similarly, some patients do change their minds about end-of-life decisions when they actually face them. In general, preferences expressed in a living will are most compelling when they reflect long held, consistently stable views of the patient. This can often be determined by conversations with family members, close friends, or health care providers with long term relationships with the patient.
Surrogate decision maker: In the absence of a written document, people close to the patient and familiar with his wishes may be very helpful. The law recognizes a hierarchy of family relationships in determining which family member should be the official "spokesperson," though generally all close family members and significant others should be involved in the discussion and reach some consensus. The hierarchy is as follows:
Legal guardian with health care decision-making authority
Individual given durable power of attorney for health care decisions
Adult children of patient (all in agreement)
Parents of patient
Adult siblings of patient (all in agreement)
Case 1
Mr. H is a 24-year-old man who resides in a skilled nursing facility, where he is undergoing rehabilitation from a cervical spine injury. The injury left him quadriplegic. He has normal cognitive function and no problems with respiration. He is admitted to your service for treatment of pneumonia. The resident suggests antibiotics, chest physiotherapy, and hydration. One day while signing out Mr. H to the cross covering intern, the intern says "he should be a DNR, based on medical futility."
Do you agree? Is his case medically futile, and if so, why?
Case 1 Discussion
Medical futility means that an intervention, in this case CPR, offers no chance of meaningful benefit to the patient. Interventions can be considered futile if the probability of success (discharged alive from the hospital) is <1%, and/or if the the CPR is successful, then the quality of life is below the minimum acceptable to the patient.
In this case, Mr. H would have a somewhat lower than normal chance of survival from CPR, based on his quadriplegia (homebound lifestyle is a poor prognostic factor) and his mild pneumonia (in cases of severe pneumonia and respiratory failure survival is <1%).
Furthermore, his quality of life, while not enviable, is not without value. Since he is fully awake and alert, you could talk with Mr. H about his view of the quality of his life. You could share with him the likely scenarios should he have an arrest and need CPR. After this discussion, Mr. H can tell you if he would like to have CPR in the event of an arrest or not.
One cannot say on the basis of the current situation that CPR is futile. A decision about resuscitation should occur only after talking with the patient about his situation and reaching a joint decision.
Case 2
Mrs. W is a 81-year-old woman with recurrent colon cancer with liver metastases admitted to the hospital for chemotherapy. Because of her poor prognosis, you approach her about a DNR order, but she requests to be "a full code."
Can you write a DNR order anyway?
Mrs. W is elderly and has a diagnosis of metastatic cancer. In several prospective outcome studies of CPR in the hospital, patients like Mrs. W had 0% survival. Thus CPR for Mrs. W could be called "futile."
Nevertheless, current policy at UWMC/Harborview and the VAMC state that one should not write a DNR order, even if CPR is judged to be futile, without patient or family concurrence. Rather, you should allow Mrs. W some time to come to grips with her diagnosis, while periodically re-addressing the CPR question with her. This is best done in the context of other medical decision that occur during her care. It is important to review other care goals with her, to allay possible fear that a DNR order may mean she will be abandoned or not cared for.
Case 3
Several days go by and Mrs. W still wants to be a "full code." Your intern suggests that you sign her out as a "slow code."
Should you do this?
Case 3 Discussion
A "slow code" allows the appearance of respecting the patient's desire for CPR while not actually complying with the respect. Slow codes are not ethically justifiable. Rather, you should continue efforts to discuss the DNR order with Mrs. W, perhaps with the help of her family or religious advisors.
It is common to have patients present for surgery, for whom a "Do-Not-Resuscitate" order is written in their chart. Physicians and patients alike suffer from misconceptions about the potential benefits and harms of resuscitation in the operating room (OR), and even the definition itself of resuscitation in the OR requires clarification prior to surgery. Because the OR environment presents patients with a situation in which cardiopulmonary resuscitation (CPR) carries significantly different risks and benefits than on the medical ward, re-discussion of the implications of the DNR order are necessary. (For a discussion of DNR Orders in other medical settings, see main topic Do Not Resuscitate Orders.)
When should CPR be administered?
Anesthesiologists and surgeons may be reluctant to accept DNR orders on patients undergoing surgery because of the scope of medical practice which constitutes "normal care" in the surgical environment. Many surgeries require intubation and mechanical control of respiration for the duration of surgery, to protect the airway from aspiration, prevent anesthetic-induced hypoventilation, to allow the administration of paralytic agents to prevent muscle contraction during surgery, and for many other reasons. Yet intubation and ventilatory assistance are mainstays of CPR.
It is inaccurate to call anesthesia "ongoing resuscitation," yet the administration of anesthetic agents frequently causes initial changes in the autonomic nervous system, such that hypotension, tachycardia, bradycardia, and temporary cardiac dysrhythmias can result. It is common to administer vasopressive medications and antiarrhythmic agents during the course of "normal" anesthetic management. Such medications are often considered a vital part of effective administration of CPR.
Finally, both invasive and noninvasive technology in the OR permits easy application of therapeutic measures which might seem extreme on the medical ward, such as external or transvenous pacing and defibrillation. Under most other circumstances, such measures would fall almost exclusively within the realm of CPR.
So where do we draw the line between "normal" and "usual" procedures in the operating room, and "extraordinary" procedures which constitute CPR? Many authorities have suggested that the application of chest compressions is an usual enough occurrence even in the OR setting, that it provides an medical and ethical boundary between CPR and normal anesthetic care.
What should we do with DNR orders in the OR?
In 1992, the American Society of Anesthesiologists (ASA) produced Guidelines for the Ethical Care of Patients with Do Not Resuscitate Orders, and Other Orders Limiting Care in the Operating Room. Out of respect for patient autonomy, or the right of competent, adult patients, to determine their own medical care, no specific definition of CPR was provided in the document. Instead, it requires a discussion with the patient to define medical procedures under anesthesia to which the patient would consent. Shortly after the ASA adopted its guidelines, the American College of Surgeons, and the Association of Operating Room Nurses (AORN) adopted guidelines which drew directly from the ASA's document.
All acknowledged that patients do not check their rights to self-determination at the OR doors, that policies automatically suspending or upholding DNR orders in the OR were ethically suspect, and that rediscussion of the DNR order should occur, whenever possible, prior to undertaking surgery and anesthesia.
When should CPR be administered?
CPR should be administered in the absence of a valid physician's order to withhold it.
When can CPR be withheld?
As with CPR on the medical wards, two general situations arise in which CPR can be withheld in the operating room:
when CPR is judged to be of no benefit to the patient (See the main topic page, Do-Not-Resuscitate Orders.)
when a patient with intact decision-making capacity (or in the case of those without decision making capacity, an appropriate surrogate decision-maker) indicates that they do no want CPR, even if the need arises.
Is the outcome from CPR different in the OR than on the medical ward?
CPR in the OR carries a very different medical prognosis than CPR administered in other hospital areas. While only 4 to 14% of all patients resuscitated in the hospital survive to discharge, 50 to 80% of patients resuscitated in the OR return to their former level of functioning. This is probably due to several differences between arrest on the medical ward and arrest in the OR. In the OR, the event of arrest is always witnessed, and the proximate cause usually known, allowing rapid, effective intervention which is directed toward the specific cause of arrest. Also, causes of arrest in the OR are often reversible effects of anesthesia or hemorrhage, and not usually due primarily to the patient's underlying disease. Patient and physicians may require correction of the perception that CPR in the OR is just as futile as CPR on the general medical ward.
Does the cause of arrest matter?
Because arrests in the OR are often due to hemorrhage or medication effects, rather than the patient's underlying disease, physicians may feel that their actions "caused" the arrest, and they are ethically obliged to resuscitate the patient, even if the patient has clearly expressed wishes to the contrary. But competent patients, or their appropriate surrogates, have the right to refuse medical procedures and care, even if the care is to counteract the effects of previous medical intervention.
Why do we agree to do surgery on patients with DNR orders?
Many types of surgery provide palliative benefits to patients who either will not survive long-term, or who do not wish resuscitation in the OR. A patient with an esophageal obstruction from cancer might benefit from gastrostomy placement through reduced pain and improved nutritional status, yet not want CPR if cardiac arrest happens in the OR. Requiring such a patient to suspend their DNR orders to be a candidate for surgery uses their discomfort, pain, and desire to benefit from surgery to coerce them into accepting medical care (CPR) they do not want. Patient refusal of some medical therapy, such as CPR, does not ethically justify physicians denying them other medical therapy, such as surgery, that might benefit them.
What should be included in a discussion of DNR orders in the OR with the patient or patient's surrogates?
As discussed above, surgery and anesthesia may require the administration of medical therapies, which under other circumstances might be considered resuscitation. It is an ongoing source of discussion about what constitutes appropriate information and choices to present to patients about to undergo surgery who have DNR orders on their charts.
Since the goal of medical therapy is to provide meaningful benefits to the patient, discussion of DNR orders in the OR should center around the patient's goals for surgical therapy. Patients may have fears of "ending up a vegetable" on a ventilator after surgery, for example. In those cases, discussion should center around the positive prognosis for patients who have CPR in the OR, together with reassurance that the patient's stated wishes in their advanced directive regarding ventilatory support would be followed postoperatively after anesthetic effects are ruled out as a cause of ventilatory depression. Most authorities now agree that a "smorgasbord" or checklist "yes-or-no" approach to the various procedures in the operating room is confusing and counterproductive to the purpose of DNR discussions.
Anesthesiologists in particular need to be aware that studies indicate that many patients with DNR orders in their charts (up to 46%) may be unaware that the order exists, even when they are competent. While policies at the University of Washington Medical Center require documentation of discussion of DNR orders with the patient or appropriate surrogates, anesthesiologists and surgeons should nevertheless approach the patient about to undergo surgery with sensitivity to the fact that they may be unaware of their DNR order. If this proves to be the case, a full discussion of the DNR order should be undertaken prior to proceeding.
What about emergencies?
Even in emergencies, physicians have an ethical obligation to recognize and respect patient autonomy. Whenever possible, physicians should obtain input from the patient, or when the patient is incapacitated, from appropriate surrogates, regarding the status of the patient's DNR orders in the OR. In the absence of such input, consensus should be reached among the caregivers about the medical benefits or futility of CPR. In any case, medical care of the patient in the absence of patient input should be directed toward realizing, to the best of the physician's ability and knowledge, the patient's goals.
Case 1
Mr. S is a 73-year-old man, with a history of severe coronary artery disease, peripheral vascular disease, and stroke. He suffers from right hemiplegia and mild expressive aphasia. He is awake and alert, and presents for right below the knee amputation (BKA) for vascular insufficiency. His chart carries a DNR order. In the holding area prior to surgery, the anesthesiologist discusses the DNR order with Mr. S, who appears depressed. Mr. S states unequivocally, that he does not wish CPR in the OR, regardless of its cause or positive prognosis. He tells his anesthesiologist that he is willing to go "so far, and no more." The patient agrees to subarachnoid anesthesia (spinal block) and sedation. He is not intubated. After about 20 minutes, the patient complains of weakness in his arms, and difficulty breathing. Within 3 minutes, his blood pressure and heart rate fall, and he abruptly arrests.
Should the patient be intubated? Should CPR be commenced?
Case 1 Discussion
The probable cause of Mr. S's arrest is a cephalad migration of local anesthetic in the subarachnoid space, leading to a "high spinal block." As a result of migration of the local anesthetic from the lumbar segments to high thoracic or even cervical segments, weakness or paralysis of respiratory muscles, including intercostal muscles and diaphragmatic muscles can result. The effect of local anesthetic on segments contributing to the cardiac accelerator fibers can cause bradycardia, and even cardiac arrest. With cardiopulmonary support, prognosis for total recovery from this event is excellent, with only rare cases of central nervous system damage or death reported. CPR would not be futile from a medical standpoint.
Intubation and institution of mechanical ventilation will not alone restore Mr. S's circulation, and these measures alone will be useless. Medications to treat blood pressure and bradycardia will require at least temporary artificial circulation. From the standpoint of medical futility, intubation and mechanical ventilation would be senseless unless accompanied by full CPR, if even briefly.
It is hard to argue ethically for the institution of CPR in this patient, who while neurologically impaired, appeared to have full capacity to understand and make decisions regarding his own medical care. Despite preoperative discussion which included information about the good prognosis from CPR in the OR, the patient stated clearly his wishes to not be resuscitated if an arrest occurs. Instituting CPR in this patient because the cause of arrest is anesthetic-related, would be like justifying transfusion in a Jehovah's Witness against their will because the surgery was the cause of life-threatening hemorrhage, yet adhering to their wishes if hemorrhage was due to non-surgical injuries.
Case 2
Mrs. P is a 74-year-old woman presenting for emergent treatment of a fracture-dislocation of her right hip, suffered in a fall at her nursing home. She appears frail, but is alert and oriented. She is accompanied by her daughter, and both state that they want her to receive full medical care. On admission two hours earlier, the emergency room physician heard a loud systolic murmur, and echocardiogram revealed critical aortic stenosis, with a valve area of 0.3 cm2. The surgeon suggests that the patient, because of her cardiac status and age, should have a DNR order in the chart.
Do you agree?
Case 2 Discussion
Cardiac arrest in the setting of critical aortic stenosis carries virtually zero chance of survival, since the tight stenosis of the left ventricular outflow tract makes generation of systemic blood pressures compatible with life virtually impossible. CPR in this setting can easily be termed "medically futile." Current policy at UWMC/ Harborview and the VAMC require that patient or family agreement accompany DNR orders. A frank discussion with Mrs. P and her daughter about the issue of CPR should be initiated with the hope of establishing understanding with the patient and her family about the question of resuscitation.
End-of-Life Issues
As care of the dying involves so much of one's self, in this topic page I will describe my approach as an one example of how clinicians think about end-of-life care. I remember, the first time one of my patients died, feeling a chill of horror and fascination. I wasn't prepared for it. The resident yawned--a long night, then a long code. "We better go talk to the family." What in the world would we say? The dead patient, now dusky blue, looked unreal and unfamiliar. I was so wrapped up in my own feelings that I can't recall much else.
Now I find care of the dying to be one of the richest parts of my clinical life. But it is demanding in a different, more personal way, than, say, treating pneumococcal pneumonia with penicillin. Here I will describe some ways of thinking about care of the dying that have helped me figure out where I am going as I guide someone who is really sick.
Many medical students first encounter care of the dying as an unsuccessful code or a strategic withholding of CPR. Of course, an ethically sound understanding of withdrawing and withholding treatment is crucial to good care of the dying. Yet "withholding and withdrawing" only describe what we, as clinicians, decide not to do. To provide excellent care of the dying requires that we also decide what we should do. What should be the goals of medical care for people who are dying? What makes a good death?
What is a "good death"? A medical perspective
The good death is not a familiar idea in American culture. Some experts in palliative care describe the United States as a "death-defying" culture, with a mass media that spotlights only youth and beauty. Yet public interest in care of the dying is currently high. The striking public interest in physician-assisted suicide is one obvious reason. But there are other reasons: over the past 100 years, there has been a epidemiologic shift in the reasons people die. In the pre-antibiotic era, people most often died young, of infectious diseases; now, thanks to medical technology, most Americans (and others with access to this technology) live much longer, to die of degenerative, neoplastic, and even man-made diseases. Finally, there is a marked public fear that a medical death, depicted in TV shows like "ER" as an unresponsive, uncommunicative body hooked up to an array of flashing monitors, represents an irresponsible use of technology and a dishonorable way to treat a person.
Interestingly, contemporary medical literature contains little that might characterize what makes a death "good." Recently, a large, expensive empirical study of intensive care unit deaths suggested that medical care for a common type of in-hospital death is "bad" (the SUPPORT study, referenced below). In this study of dying patients, severe pain was common, decisions to withhold invasive treatments were made at the last minute, and physicians often had no knowledge of patient preferences not to have CPR. Even worse, an intervention designed to provide physicians with better prognostic information had no effect on medical decision making prior to death. While the SUPPORT authors did not actually describe these deaths as "bad," we could certainly agree that they were not "good deaths."
In caring for a person who is dying, knowing what would make the experience of dying "good" is an important goal for physicians and other members of the care team. I find it doesn't take fancy techniques-you just need to be sincere and patient and interested. Listen more and talk less. Try asking something like, "Knowing that all of us have to think about dying at some point, what would be a good death for you?" What people choose when they think about a good death for themselves is often beyond what medicine can provide-for instance, an affirmation of love, a completion of important work, or a last visit with an important person. As a physician, I can't always make those things happen. But I can help the dying person get ready-and in this way, contribute to a death that is decent.
What goals should I have in mind when working towards a decent death for my patient?
I have several working clinical goals when I am caring for someone near the end of life. I work towards:
Control of pain and other physical symptoms. The physical aspects of care are a prerequisite for everything that follows.
Involvement of people important to the patient. Death is not usually an individual experience; it occurs within a social context of family, significant others, friends, and caregivers.
A degree of acceptance by the patient. Acceptance doesn't mean that the patient likes what is going on, and it doesn't mean that a patient has no hopes--it just means that he can be realistic about the situation.
A medical understanding of the patient's disease. Most patients, families, and caregivers come to physicians in order to learn something about what is happening medically, and it is important to recognize their need for information.
A process of care that guides patient understanding and decision making. One great physician does not equal great care--it takes a coordinated system of providers.
How do you know when someone is dying?
This question is not as simple as it might sound. The SUPPORT study demonstrated that even for patients with a high probability of dying, it is still difficult for a clinician to predict that a particular patient is about to die. Thus it may be more useful for clinicians to give up relying on their predictive skills, and look at the common clinical paths (or trajectories) taken by dying patients, and design medical care that includes "contingency plans" for clinical problems that a person with incurable lung cancer (for example) is likely to experience. Such contingency plans might include advance directives and perhaps DNAR orders, as well as lines such as: "You will probably die from this, although we can't predict exactly when. What is really important for you in the time you have left?"
What should I know about the hospice approach?
In order to help someone towards a decent, or even good, death, the hospice framework is very helpful. Hospice started as a grassroots effort, as a view of dying that lets go of the possibility of cure. Instead, hospices emphasize symptom control and attention to psychological and spiritual issues. Pathophysiology becomes less important and personal meaning becomes more important. Thus this framework analyzes a person's medical care into four major topics, and this can be used to outline day-to-day care plans for a patient:
Pain - one of the things most feared by patients with life-threatening illness.
Symptom control - including dyspnea, nausea, confusion, delirium, skin problems, and oral care.
Psychological issues - especially depression, sadness, anxiety, fear, loneliness.
Spiritual or existential issues - including religious or non-religious beliefs about the nature of existence, the possibility of some type of afterlife.
Hospice care in Washington State is most often provided by multidisciplinary teams who go to patients' homes. This care is covered by Medicaid for patients judged to have less than six months to live. Hospice care is generally underutilized, and even though most hospice teams feel that at least six weeks of hospice care is optimal, most patients receive much less because they are either referred very late or have not wanted hospice. A major problem in connecting hospice care to acute medical care is that referral implies a "switch" from curative to palliative medicine-a model that does not fit comfortably in many illnesses.
What you need to understand to care for the dying
Another useful framework was outlined by Joanne Lynn, who was one of the principal investigators of SUPPORT. She suggests that there are four things clinicians must know to care for the dying.
The patient's story - including how that person has viewed her life, the other persons important to her, and how she could bring her life to a close in a way that would be true to herself.
The body - which covers the biomedical understanding of disease, and what limits and possibilities exist for that person.
The medical care system available for this particular patient - knowing how you can make the system work for the patient, as well as the relevant law and ethics.
Finally, you must understand yourself - because you, as a physician, can be an instrument of healing, or an instrument that does damage.
Obviously, learning how to do all this is beyond the scope of this web page--these are goals that guide a career of learning and reflection. But this framework provides guidelines for you as you develop your own approach to caring for dying patients.
How do physicians who care for the dying deal with their own feelings?
It is not hard to find physicians who are burned out - ask any nurse. What is difficult is to find for yourself a type of self-care that will enable you to develop your gifts as a physician, and continue to use them in practice. It helps to learn your strengths and weaknesses, and to actively seek whatever will nurture you - in or out of medicine. A strategy of detachment may not serve you well in the long run. There are indeed rewards for physicians who care for the dying, but as a Zen master once observed of a bingo game, "you must be present to win."
End-of-Life Issues:
Case 1
Skip is a 50-year-old man with metastatic nonsmall cell lung cancer. He decided to try palliative chemotherapy because "otherwise I might just as well roll over and give up." After the first cycle of carboplatin and taxol, he requires hospitalization for fever and neutropenia (a complication of the chemotherapy). You stop by for a visit, and he says he feels terrible, wonders "if the chemo is worth all this", but that he's too scared to stop.
How would you respond?
Case 1 Discussion
For metastatic nonsmall cell lung cancer, palliative chemotherapy is an intervention providing, on average, a small benefit at considerable toxicity (a consideration for the Medical Indications box in a Clinical Ethics 4-box analysis). Yet for a patient who is well informed, understands the benefits and burdens, and wishes to proceed, a trial of palliative chemotherapy is justified. However, now Skip is voicing concern: the most important thing to do is hear him out. Find out what he is worried about, how he rates his quality of life, and what his goals are. This information will help you sort out what is going through his mind and help you guide him to a decision that will be the best for him.
As Skip thinks through his situation, ask him if he wants you to describe what would happen if he decides to have more chemotherapy, or stops his chemo and starts hospice care. Eventually you might ask him what a good death would be for him--he may not be able to answer immediately, but it might help him (and you) shape a care plan later. When you talk with Skip, keep in mind the goals for a decent death
End-of-Life Issues:
Case 2
Angela is a 72-year-old woman with end stage congestive heart failure from coronary artery disease--she has had two myocardial infarctions. When her medical management is optimal, she is just able to take care of herself in her own apartment, but with any small decompensation, she ends up in the hospital. She comes in for a clinic visit, and her weight is up 2 kilograms and she is complaining of paroxysmal nocturnal dyspnea, even though she has been taking her meds as prescribed. Exasperated and discouraged, she asks, "Am I dying?". The cardiologist replies: "Well, no--this is all reversible."
What would you say?
Case 2 Discussion
The SUPPORT study has shown us that the clinical course of dying from congestive heart failure is quite different from dying of lung cancer. Patients with lung cancer begin a visible, predictable decline several weeks before death that usually evident to experienced clinicians. Patients with congestive heart failure, however, experience periods of fairly good function alternating with decompensation right up until death, and the terminal event for these patients is often sudden. This pattern of decline is not usually labeled by patients or physicians as "dying." The unpredictable course has resulted in very few hospice referrals for patients with end-stage congestive heart failure.
The best care plan in this situation would be based on a discussion with Angela about what kinds of contingency plans should be in place if she has a severe, possibly fatal decompensation (see Advance Care Planning). Some medical centers are developing Palliative Care or Comfort Care services to try to better match the needs of patients with less predictable end-stage illnesses
Ethics Committees and Ethics Consultation
Most hospitals are now required to have an ethics committee, and many in the Seattle area provide an ethics consult service. This topic page will discuss the role and activities of these groups.
What does an ethics committee do?
Ethics committees involve groups of individuals from diverse backgrounds who support health care institutions with three major functions: providing ethics consultation, developing and/or revising select policies pertaining to clinical ethics (e.g., advance directives, withholding and withdrawing life-sustaining treatments, informed consent, organ procurement), and facilitating education about topical issues in clinical ethics.
The underlying goals of ethics committees are:
to promote the rights of patients;
to promote shared decision making between patients (or their surrogates if decisionally incapacitated) and their clinicians;
to promote fair policies and procedures that maximize the likelihood of achieving good, patient-centered outcomes; and
to enhance the ethical tenor of health care professionals and health care institutions.
Ethics committees or select members often help resolve ethical conflicts and answer ethical questions through the provision of consultations.
Who becomes a member of an ethics committee?
Ethics committee members usually represent major clinical services and other stakeholders in health care delivery. Thus, it is not uncommon for committee members to include clinicians (physicians and nurses) from medicine, surgery, and psychiatry, a social worker, a chaplain, and a community representative. Oftentimes, these committees also have a quality improvement manager, an individual responsible for the education program at the facility, a lawyer, and at least one individual with advanced training in ethics. This latter representative can come from a number of disciplines, including philosophy, law, medicine, theology, and anthropology. All members of the ethics committee take responsibility for learning techniques of ethical analysis (see Bioethics Tools) and the arguments surrounding most of the ethically charged issues in clinical practice.
Some ethics committees allow guests. These can include health sciences students, philosophy graduate students, physician trainees, facilitators, and patient representatives. Guests need to maintain the confidentiality of the information discussed at the meetings, often signing oaths to that effect.
What is the difference between an ethics committee and an ethics consultant?
An ethics consultant is an expert in clinical ethics who either provides ethics consultations or serves as an educator to the committee. Sometimes in lieu of an ethics consultant, the ethics committee will develop subcommittees to handle these functions. The decision to have an ethics consultant versus subcommittees rests with the available resources and the expertise of the committee members.
In general, the strengths of having an ethics consultant is that she is a recognized expert, and the logistics of having someone perform a consultation is straight forward. The weaknesses are that clinicians can rely on this outside person for the answers to their questions and not develop their own expertise, and only one voice/perspective gets expressed. The major strength of having subcommittees (sometimes having 2-3 individuals per month) perform consultations is that this structure incorporates a diversity of views when considering a response to a consultative request. The major weakness is the difficulty in organizing having more than one person respond to a consult. Regardless of the ethics consultant versus subcommittee structure, it is advisable to review consults at the next available ethics committee meeting.
Under what circumstances should I use an ethics committee?
You should consider asking for a consult when two conditions are met:
you perceive that there is an ethical problem in the care of patients, and
resolution does not occur after bringing this to the attention of the attending physician.
Most "ethical problems" turn out to be problems due to lack of communication. However, sometimes a true ethical dilemma occurs, frequently because there is a conflict between principles (autonomy, beneficence, justice) or between principles and outcomes.
Check with your hospital to see if there are any constraints on who can request an ethics consult. This differs across the medical centers. Some require that physicians initiate the consult, while others permit consults from anyone, including family members.
What will the ethics consultant do if I page her or him?
The consultant usually will ask you to specify the nature of the perceived ethical problem. He will meet with you and the other people involved in the situation. He will review the medical records. Oftentimes, the consultant will arrange an interdisciplinary meeting to review the specifics of the case and to facilitate communication across disciplines or between clinicians and the patient (and/or the family). The consultant will write a note and attempt to answer the proposed question(s). In the Seattle area, the recommendations will be anchored to the 4 box analysis of relevant case information, utilization of principles of clinical ethics, rigorous analysis of similar and dissimilar cases, and supporting arguments or data from the literature. If definitive recommendations cannot be made because there is disagreement among the ethics consult team, a clear explication of the arguments will be presented in the consultant's note.
How do I contact the ethics committee or request an ethics consultation?
Check with your hospital to identify the pager number to reach the ethics consultant. There should be an individual at each hospital who carries a pager for responding to ethics consultations. If this information is not readily available, call the UW Department of Medical History and Ethics for help locating a consultant (543-5145).
While you will hear colleagues referring to particular cases or interventions as "futile", the technical meaning and moral weight of this term is not always appreciated. As you will make clinical decisions using futility as a criterion, it is important to be clear about the meaning of the concept. (For a related discussion, see Do-Not-Resuscitate Orders.)
What is "medical futility"?
"Medical futility" refers to interventions that are unlikely to produce any significant benefit for the patient. Two kinds of medical futility are often distinguished:
quantitative futility, where the likelihood that an intervention will benefit the patient is exceedingly poor, and
qualitative futility, where the quality of benefit an intervention will produce is exceedingly poor.
Both quantitative and qualitative futility refer to the prospect of benefiting the patient. A treatment that merely produces a physiological effect on a patient's body does not necessarily confer any benefit that the patient can appreciate.
What are the ethical obligations of physicians when an intervention is clearly futile?
The goal of medicine is to help the sick. You have no obligation to offer treatments that do not benefit your patients. Futile interventions are ill advised because they often increase a patient's pain and discomfort in the final days and weeks of life, and because they can expend finite medical resources.
Although the ethical requirement to respect patient autonomy entitles a patient to choose from among medically acceptable treatment options (or to reject all options), it does not entitle patients to receive whatever treatments they ask for. Instead, the obligations of physicians are limited to offering treatments that are consistent with professional standards of care.
Who decides when a particular treatment is futile?
The ethical authority to render futility judgments rests with the medical profession as a whole, not with individual physicians at the bedside. Thus, futility determinations in specific cases should conform with more general professional standards of care.
While a patient may decide that a particular outcome is not worth striving for (and consequently reject a treatment), this decision can be based on personal preferences and not necessarily on futility.
What if the patient or family requests an intervention that the health care team considers futile?
In such situations, you have a duty as a physician to communicate openly with the patient or family members about interventions that are being withheld or withdrawn and to explain the rationale for such decisions. It is important to approach such conversations with compassion for the patient and grieving family. For example, rather than saying to a patient or family, "there is nothing I can do for you," it is important to emphasize that "everything possible will be done to ensure the patient's comfort and dignity."
In some instances, it may be appropriate to continue temporarily to make a futile intervention available in order to assist the patient or family in coming to terms with the gravity of their situation and reaching a point of personal closure. For example, a futile intervention for a terminally ill patient may be continued temporarily in order to allow time for a loved one arriving from another state to see the patient for the last time.
What is the difference between futility and rationing?
Futility refers to the benefit of a particular intervention for a particular patient. With futility, the central question is not, "How much money does this treatment cost?" or "Who else might benefit from it?" but instead, "Does the intervention have any reasonable prospect of helping this patient?"
What is the difference between a futile intervention and an experimental intervention?
Making a judgment of futility requires solid empirical evidence documenting the outcome of an intervention for different groups of patients. Futility establishes the negative determination that the evidence shows no significant likelihood of conferring a significant benefit. By contrast, treatments are considered experimental when empirical evidence is lacking and the effects of an intervention are unknown.

A young accident victim has been in a persistent vegetative state for several months and family members have insisted that "everything possible" be done to keep the patient alive.
Should you honor the family's request? What are your professional obligations?

Case 1 Discussion
Both Case 1 and Case 2 illustrate the possible conflicts that can arise with patients or family members about withholding or withdrawing futile interventions. If you and other members of the health care team agree that the interventions in question would be futile, the goal should be to withdraw or withhold these interventions. Achieving this goal requires working in tandem with the patient and/or family, as well as drawing upon resources, such as social workers, hospital chaplains, and ethics committees. If there is no professional consensus about the futility of a particular intervention, then there is no ethical basis for overriding the requests of patients and/or family members for that intervention
Case 2
An elderly patient with irreversible respiratory disease is in the intensive care unit where repeated efforts to wean him from ventilatory support have been unsuccessful. There is general agreement among the health care team that he could not survive outside of an intensive care setting. The patient has requested antibiotics should he develop an infection and CPR if he has a cardiac arrest.
Should a distinction be made between the interventions requested by the patient?
Case 2 Discussion
Both Case 1 and Case 2 illustrate the possible conflicts that can arise with patients or family members about withholding or withdrawing futile interventions. If you and other members of the health care team agree that the interventions in question would be futile, the goal should be to withdraw or withhold these interventions. Achieving this goal requires working in tandem with the patient and/or family, as well as drawing upon resources, such as social workers, hospital chaplains, and ethics committees. If there is no professional consensus about the futility of a particular intervention, then there is no ethical basis for overriding the requests of patients and/or family members for that intervention.
Case 3
An elderly man who lives in a nursing home is admitted to the medical ward with pneumonia. He is awake but severely demented. He can only mumble, but interacts and acknowledges family members. The admitting resident says that treating his pneumonia with antibiotics would be "futile" and suggests approaching the family with this stance.
Do you agree?
Case 3 Discussion
In many cases, "futility" is used inaccurately to describe situations that appear undesirable. For this patient, treating pneumonia with antibiotics stands a reasonable chance of success. The patient's quality of life, though low, is not unacceptably so. Unless the patient (or if found incapacitated, his surrogate) was to say that he would find this quality of life unacceptably low, there is neither quantitative nor qualitative grounds for calling antibiotics futile in this case.
The Acquired Immunodeficiency Syndrome (AIDS) epidemic has had an enormous impact on health care provision in the United States. This impact has occurred largely because the AIDS epidemic has forced the medical community to openly address the needs of populations who have historically been marginalized in our society: gay men and intravenous drug users. The influence of the epidemic was felt on many levels. On the federal level AIDS activists forced the more rapid approval of medicines by the Federal Food and Drug Agency (FDA). State and city departments of public health had to organize culturally sensitive, anonymous HIV counseling and testing centers and on the individual practice level, physicians were forced to confront their own biases to provide ongoing care for a new and possibly transmissible epidemic.
AIDS cases seen by the author in his own practice are used to try to demonstrate some, but certainly not all, of the many ethical issues that confront the practitioner in the day to day care of people with AIDS.
Case 1 addresses these questions:
What is the legal decision-making status of a long-term partner?
How should I facilitate communication between family members?
Who are some other staff members who may be able to help?
How should I deal with any prejudices I may have in this case?
Case 2 addresses:
What should you do if a patient refuses to be tested?
Case 3 addresses:
When should you report a patient's HIV status to the Public Health Department?
Case 4 addresses:
Should you prescribe protease inhibitors to a patient who is unlikely to follow through on the treatment regimen?
Case 1
You are the ICU attending physician taking care of a 40-year-old gay man with AIDS who is intubated with his third bout of pneumocystis pneumonia. His condition is worsening steadily and he has not responded to appropriate antibiotic therapy. The patient's longtime partner, Richard, has a signed durable power of attorney (DPOA) and states that if the patient's condition becomes futile the patient would not want ongoing ventilation. As the ICU attending you decide that ongoing intubation is futile. You consult with Richard and decide to remove the patient from the ventilator to allow him to die in the morning. The patient's Roman Catholic parents arrive from Kansas and threaten a lawsuit if the ventilator is withdrawn.
There are several key questions which come out of this case:
Who is the legal decision maker here?
What are some of the pertinent social influences in this case?
Who are some other staff members who may be able to help?
How should the physician deal with any prejudices they have in this case?
What is the legal decision making status of a long-term partner?
Richard, the durable power of attorney is the legal decision maker in this case. The document is a legally binding agreement that states Richard is the final arbiter of all medical decisions once the patient becomes incapacitated. This creates a legal foundation for Richard to keep his role as the final medical decision maker in conjunction with the attending physician while allowing room for discussion with the family on this difficult topic.
How should I facilitate communication between family members?
This is an unfortunate situation for everybody involved. The physician can help diffuse this situation by trying to understand the different perspectives that each of the involved individuals brings to the situation. The family arrives to see their dying son and may be confronted with multiple issues for the first time. First they may be finding out that their son is gay, that he has AIDS, and that he is immanently dying all at the same time. Any of these issues may be a shock to the family, so it is important to keep this perspective in mind when making difficult care decisions and to communicate clearly and honestly with them. Communication regarding the patient's care should be consented to by the patient whenever possible.
Alternatively, individuals in the gay communities in metropolitan areas that have been severely affected by AIDS have watched many of their friends die of their disease and are very well educated about end of life issues. It is likely that Richard as your patient's DPOA has spent significant time considering these issues with the patient before becoming the patient's surrogate. His role as the patient's significant other is not legally defined in many areas of the United States at this time. This relationship is often the equivalent of marriage in the gay community and should be respected by the hospital personnel in all points of medical care.
Who are some other staff members who may be able to help?
This is a case where several members may help with the decision. ICU nurses often have experience and perspective in dealing with grieving families of terminally ill patients as do staff social workers or grief counselors. Another invaluable resource in this case is a hospital chaplain or spiritual counselor who may be able to provide spiritual support and guidance to the family. It is important here to find out what resources are available in the hospital for Richard and the patient's family and after discussing the case with them, seek help from these other skilled professionals. If you as a physician have cultivated a relationship with these services it is often appropriate to invite them to a family meeting so that they can help you focus the discussion on the care of the patient, who is always your first priority as a physician.
How should I deal with any prejudices I may have in this case?
Much has been written on the responsibility of the physician in taking care of the patient with AIDS. The AMA position is "A physician may not ethically refuse to treat a patient whose condition is within the physician's realm of competence.... neither those who have the disease or are infected by the virus should be subject to discrimination based on fear or prejudice, least of all from members of the health care community." From this quote it is safe to say that the physician has a fiduciary responsibility toward the care of the HIV infected patient and there is no room within the profession for prejudice for people with AIDS. This stand on prejudice should cover not only gay men with AIDS, but also all other patients that a physician takes care of, even the next two cases (Case 2 and Case 3). (See also Personal Beliefs.)
Case 1 Resolution
A family conference was called involving multiple staff members including the hospital chaplain. The family's major fear was that withdrawing the ventilator was equivalent morally to suicide and they were afraid of this being a mortal sin. The chaplain was able to address their fears. The ventilator was withdrawn the next morning after the family and friends of the patient had a chance to say good-bye and the patient quickly expired.
Case 2
A 22-year-old woman is admitted to the hospital with a headache, stiff neck and photophobia but an intact mental status. Lab test reveal cryptococcal meningitis, an infection commonly associated with HIV infection. When given the diagnosis, she adamantly refuses to be tested for HIV.
Should she be tested anyway by the medical staff?
Case 2 Discussion
Testing for HIV, as for any other medical procedure should be done only with the informed consent of the patient. Testing without consent is unethical in this setting. The physician's role in the care of this patient is ongoing support, education and guidance about her various options for care.
Case 3
Your patient with cryptococcal meningitis eventually agrees to be tested for HIV and her test comes back positive. Due to her opportunistic infection she receives the diagnosis of AIDS.
Should she be reported to the department of public health?
Case 3 Discussion
AIDS is a currently a reportable diagnosis in all 50 states of the union. Her diagnosis should be reported to the department of public health. Notably, HIV positivity without the diagnosis of AIDS is not reportable in all states. Currently, 30 of 50 states requires reporting of a positive test. It is important to find out the local states laws where you are practicing to know how to approach this problem. (See also Confidentiality.)
Case 4
One of your clinic patients is a 35-year-old man with AIDS on Medicare who is an active intravenous drug user. He uses heroin and cocaine, but he never shares needles and is reliably present at all his clinic visits. He admits that he is often unable to take his medicines regularly when he is using drugs. He is asking about antiretroviral therapy with protease inhibitors. You have just read that HIV viral resistance to protease inhibitors occurs rapidly when patients are unable to take their medicines reliably.
Should you prescribe protease inhibitors to this patient?
Case 4 Discussion
This is a difficult and ongoing debate in the care of patients with HIV. Protease inhibitors used in combination with nucleoside analogues have proven a powerful weapon in the fight against HIV. The problem of resistance is a real concern in a patient who cannot take his medicines reliably. Many public health advocates feel that these medicines should not be offered to patients who are admittedly noncompliant because they would be creating resistant clones of virus which could then be passed on to others, or make the individual unable to benefit later if they were able to become compliant. They also argue that the cost of these medications on the health care system is so extreme that they should only be used by those who can fully benefit from them. Others argue the principle of justice which espouses equitable distribution of resources amongst all available people in need, and if the patient wants the medications he should have equal access to them.
There is no answer to this debate at this time. The only clear principle that should be followed here is that of non-abandonment. Whatever your choice is with the patient, the physician's responsibility is to remain available to the patient and continue an ongoing therapeutic relationship and encourage him with information and guidance about his HIV disease and issues of addiction.
Informed Consent
Opportunities to "consent" a patient abound on the wards. The aim of this section is to provide you with the tools required for the "basic minimum" as well as providing a more complete picture of the ideal informed consent process. You will find that the particular circumstances (e.g. the patient's needs or the procedure) will determine whether a basic or complete informed consent process is necessary. (See also Informed Consent in the OR.)
What is informed consent?
Informed consent is the process by which a fully informed patient can participate in choices about her health care. It originates from the legal and ethical right the patient has to direct what happens to her body and from the ethical duty of the physician to involve the patient in her health care.
What are the elements of full informed consent?
The most important goal of informed consent is that the patient have an opportunity to be an informed participant in his health care decisions. It is generally accepted that complete informed consent includes a discussion of the following elements:
the nature of the decision/procedure
reasonable alternatives to the proposed intervention
the relevant risks, benefits, and uncertainties related to each alternative
assessment of patient understanding
the acceptance of the intervention by the patient
In order for the patient's consent to be valid, he must be considered competent to make the decision at hand and his consent must be voluntary. It is easy for coercive situations to arise in medicine. Patients often feel powerless and vulnerable. To encourage voluntariness, the physician can make clear to the patient that he is participating in a decision, not merely signing a form. With this understanding, the informed consent process should be seen as an invitation to him to participate in his health care decisions. The physician is also generally obligated to provide a recommendation and share her reasoning process with the patient. Comprehension on the part of the patient is equally as important as the information provided. Consequently, the discussion should be carried on in layperson's terms and the patient's understanding should be assessed along the way.
Basic consent entails letting the patient know what you would like to do and asking them if that will be all right. Basic consent is appropriate, for example, when drawing blood. Decisions that merit this sort of basic informed consent process require a low-level of patient involvement because there is a high-level of community consensus.
How much information is considered "adequate"?
How do you know when you have said enough about a certain decision? Most of the literature and law in this area suggest one of three approaches:
reasonable physician standard: what would a typical physician say about this intervention? This standard allows the physician to determine what information is appropriate to disclose. However, it is probably not enough, since most research in this area shows that the typical physician tells the patient very little. This standard is also generally considered inconsistent with the goals of informed consent as the focus is on the physician rather than on what the patient needs to know.
reasonable patient standard: what would the average patient need to know in order to be an informed participant in the decision? This standard focuses on considering what a patient would need to know in order to understand the decision at hand.
subjective standard: what would this patient need to know and understand in order to make an informed decision? This standard is the most challenging to incorporate into practice, since it requires tailoring information to each patient.
Most states have legislation or legal cases that determine the required standard for informed consent. In the state of Washington, we use the "reasonable patient standard." The best approach to the question of how much information is enough is one that meets both your professional obligation to provide the best care and respects the patient as a person with the right to a voice in health care decisions. (See also Truth-Telling and Law and Medicine.)
What sorts of interventions require informed consent?
Most health care institutions, including UWMC, Harborview, and VAMC have policies that state which health interventions require a signed consent form. For example, surgery, anesthesia, and other invasive procedures are usually in this category. These signed forms are really the culmination of a dialogue required to foster the patient's informed participation in the clinical decision.
For a wide range of decisions, written consent is neither required or needed, but some meaningful discussion is needed. For instance, a man contemplating having a prostate-specific antigen screen for prostate cancer should know the relevant arguments for and against this screening test, discussed in layman's terms. (See also Research Ethics.)
When is it appropriate to question a patient's ability to participate in decision making?
In most cases, it is clear whether or not patients are competent to make their own decisions. Occasionally, it is not so clear. Patients are under an unusual amount of stress during illness and can experience anxiety, fear, and depression. The stress associated with illness should not necessarily preclude one from participating in one's own care. However, precautions should be taken to ensure the patient does have the capacity to make good decisions. There are several different standards of decision making capacity. Generally you should assess the patient's ability to:
understand his or her situation,
understand the risks associated with the decision at hand, and
communicate a decision based on that understanding.
When this is unclear, a psychiatric consultation can be helpful. Of course, just because a patient refuses a treatment does not in itself mean the patient is incompetent. Competent patients have the right to refuse treatment, even those treatments that may be life-saving. Treatment refusal may, however, be a flag to pursue further the patient's beliefs and understanding about the decision, as well as your own.
What about the patient whose decision making capacity varies from day to day?
Patients can move in and out of a coherent state as their medications or underlying disease processes ebb and flow. You should do what you can to catch a patient in a lucid state - even lightening up on the medications if necessary - in order to include him in the decision making process.
What should occur if the patient cannot give informed consent?
If the patient is determined to be incapacitated/incompetent to make health care decisions, a surrogate decision maker must speak for her. There is a specific hierarchy of appropriate decision makers defined by state law (also see the DNR topic page). If no appropriate surrogate decision maker is available, the physicians are expected to act in the best interest of the patient until a surrogate is found or appointed.
Is there such a thing as presumed/implied consent?
The patient's consent should only be "presumed", rather than obtained, in emergency situations when the patient is unconscious or incompetent and no surrogate decision maker is available. In general, the patient's presence in the hospital ward, ICU or clinic does not represent implied consent to all treatment and procedures. The patient's wishes and values may be quite different than the values of the physician's. While the principle of respect for person obligates you to do your best to include the patient in the health care decisions that affect his life and body, the principle of beneficence may require you to act on the patient's behalf when his life is at stake.
Informed Consent:
Case 1
A 64-year-old woman with MS is hospitalized. The team feels she may need to be placed on a feeding tube soon to assure adequate nourishment. They ask the patient about this in the morning and she agrees. However, in the evening (before the tube has been placed), the patient becomes disoriented and seems confused about her decision to have the feeding tube placed. She tells the team she doesn't want it in. They revisit the question in the morning, when the patient is again lucid. Unable to recall her state of mind from the previous evening, the patient again agrees to the procedure.
Is this patient competent to decide? Which preference should be honored?
Case 1 Discussion
This patient's underlying disease is impairing her decision making capacity. If her wishes are consistent during her lucid periods, this choice may be considered her real preference and followed accordingly. However, as her decision making capacity is questionable, getting a surrogate decision maker involved can help determine what her real wishes are.
Case 2
A 55-year-old man has a 3-month history of chest pain and fainting spells. You feel his symptoms merit cardiac catheterization. You explain the risks and potential benefits to him, and include your assessment of his likely prognosis without the intervention. He is able to demonstrate that he understands all of this, but refuses the intervention.
Can he do that, legally? Should you leave it at that?
Case 2 Discussion
This patient understands what is at stake with his treatment refusal. As he is competent to make this decision, you have a duty to respect his choice. However, you should also be sure to explore his reasons for refusing treatment and continue to discuss your recommendations. A treatment refusal should be honored, but it should also not be treated as the end of a discussion.
Informed Consent
in the Operating Room
The informed consent process for surgery usually begins long before the patient enters the operating room environment, with the patient's first visit to the surgeon's office. In contrast, the informed consent for anesthesia is often obtained in the minutes before surgery in which the anesthesiologist and patient meet for the first time. (See also the main topic page for Informed Consent.)
What are some common situations in which a patient's ability to make decisions about surgery and anesthesia may be questioned?
Many situations commonly arise around the time of surgery, in which a patient's ability to make health care decisions may be, rightfully or wrongfully, called into question. Some of them include:
the premedicated patient
the patient in labor
the patient under stress
the patient with known mental illness
the patient with organic brain disease
the immature patient (i.e. patient who is minor in age, or who has immature mental capacity, such as some forms of mental handicap)
How does medication affect a patient's ability to give valid consent to a procedure?
It is common to encounter patients who have received sedation and/or pain medication prior to coming to surgery, and it is also common for such medications to be deliberately withheld prior to surgery in anticipation of the necessity to obtain consent. When pain medications are withheld, patients may feel pressured to consent in order to obtain medication to relieve their suffering.
In some instances, premedication may actually enhance a patient's ability to make decisions, by providing pain relief or relief from emotional distress, so that they can focus on the choices they are making. Clearly, if premedication has rendered the patient unable to listen, to understand their situation, the need for care, the risks, and alternatives, or to communicate a decision, then it has negated the informed consent process. But pain medication should never be withheld from a suffering patient under the guise of obtaining informed consent.
How does the physical or mental stress of the OR affect the informed consent process?
Many studies have examined the ability of laboring patients to give informed consent. While many patients do not later remember the informed consent process, laboring patients in general demonstrate the capacity to understand their situation, understand proposed care, risks, and alternatives, and express consent. Legal cases have recognized the complex voluntary physical control required from a laboring woman to permit epidural placement, and cite the physical cooperation of the woman in the process as an indication of motivation and consent for the procedure.
While many, if not most patients coming to the OR are experiencing stress, there is little evidence that most are not able to meet the standards mentioned on the main topic page (Informed Consent) to make decisions regarding their health care.
Patient immaturity can be relevant when the patient is of a very young age (minor) and presumed to not have the cognitive development to make meaningful decisions, or when the patient suffers from mental handicap which impairs her cognitive development. Once again, neither condition in itself precludes participation of the patient in decision making, but expert consultation may be needed to determine whether the patient is capable of understanding their situation and options, and making a decision based on them. In the case of minor patients, legal precedents determine when a minor can give legal consent, but do not address the issues of when a minor patient should be invited ethically to participate in the informed consent process. A more detailed discussion of these issues will occur in the Pediatrics Clerkships.
What information should be provided to surgical patients in the consent process?
General rules to follow in consent for surgery and anesthesia are to inform the patient of common risks even if they are not serious, and very serious risks, such as death, even if they are not common. By asking the patient if they have any specific concerns, you can invite the patient to let you know of any "special" informational needs that they may have which are not obvious to you.
When discussing risks with patients, understand that mere recitation of statistical risks may mean little to patients, and it can be helpful to relate the information to risks which have some meaning for the patient. The approximately one in 50,000 risk of death during general anesthesia in a healthy patient can be compared to that of the risk of death in an automobile accident (about twice that), as a way of putting perspective on the information being provided.
Can I influence patients during the informed consent process?
Influence can be applied to the information given to patients, and generally falls into three categories:
Coercion is the application of a credible threat to the patient, and is always unethical. Manipulation involves incomplete or nontruthful presentation of information, such as lying, omitting vital information, or deliberately deceiving. Manipulation is always ethically suspect. Persuasion involves the presentation of a rational argument for a choice, and is permissible, even desirable during the consent process. Patients recognize that physicians have expertise and advice to offer about their care, and expect physicians to be forthright with recommendations.
Do we harm patients by causing stress and anxiety when we tell them about the risks of anesthesia and surgery?
"Therapeutic privilege," or the idea that information may harm patients, is often cited as a reason to curtail the discussion of risks with patients about to undergo anesthesia and surgery. Multiple studies have failed to demonstrate differences in the way patients and observers rate the stress levels of patients who receive detailed information when compared with patients who received little or no information about risks.
What do I do in an emergency, or when the patient is incapable of making a decision?
Conscious, competent patients have the right to make choices regarding their health care in emergencies, just as in routine care.
When patients are incapacitated, it is important to seek the advice of appropriate surrogate decision makers and others who know the patient and are aware of his or her usual choices. When such information cannot be obtained, the physician should try to act in the best interest of the patient until such a surrogate can be found.
Is the surgical consent sufficient to cover anesthesia care?
Principles involving the informed consent process require that the best available information about procedures and risks be provided to patients. Just as anesthesiologists lack the expertise to discuss risks of surgery, surgeons lack expertise to discuss the nature and risks of anesthesia. While the surgical consent form does contain a phrase regarding consent for anesthesia care, the informed consent process requires that a separate discussion of anesthesia risks be carried out by the anesthesia provider.
What if the patient requests not to hear about risks?
Patients have the right to refuse information, but the request must originate from the patient and not the physician.
Informed Consent in the Operating Room:
Case 1
A 28-year-old man presents to the emergency room with testicular torsion, in extreme pain. Emergency surgery is scheduled, but the urologist will be unable to see the patient for at least one hour. He asks that the patient not be given any pain medication, so that "consent can be obtained" when he sees the patient.
Are the surgeon's concerns about informed consent valid? What ethical issues should be considered with regard to pain treatment for this patient?
Case 1 Discussion
The surgeon has the common misconception that informed consent is somehow invalidated by the presence of specific medications. Patients who present for surgery may have taken a variety of medications, many of which can have effects on mental function. The issue is not whether the patient has been premedicated, but whether premedication has impaired the patient's ability to participate in the informed consent process.
The ethical issues involved in this case include assessment of the patient's capacity to make decisions, and whether the patient is deliberately or otherwise, being coerced into consenting for surgery. The patient's capacity to provide consent is determined not by what recent medications have been given, but by whether the patient understands the need for treatment, can listen to and understand treatment options and risks, and can then express a choice regarding their care. Respect for patient autonomy requires that we promote a patient's ability to make an "unencumbered" choice. Severe pain, by impairing a patient's ability to listen and understand, is an encumbrance to the informed consent process. Further, withholding pain medication for the purpose of obtaining consent might be coercive.
Case 2
A 36-year-old man presents for bone marrow donation for transplantation. His primary care physician contacts the anesthesiologist to report that the patient is extremely anxious about the procedure. The primary doctor requests that the anesthesiologist not discuss risks with the patient, since it might "scare" the patient into not providing bone marrow for a sick cousin.
Should you curtail risk discussion? What should you tell this anxious patient?
Case 2 Discussion
This request to curtail discussion of risks is not originating with the patient. To avoid discussion for the purpose of improving the likelihood that the patient will cooperate with bone marrow harvest not only carries some mistaken assumptions about the effects of risks discussions, but it "uses" the patient to meet the ends of another individual, rather than to further his own goals, a distinctly unethical practice.
Since the patient is anxious, it is reasonable to offer to discuss risks with him, but inform him that he has the choice to not have a detailed discussion if he thinks it might unduly stress him.
More importantly, a well-done discussion of risks with this patient can be reassuring, and serve to decrease his anxiety about the upcoming procedure. The patient may be suffering from unreasonable fears about the risks of the procedure. Since the patient is healthy, anesthesia and procedure risks are minimal. He can be reassured that the procedure presents him with less risk than many things he does every day without much concern--such as driving a car to his appointment in your office.
Interdisciplinary Team Issues
Because of the increasing complexity and scope of patient problems presenting to the health care environment, patient care now routinely combines the efforts of physicians of different disciplines, skilled nursing professionals, and other health care professionals. Comprehensive patient care often involves trying to solve problems which are beyond the scope of expertise and training of any one provider. Thus, the organization of professionals involved in one patient's care has evolved from that of a hierarchy, with the physician in a "command" position, to that of a multidisciplinary team, interfacing many different kinds of health care professionals, each with separate and important knowledge, technical skills, and perspectives. In a teaching hospital, team membership becomes that much more complex with the presence of students, interns, residents, and fellows.
How do teams work together?
Working together as a team, professionals must balance responsibilities, values, knowledge, skills, and even goals about patient care, against their role as a team member in shared decision-making. Because many physicians, in particular, are accustomed to a practice environment in which decisions are "made" by the doctor, and "carried out" by other professionals, it is difficult sometimes for physicians to adjust to a team approach, in which majority opinion, deference to more expert opinion, unanimity, or consensus may be more appropriate methods of decision-making than autocratic choice. Further, physicians who maintain a hierarchical concept of medical care may face serious problems when disagreements arise with other physicians of equal "stature" on the medical team. Interdisciplinary conflicts are seen in all areas of medical practice, but the operating room environment is particularly rich in examples in which patient care involves interdisciplinary cooperation, conflict, and compromise.
Who is in charge in the operating room? Isn't the surgeon "Captain of the Ship"?
You will certainly hear at some point in your medical training that the surgeon is "captain of the ship" in the operating room. While recent legal decisions have essentially "sunk" the concept, it is important to understand the ethical and legal terrain. The phrase "captain of the ship" was first used by the Pennsylvania Supreme Court in 1949 in McConnell vs. Williams. In that case, an intern at a charity hospital was responsible for blinding a newborn by improperly applying silver nitrate drops to her eyes. Laws in widespread application at the time provided many hospitals with "charitable immunity" from legal damages, and the parents of the newborn were unable to get money from the intern because he acted as a hospital employee. They therefore brought suit against the obstetrician. The Pennsylvania Supreme Court allowed a finding of negligence against the obstetrician, despite the fact that the obstetrician had had no direct part in the negligent act, specifically so that someone would pay money to the parents. In its decision, the court used an analogy from maritime law, in which a captain can be held liable for the action of all members of the crew of his ship.
Since 1949, several key changes have taken place. Hospitals are no longer immune from liability in most jurisdictions, in part because hospitals generally carry insurance against the negligent acts of their employees. Courts also recognize that the scope and complexity of medical practice is such that no single provider generally has complete control over a patient's medical care. The diversity of medical practice and the different forms of training and certifications required for specialty practice testify that different professionals have different expertise and therefore diverse levels of responsibility for individual acts in patient care. In this aspect the law is fair: the greater the authority and expertise asserted in a given act, the greater an individual's legal responsibility becomes.
In recent years, many state Supreme Courts have specifically thrown out the "captain of the ship" doctrine in disgust. Cases in which the captain of the ship doctrine has been specifically discarded include those in which plaintiffs have asserted that the surgeon was responsible for the acts of nurses, nurse anesthetists, anesthesiologists, radiologists, and radiology technologists, and in which plaintiffs asserted that the anesthesiologist was responsible for the acts of surgeons, nurses, and nurse anesthetists. Ironically, some recent law suits have been successfully pursued against surgeons for the actions of other operating room personnel, only because the surgeon himself asserted that he had, or should have had, complete control over everyone in the room at the time of the negligent act!
What are the ethical obligations of members of the interdisciplinary team in patient care?
Ethically, every member of the operating room team has separate obligations, or duties, toward patients, which are based on the provider's profession, scope of practice and individual skills. Team members also have ethical obligations to treat each other in a respectful and professional manner.
Relationships between professionals on the multidisciplinary team are by their nature unequal ones. Different knowledge and experience in specific issues both ethically and legally imparts unequal responsibility and authority to those care providers with the most knowledge and experience to handle them. But also because of differences in training and experience, each member of the team brings different strengths. Team members need to work together in order to best utilize the expertise and insights of each member.
Do I have to do whatever I am told by the attending physician, even if I disagree with their plans?
Professional relationships not only exist between different professions, and specialties within similar professions, but between students and teachers as well. The student-teacher relationship is also an unequal one, not merely because teachers generally have more authority than students, based on their training and years of experience, but much greater responsibility as well. An attending physician, for example, may be held both morally and legally liable for the actions of students or residents, whether or not she approved of those actions. Ethically, teachers have obligations to observe and control the actions of junior members of the medical team, both to prevent harm to patients from inexperienced care-givers, and to educate students in appropriate care. Students and residents, conversely, have obligations to their patients and to their teachers, to not act recklessly or without the knowledge and approval of supervisors. Whenever a student or resident disagrees with an attending physician's plans, he should seek input from the attending, both about the reasoning to pursue the attending's plan, and about the reasoning for rejecting her own. A respectful exchange of views may provide both parties with new information, and certainly serves to further education.
What is meant by "respectful" exchange of views?
Precisely because of the inequality of authority and responsibility in inter-professional, inter-physician, and student-teacher relationships, obligations of mutual respect are particularly important on the multidisciplinary team.
Disagreements between professionals are common and expected, because of different knowledge, experience, values, and perspectives of the various team members. While disagreements might be settled in a number of ways, mutual respectful behavior is a mandatory feature of professionalism. Thus, while it is not only possible, but expected, that members of the patient care team will disagree at times, it is never acceptable for disagreements to be verbalized in an unprofessional manner.
Respectful behavior begins with both listening to and considering the input of other professionals. Ask yourself whether your perception of whether you are respected depends more upon whether the other party agrees with you, or whether, despite disagreeing, they listened and acknowledged your point of view.
Respect is demonstrated through language, gestures, and actions. Disagreement can and should be voiced without detrimental statements about other members of the team, and without gestures or words that impart disdain. Both actions and language should impart the message: "I acknowledge and respect your perspective in this matter, but for the following reasons. I disagree with your conclusions, and believe I should do something else..."
It should go without saying that disrespectful behavior from a colleague does not justify disrespectful behavior in return.
How can disagreements on the multidisciplinary team be handled?
In the best situations, disagreement leads to a more complete interprofessional discussion of the patient's care, resulting in a new consensus about the best course of action. The new consensus may require compromises from each individual.
When members of a team cannot arrive at a consensus of what should be done, it may be helpful to consult other professionals who are not directly involved in the patient's care team for objective input. If the disagreement still cannot be resolved, another resource may be the hospital's ethics committee, which can listen to disagreements and help suggest solutions.
Case 1
An otherwise healthy 54-year-old man presents for radical retropubic prostatectomy, and expresses interest to his anesthesiologist in having postoperative epidural narcotic pain management. The anesthesiologist believes it provides superior pain control, but is informed by the surgeon that the patient "is not to have an epidural."
Is the anesthesiologist obliged to "take an order" from the surgeon?
Should the anesthesiologist provide the anesthetic he feels is best, regardless of the surgeon's input?
Case 1 Discussion
The answer to both questions is no. Anesthesiologists have special knowledge and training which are not shared by the surgeon with regard to the safe administration of anesthesia. They also have direct obligations to the patient to provide safe medical care which is as far as possible in keeping with the patient's wishes. When medical issues of safety, or specific patient goals are in conflict with the surgeon's desires, the anesthesiologist is first ethically obliged to provide the best care to the patient. But the anesthesiologist would be incorrect to proceed at this point without some discussion with the surgeon, for at least two reasons. First, ignoring the surgeon's communication is disrespectful. Second, the surgeon may have valuable information to impart, such as "my patients achieve very good pain control with intravenous and oral medication, and end up being discharged two days sooner than epidural patients, because they do not require prolonged urinary catheterization from epidural-associated urinary retention." This dialogue between team members can result in improved team relations, and better care for the patient.
Case 2
A 28-year-old woman presents for diagnostic laparoscopy for pelvic pain. During laparoscopy, the surgeon announces that she intends to proceed to hysterectomy for multiple uterine myomata. The anesthesiologist then declares that he will "wake the patient up" rather than allow the surgeon to proceed, due to lack of consent for the procedure, and questionable medical necessity.
Can the anesthesiologist "tell" the surgeon what to do?
Who is in charge when two physicians on the team disagree?
Case 2 Discussion
The anesthesiologist can stop the surgery, and may even have an ethical obligation to the patient to do so, but should take such action only after discussing several issues with the surgeon.
Is the surgery in fact included in the consent?
If not, is the surgery medically necessary at this moment (i.e., would delay place the patient's life in significant danger) or can it be postponed until the patient can be awakened and asked for consent?
If the surgery is not emergent, and there is no consent, the anesthesiologist is morally obliged to protect the patient's autonomy and right to give consent. Anesthesiologists have been also held legally liable for harm done to patients during elective surgery for which they did not consent, because the anesthesiologist renders the patient insensate and unable to protect themselves from unwanted intrusion.
Often, in a case like this one, consensus can be obtained from the health care team, which in this case could consult the hospital legal counsel and the hospital ethics committee prior to proceeding.

Law and Medical Ethics
Law and Medical Ethics are disciplines with frequent areas of overlap, yet each discipline has unique parameters and a distinct focus.
To better understand the relationship between law and medical ethics, these materials will briefly review:
Definitions - Sources of Authority
Conceptual Models
Roles of Medical Ethics and the Law
How can I find out what the law says on a particular subject?
The two cases further explore this topic, and check out the additional readings for bibliographic references
Definitions - Sources of Authority
In the course of practicing medicine, a range of issues may arise that require consultation from either a lawyer, a risk manager, or an ethicist. The following discussion will outline key distinctions between these roles.
The role of lawyers and risk managers are closely linked in many health care institutions. Indeed, in some hospitals the Risk Manager is an attorney with a clinical medicine background. There are, however, important distinctions between law itself and risk management.
Law is the established social rules for conduct; a violation of law may create criminal or civil liability.
Risk Management is a method of reducing risk of liability through institutional policies/practices.
Risk Management is guided by legal parameters but has a broader institution specific mission. It is not uncommon for a hospital policy to go beyond the minimum requirements set by the legal standard.[1]
When legal and risk management issues arise in the delivery of health care, there may be ethical issues, too. Conversely, what is originally identified as an ethical problem may raise legal and risk management concerns.
Medical ethics may be defined as follows:
Medical ethics is a discipline/methodology for considering the implications of medical technology/treatment and what ought to be.
To better understand the significant overlap among these disciplines, consider the sources of authority and expression for each.
Law is derived/expressed through:
federal and state constitutions
federal and state statutes (ex. Revised Code of WA.)
federal and state regulations (ex. WA. Administrative Code)
federal and state case law (individual lawsuits-decisions at appellate level.)
Risk Management is derived from law and professional standards and is expressed through institutional policies/practices.
Medical Ethics is derived/expressed through:
institutional policies/practices
policy of professional organizations
professional standards of care, fiduciary obligations
Conceptual Models of Law and Ethics
Conceptual Model - Linear

Conceptual Model - Distinctions

Conceptual Model - Interconnectedness

Roles of Medical Ethics and the Law
Within their distinctive roles, the disciplines of law and medical ethics nevertheless significantly overlap. Consider that both disciplines address:
access to medical care (provision of care, emergency treatment, stabilization and transfer)
informed consent
confidentiality of health care information and exceptions to confidentiality (mandatory reporting obligations such as: child and elder abuse, duty to warn)
privileged communications with health care providers
advance directives
physician-assisted suicide
There are, however, significant distinctions between law and medical ethics in philosophy, function and power. A court ruling is a binding decision that determines the outcome of a particular controversy. A statute or administrative code sets a general standard of conduct, which must be adhered to or civil/criminal consequences may follow a breach of the standard. Conversely, an ethics pronouncement which is not adopted into law may be a significant professional and moral guidepost but it is generally unenforceable. Lawmakers (courts and legislatures) frequently do turn to the policy statements (including any medical ethics statements) of professional organizations when crafting laws affecting that profession. Thus, health care providers may greatly influence legal standards by their work in creating professional ethics standards.

Good ethics has been described as beginning where the law ends.[2] The moral conscience is a precursor to the development of legal rules for social order. Law and medical ethics thus share the goal of creating and maintaining social good and have a symbiotic relationship as expressed in this quote:
Conscience is the guardian in the individual of the rules which the community has evolved for its own preservation.
William Somerset Maugham

How can I find out what the law says on a particular subject?
Law and medical ethics are both dynamic and are in a constant state of change, i.e., new legislation and court decisions occur and medical ethics responds to challenges created by new technology, law or other influences. To locate information about what the law on a particular topic is or to get copies of statutes, regulations or case law you may need to go to a law library. There are also legal search tools available on the Internet. Another potential resource are medical journals which frequently have articles on ethical issues which mention relevant legal authority.
The Relationship Between Law and Medical Ethics:
Case 1[3]

A 32 year old woman was admitted to the Trauma Intensive Care Unit following a motor vehicle accident; she had multiple injuries and fractures, with several complications which continued to develop over the first couple of weeks. The patient rapidly developed Adult Respiratory Distress Syndrome, was on a ventilator, and was continuously sedated. Shortly after the patient's admission, her parents were contacted and remained vigilant at her bedside. The parents reported that the patient was one month away from having her divorce finalized. The patient's husband was reportedly physically and emotionally abusive to her throughout their five years of marriage. The parents had not notified this man of the patient's hospitalization, and reported that visit by him would be distressing to the patient if she were aware of it. The patient's soon to be ex-husband is her legal next of kin.
Should the husband be responsible for treatment decisions which the patient cannot make?[4]

Case 1 Discussion
Some key legal and ethical issues raised by Case #1 are informed consent and surrogate decision-making. While the details of each case will determine the advice provided, Case #1 raises a number of issues with legal ramifications.
Specific legal issues:
There is implied consent by law for provision of "emergency" medical treatment. The Washington law (statute-RCW 7.70.050(4)) uses the term "emergency" but doesn't define it. However, the hospital policy in the UW/HMC Medical Centers Consent Manual (p. A-5) defines what the University's hospitals will consider an "emergency" and sets an institutional documentation standard:
Consent for care is implied by law when immediate treatment is required to preserve life or to prevent serious impairment of bodily functions and it is impossible to obtain the consent of the patient, his/her legal guardian, or next-of-kin.
In such emergency situations, the physician should consult, whenever possible, with the patient's attending physician or with another physician faculty member about the existence of an emergency. This must be noted in the patient's medical record, together with statements by each physician that the emergency treatment was necessary for the reasons specified. These notations should clearly identify the nature of the threat to life or health, its immediacy, and its magnitude.
Thus, if a medical emergency exists and implied consent is relied on by the health care providers, it should be documented in the patient's medical record in accordance with legal and institutional standards.
The patient may have provided her own consent to treatment either at the time of her admission or earlier in her hospitalization. At that time, she may have expressed her ongoing wishes for care. The patient's own previous statements/consent may therefore be the basis for continued consent for her ongoing care. Also, it is important to note that neither the law nor our UW institutional policy sets an explicit time limitation on implied consent based on an "emergency."
If there is a need for informed consent for a new treatment decision on behalf of the patient, the patient's previously expressed wishes may still be relevant to her legally authorized surrogate decision-maker and her treatment plan.
If the patient already filed for divorce, it is likely that there is a temporary court order in effect and this order may affirmatively remove the patient's estranged husband from making medical decisions for her. Also, it is common in divorce paperwork to have mutual restraining orders which prevent both spouses from contacting each other. The patient's parents should be asked to provide the name of her divorce attorney to obtain copies of the relevant legal papers - which can then be placed in the legal section of the patient's medical record. With the husband thus removed as her surrogate decision-maker, it appears the patient's parents would become the highest level class of surrogate decision-maker and could provide informed consent for her care if the patient is unable to do so.
Even if the patient's husband remains as her legal surrogate decision-maker, his decisions on the patient's behalf are constrained by legally imposed standards. First, a surrogate is legally required to provide "substituted judgment" on behalf of the patient. This means that the surrogate must act in accordance with the patient's wishes. If substituted judgment isn't possible (i.e., unknown what the patient would want under the current medical circumstances), then the law requires the surrogate to act in the patient's "best interests." Since the medical team has significant input about what would medically be in the patient's interest, a decision by a surrogate which doesn't adhere to this standard should not be automatically followed and may need to be reviewed by the institutional ethics committee, risk management, or legal counsel.
The patient's husband may be willing to waive his surrogate decision-maker role to his estranged wife. If this occurs, then he would agree to remove himself from the list of potential surrogate decision-makers and the next highest level surrogate decision-maker(s) would be contacted as necessary to provide informed consent for the patient.
A final option may be for the patient's parents to file to become the patient's legal guardians for health care decision-making.
Case 2[3]

A 72 year old woman was admitted to the Neurological Intensive Care Unit following a cerebral hemorrhage which left her with severe brain damage and ventilator dependent. One year before this event, the patient and her husband had drawn up "living wills" with an attorney. The patient's living will specified that the patient did not want ventilator support, or other artificial life supports, in the event of a terminal condition or a permanent vegetative state.[5]
The patient's husband is her legal next of kin and the person with surrogate decision-making authority. When the living will was discussed with him, he insisted that the patient had not intended for the document to be used in a situation like the present one. By this, the husband apparently meant that although the patient would not be able to recover any meaningful brain function, her condition was not imminently terminal. The husband did not consider his wife to be in a permanent vegetative state.
The treatment team allowed a week to pass, with the goal of providing the husband more time to be supported in his grief and to see how ill his wife was. Nevertheless, at the end of this time, the husband was unwilling to withdraw life support measures consistent with the patient's wishes as expressed in her living will.
What should be done?
What are the legal and ethical parameters?
Case 2 Discussion
The legal parameters and the ethical parameters in Case #2 are informed consent, surrogate decision-making and the patient's ability to direct her care - expressed in law as a liberty or privacy right and in ethics as respect for patient autonomy. While the details of each case will determine the advice provided, Case #2 raises a number of issues with legal ramifications.
Specific legal issues:
Patient is unable to provide her own informed consent for medical care. Informed consent means making a medical treatment choice and includes the choice of nontreatment. What is known about the patient's wishes for continued medical treatment under her current circumstances?
The patient's Advance Directive is strong evidence and significant in determining what the patient would want for substituted judgment. Since the patient's husband (her legal surrogate) only made vague statements as to why he thought she would want continued care under these circumstances and the husband's perspective was contradicted by their adult children - it appears the situation requires further communication efforts, e.g., patient care conference, ethics consult.
If these additional communication efforts fail to resolve the impasse - one legal/risk management approach may be to go forward with withdrawal of life support under the following conditions:
Verify that the content of the patient's Advance Directive is consistent with a decision to forego further life-sustaining measures. Check, if possible, with those persons who were present when she prepared/signed the document to gather further information about the patient's intentions.
Affirm that the requisite clinical determination(s) were made ("terminal" or "permanent unconscious" conditions) to activate the patient's Advance Directive. Check to make sure the clinical determination is well-documented in the patient's chart.
Affirm consensus among the medical team about: the clinical determinations; the appropriateness of withdrawing life support as in the patient's best interests; and that withdrawal is consistent with her Advance Directive.
Set a final patient care conference with the family members to review the patient's prognosis and the medical team's decision to withdraw care at a specific future date and time. This advance notice of planned future action allows the patient's husband an opportunity to seek judicial review or arrange for a transfer of care to another medical facility before the withdrawal of care. Under the circumstances, if the husband sought such review or transfer, the patient would need to be continued on life support pending completion of review or transfer. The legal benefit of this notice and time to act is it eliminates any claim that the hospital unilaterally took irreversible action without the family's consent or at least without their acquiescence. This course of action would also break the stalemate of the patient's situation and force a resolution.
Managed Care
An increasing amount of health care in the United States is administered though managed care plans. The phrase "managed care" evokes strong, often negative reactions from health care providers. Yet it is important to have an explicit understanding of managed care and particular types of potential ethical dilemmas that arise for health care providers in such systems.
What is "managed" care?
Managed care refers to a variety of techniques for influencing the clinical behavior of health care providers and/or patients, often by integrating the payment and delivery of health care. The overall aim of managed care is to place administrative control over cost of, quality of, or access to health care services in a specific population of covered enrollees.
What do "capitation" and other managed care systems involve?
Capitation involves paying physicians a fixed, prospective amount for each patient regardless of the cost of caring for the patient. Preferred provider organizations involve arrangements between physicians and purchasers in which physicians agree to offer discounts from their usual charges or fees in exchange for providing health care for a group of patients. Other examples of managed care include individual practice associations, health maintenance organizations, physician/hospital associations, and exclusive provider organizations.
Capitation is one example of managed care practices that seek to control costs of health care. Some managed care practices seek to impact the quality of care. For instance, clinical guidelines that aim to alter the clinical management of specific health concerns (e.g., treatment of hypertension) are also common managed care practices.
What ethical concerns does managed care raise?
Managed care is structured around a variety of incentives to encourage the practice of cost-effective medicine, and to minimize variation in clinical practice patterns. "Efficiency" here means providing a product, in this case health care, while minimizing resources used, most often dollars. Most often, efficiency is maximized by increasing productivity while fixing cost. Hence, managed care may create pressure to do more with less: less time per patient, less costly medicines, and fewer costly diagnostic tests and treatments.
Monetary incentives are often used to affect physician behavior, and may include rewarding physicians who practice medicine frugally by offering financial rewards, such as bonuses, for those who provide the most cost-efficient care. Those who perform too many procedures or are cost-inefficient in other ways may be penalized, often by withholding bonuses or portions of income. Nonmonetary inducements to limit care take the form of bringing peer pressure, or pressure from superiors, to bear on those who fail to take into account the financial well being of their employer. These monetary and nonmonetary incentives raise the ethical concern that physicians may compromise patient advocacy in order to achieve cost savings.
A related ethical concern pertains to the effect of managed care on physician-patient relationships. Many worry that managed care will undermine physician-patient relationships by eroding patients' trust in their physicians, reducing the amount of time physicians spend with patients, and restricting patients' access to physicians.
What specific impact does managed care have on relationships between doctors and patients?
Managed care can alter relationships between doctors and patients in a variety of ways. First, it may change the way in which such relationships begin and end. Health maintenance organizations, for example, pay only for care provided by their own physicians. Preferred provider groups restrict access to physicians by paying a smaller percentage of the cost of care when patients go outside the network. These restrictions limit patients' ability to establish a relationship with the physician of their choosing. Termination of physician-patient relationships can also occur without patients' choosing. For example, when employers shift health plans employees may have no choice but to sever ties with their physicians.
In addition, some forms of managed care create a financial incentive for doctors to spend less time with each patient. For instance, under preferred provider arrangements physicians may compensate for reduced fees-for-services by seeing more patients. This reduces the time available to discuss patients' problems, explore treatments options, and maintain a meaningful relationship with patients.
Finally, managed care arrangements often control patients' access to medical specialists, thereby restricting patients' freedom to choose providers and obtain the medical services they desire. This occurs, for example, in health maintenance organizations where primary care physicians function as "gatekeepers" who authorize patient referrals to medical specialists. Critics of managed care claim that this will lower the quality of care, while supporters believe that gatekeeping functions yield benefits such as reducing iatrogenic effects, promoting rigorous review of standards of care, and emphasizing low-technology, care oriented services.
What should physicians think about when evaluating managed care contracts?
As a physician, you may likely encounter health plans that employ managed care techniques. You should evaluate the nature of financial or other mechanisms that affect your practice and determine whether such mechanisms are consistent with providing competent and compassionate care to your patients.
For example, before signing contracts with insurers who restrict the amount you are allowed to charge, figure out if this amount will enable you to spend sufficient time with each patient. Before becoming the employee of a health maintenance organization, confirm that patients are not denied clinically effective health care services. Prior to accepting patients on a capitated basis, verify that you will be able to provide competent, high quality care under such an arrangement. Review contracts with health plans for clauses that limit or restrict your ability to discuss all potentially beneficial health care services with patients, even if they are not covered by the health plan (such clauses are often referred to as "gag" clauses). These kinds of inquiries can help to prevent serious ethical concerns from arising.
Existing arrangements with insurers should also be evaluated on an ongoing basis. For instance, after contracting with a preferred provider organization, you may decide that the financial pressure to take "short cuts" in providing high quality care is too great and the contract should not be renewed. You should also make full use of appeal mechanisms that exist for denied coverage. When coverage for a service you believe to be effective and clinically indicated is denied, your role as advocate for the patient obligates you to take every reasonable avenue to appeal the decision.
Case 1
Mrs. Jones is a patient of yours who has hypertension that has been difficult to control. You recently tried a new once-daily calcium channel blocker by giving her some free office samples, and had good success in controlling her blood pressure.
Later that week, Mrs. Jones calls your office, upset because the health plan refuses to cover the brand name prescription you wrote for this new medication. A generic equivalent is covered, however. Mrs. Jones adamantly wants the name brand, expressing frustration with being unable to get the medication "that finally works"
Case 1 Discussion
Managed care plans often look to prescription benefits as a way to cut their costs. One common mechanism is formulary restrictions and co-pays on prescription medications. In this case, one initial question is whether the generic equivalent has the same clinical effectiveness as the name brand. When cost can be reduced without sacrificing clinical benefit, the ethical conflict is greatly diminished. If this is the case, Mrs. Jones should be reassured that the generic medication should be just as effective as the name brand.
Another issue is whether the patient should be informed that the pharmacy benefit is restricted because of cost. Many physicians believe that costs should not enter into clinical decision making. In modern health care, however, it is inevitable that costs affect clinical decisions. Patient involvement in clinical decisions is an important ingredient for respecting patient autonomy and fostering trust between provider and patient (see also informed consent). Your discussion should involve an honest disclosure of factors involved in a clinical decision, including costs. Mrs. Jones might be told, "I've looked at the medical literature and consulted colleagues I respect, and found that the generic equivalent is just as good as the brand name. Your health plan wants to save money when it can, which is ok as long as it doesn't result in inferior treatment. I don't believe it will in this instance; if it did, I would appeal."
If on the other hand, your research reveals that the generic is not as effective as the name brand, your duty as a patient advocate would obligate you to take all reasonable steps to appeal the decision. Most health plans have appeal mechanisms that will overturn coverage criteria with fairly minimal physician effort. They maintain this stance to limit their potential liability and to foster good customer relations. While the phone calls and letters this often entails are certainly an inconvenience, the effort is an important part of patient advocacy in a managed care environment.
Maternal-Fetal Conflict

In caring for pregnant women, the physician must consider the health of two patients who are biologically linked, yet individually viable. Although most pregnant women willingly accept some risk to their own health in order to optimize fetal outcome, occasionally women refuse treatment recommended for their fetus. When a pregnant woman refuses medical therapy which could be life-saving for her fetus, complicated ethical issues arise.
What accounts for the rising awareness of maternal-fetal conflict?
Advances in medical technology have increased the physician's ability to direct medical procedures towards the fetus. Previously, physicians conceptualized the maternal-fetal dyad as one complex patient. Viewed as an organic whole, the combined maternal and fetal benefits of a proposed therapy could be weighed against the combined burdens. Distribution of benefits and burdens between the fetal and maternal components of the one patient was not ethically relevant. Over time, the medical model for the maternal-fetal relationship has shifted from unity to duality. When there are two individual patients, the physician must decide what is medically best for each patient separately.
What happens when medical therapy is indicated for one patient, yet contraindicated for the other?
Fetal care becomes problematic when what is required to benefit one member of the dyad will cause an unacceptable harm to the other. When a fetal condition poses no health threat to the mother, caring for the fetal patient will always carry some degree of risk to the mother, without direct therapeutic benefit for her. The ethical principles of beneficence ("be of benefit") and nonmaleficence ("do no harm") can come into conflict.
Because the patients are biologically linked, both, or neither, must be treated alike. It would be unethical to recommend fetal therapy as if it were medically indicated for both patients. Still, given a recommendation for fetal therapy, pregnant women, in most cases, will consent to treatment which promotes fetal health. When pregnant women refuse therapy, physicians must remember that the ethical injunction against harming one patient in order to benefit another is virtually absolute.
When does a fetus or a newborn become a person?
Some ethicists purport that viability entitles the fetus to "moral personhood". Viability is the physical capacity for life independent of maternal corporeal support. They argue that newborns and fetuses participate in the social matrix, and that this social role develops over time, beginning prior to birth. Others note that it is impossible to treat fetuses as persons without treating pregnant women as if they were less than persons. The birth of the fetus results in a distinct patient towards whom medical therapy can be individually directed. As such, many believe that the moral status of a developmentally younger newborn supersedes that of an older viable fetus.
People have rights. Does a fetus have rights?
Throughout the world, the legal status of fetuses is generally subordinated to that of pregnant women. In most countries, the legal status of the fetus is bolstered as gestation progresses. Viability signifies a change in its legal status. Still, although the human fetus has the potential for personhood, this does not imply that it is a person or that it has rights. So long as the fetus is attached to the pregnant woman, her body maintains its life, and bars access to it.
US courts have ruled that a child has a legal right to begin life with a sound body and mind. Such a right may create a legal duty, on the part of a pregnant woman, to protect the health of her fetus. Failure to fulfill that duty could subject her to charges of fetal abuse, or render her liable for consequent damage to her child. Pregnant women's refusals of hospitalization, intrauterine transfusion, or surgical delivery have been legally challenged on the grounds of an obligation to the fetus.
What if maternal decisions seem to be based on unusual beliefs?
Parents are granted wide discretion in making decisions about their children's lives. However, when the exercise of certain beliefs would disadvantage the child's health in a serious way, there are limits in exercising this discretion (for further discussion, see the pediatric portion of the Cross-Cultural Issues topic page).
What about obtaining court orders to force pregnant women to comply?
US courts have demonstrated a willingness to force treatment on a mother for the sake of her viable fetus. However, the decisions of lower-court judges do not necessarily reflect settled law. Of the two court orders that have been reviewed by the highest courts of their respective states, one was upheld and the other was overruled.
The use of court orders to force treatment on pregnant women raises many ethical concerns. Court orders force pregnant women to forfeit their autonomy in ways not required of competent men or nonpregnant women. There is an inconsistency in allowing competent adults to refuse therapy in all cases but pregnancy. Hospital administrators, lawyers and judges have little warning of impending conflicts and little time for deliberation; this time pressure makes it unlikely that pregnant women will have adequate legal representation. Furthermore, forced obstetrical interventions have the potential to adversely affect the physician-patient relationship. The American College of Obstetrics and Gynecology has stated that "Obstetricians should refrain from performing procedures that are unwanted by pregnant woman....The use of the courts to resolve these conflicts is almost never warranted."
Maternal-Fetal Conflict:
Case 1
A 29-year-old woman had an obstetrical ultrasound at 33 weeks to follow-up a previous finding of a low-lying placenta. Although the placental location was now acceptable, the amniotic fluid index (AFI) was noted to be 8.9 cm. Subsequent monitoring remained reassuring until 38.5 weeks, when the AFI was 6 cm. The patient declined the recommendation to induce labor, and also refused to present for any further monitoring. She stated that she did not believe in medical interventions. Nevertheless, she continued with her prenatal visits. At 41 weeks, she submitted to a further AFI, which was found to be 1.8 cm. She and her husband continued to decline the recommendation for induced labor.
Which ethical duty takes precedence, the duty to respect the patient's autonomous decision, or the duty to benefit a viable fetus? Is induction of labor a harmful intervention, subject to the principle of nonmaleficence?
Case 1 Discussion
Induction of labor at term is an intervention with demonstrated efficacy and carries low risk to the mother. In this case, it could prevent serious damage to a viable fetus. Informed discussion and persuasive efforts should be continued towards this goal. However, deliberate disregard of maternal refusal for therapy could constitute assault. So long as the fetus is attached to the pregnant woman, her body maintains its life, and bars access to it.
Case 2
A 22-year-old woman in her first pregnancy with an unremarkable prenatal course presents with preterm labor at 28 weeks gestation. Her contractions were successfully stopped with terbutaline. Discharge planning was reviewed with her, and she was instructed to follow a regimen of bedrest and oral terbutaline. She reported that she did not intend to comply with these instructions. She believed that God would not allow her to labor unless it was time for the baby to deliver, and she indicated that He had communicated this to her.
How can the physician ensure nonmaleficence towards the mother and still promote beneficence towards her fetus? Is the mother competent? Should maternal autonomy prevail over other ethical concerns?
Case 2 Discussion
The gestational age of this pregnancy places the fetus on the border of viability. Extensive, non-coercive discussions are essential to ensure that this patient understands the implications of refusing therapy. You may suggest that she invite her spiritual advisor to meet with both of you to talk together about her beliefs and the impact on her fetus.
If her refusal persists, in light of her unconventional religious claims, a psychiatric consultation might be requested to evaluate her competency. If competency is documented, the ethical principle of nonmaleficence would support refraining from performing any unwanted interventions. If the patient is found to be incompetent, judicial intervention could be considered.
Errors are inevitable in the practice of medicine. Sometimes these result from medicine's inherent uncertainty. Occasionally they are the result of mistakes or oversights on the part of the individual provider. In either case, a physician will face situations where she must address mistakes with her patient.
How do mistakes occur?
All physicians make mistakes, and most mistakes are not the result of negligence. A physician may make a mistake because of an incomplete knowledge base, an error in perception or judgment, or a lapse in attention. Making decisions on the basis of inaccurate or incomplete data may lead to a mistake. The environment in which physicians practice may also contribute to errors. Lack of sleep, pressures to see patients in short periods of time, and distractions may all impair an individual's ability to avoid mistakes.
Do physicians have an ethical duty to disclose information about medical mistakes to their patients?
Physicians have an obligation to be truthful with their patients. That duty includes situations in which a patient suffers serious consequences because of a physician's mistake or erroneous judgment. The fiduciary nature of the relationship between a physician and patient requires that a physician deal honestly with his patient and act in her best interest.
How do I decide whether to tell a patient about an error?
In general, even trivial medical errors should be disclosed to patients. Any decision to withhold information about mistakes requires ethical justification. If a physician believes there is justification for withholding information about medical error from a patient, his judgment should be reviewed by another physician and possibly by an institutional ethics committee. The physician should be prepared to publicly defend a decision to withhold information about a mistake from the patient.
Won't disclosing mistakes to patients undermine their trust in physicians and the medical system?
Some patients may experience a loss of trust in the medical system when informed that a mistake has been made. Many patients experience a loss of trust in the physician involved in the mistake. However, nearly all patients desire some acknowledgment of even minor errors. Loss of trust will be more serious when a patient feels that something is being hidden from them.
By disclosing a mistake to my patient, do I risk having a malpractice suit filed against me?
It has been shown that patients are less likely to consider litigation when a physician has been honest with them about mistakes. Many lawsuits are initiated because a patient does not feel they have been told the truth. Litigation is often used as a means of forcing an open and honest discussion that the patient feels they have not been granted. Furthermore, juries look more favorably on physicians who have been honest from the beginning than those who give the appearance of having been dishonest.
What if I see someone else make a mistake?
A physician may witness another health care provider making a major error. This places the physician in an awkward and difficult position. Nonetheless, the observing physician has some obligation to see that the truth is revealed to the patient. This should be done in the least intrusive way. If the other health care provider does not reveal the error to the patient, the physician should encourage her to disclose her mistake to the patient. Should the health care provider refuse to disclose the error to the patient, the physician will need to decide whether the error was serious enough to justify taking the case to a supervisor or the medical staff office, or directly telling the patient. The observing physician also has an obligation to clarify the facts of the case and be absolutely certain that a serious mistake has been made before taking the case beyond the health care worker involved.
Case 1
An 18-month-old child presents to the clinic with a runny nose. Since she is otherwise well, the immunizations due at 18 months are administered. After she and her mother leave the clinic, you realize that the patient was in the clinic the week before and had also received immunizations then.
Should you tell the parents about your mistake?
Case 1 Discussion
The error is a trivial one. Aside from the discomfort of the unnecessary immunization, no harm has resulted. Nonetheless, an open and honest approach to errors is most appropriate. While the parents may be angry initially about the unnecessary injection, they will appreciate your candor. On the other hand, should they discover the error and believe you have been dishonest, their loss of trust will be significant.
Case 2
A 3-month-old has been admitted to the hospital with a newly diagnosed ventricular septal defect. She is in early congestive heart failure and digoxin is indicated. After discussing the proper dose with the attending physician, you write an order for the drug. Thirty minutes later the baby vomits and then has a cardiac arrest and dies. You discover that in writing the digoxin order you misplaced the decimal point and the child got 10 times too much digoxin.
What is your duty here? Will you get sued if you tell the truth?
Case 2 Discussion
This unfortunate event represents a serious error with profound implications for the patient and family. You owe this family an honest explanation. They need to hear you say that you're sorry. Any attempt to hide the details of the event would be dishonest, disrespectful, and wrong. Though a lawsuit may follow, these parents are less likely to litigate if you deal with them honestly and take responsibility for the error.
Case 3
A 3-year-old presents to the emergency department. She was diagnosed with pyelonephritis by her physician yesterday, treated with an intramuscular injection of antibiotic and sent home on an oral antibiotic. She is vomiting today and unable to keep the antibiotic down. As you prepare to admit her, you feel she should have been admitted yesterday.
Should you tell the parents that their physician made a mistake? How should you handle this disagreement?
Case 3 Discussion
The practice of medicine is not an exact science. Frequently physicians will disagree about what constitutes the most appropriate management in a given case. Often these are legitimate disagreements with more than one acceptable course of action. Simply because you would have managed a patient differently does not mean the other physician made a mistake. In this case, you may wish to discuss the case with the other physician and explain why you manage children with pyelonephritis differently. However, in situations where standard practice varies, the parents should not be told that a mistake has been made.
Neonatal ICU Issues
The evolution of aggressive treatment of the newborn infant over the past 35 years has been associated with a dramatic reduction in mortality for virtually all major disease categories in the newborn period. Such care is costly; often causes suffering; and sometimes can result in considerable long-term morbidity.
The following quotes provide a perspective:
"Neonatal intensive care is responsible for the survival of a significant number of infants who formerly would not have survived. This increased survival has been accomplished with an acceptable level of burden and without substantially increasing the population of handicapped children."
- A proponent
"Neonatal intensive is a good example of medicine out of control. There is inappropriate use of technology by health care professional who are out of touch with patients and their families. The benefits of increases survival of high risk infants are outweighed by the associated burdens."
- An opponent
What is the primary justification for the existence of neonatal intensive care units?
Increased survival in all birthweight categories from extreme prematurity to term infants with complex congenital anomalies.
Low Birthweight Survival (%)
Est. G.A.* Birthweight (gm) Before 1970 1980 1990 1997
23-24 wk. 500-599 Less
10 %


55 22 29
24-25 wk. 600-699 47 61
25-26 wk. 700-799 89 85
26-27 wk. 800-899 80 81
900-999 90 90
(University of Washington NICU Data Base)
*Gest Age in Weeks Added Arbitrarily Assuming Infants +- AGA at Birth
Infant Mortality by Selected Causes
(Deaths per 100,000 live births)
1970 1984 1997
Congenital Anomalies 302 228 156
Respiratory Distress Syndrome 156
1979) 103 32
Intrauterine Hypoxia (Birth Asphyxia) 253 26 11
Disorders relating to short gestation and low birthweight 234 100
(1979) 96
Data source: National Center for Health Statistics
Is there an increased morbidity associated with higher survival rates?
Long-term follow up studies of NICU very low birthweight survivors demonstrate that while most are normal, there are significant numbers of children with both minor and major handicapping conditions.
Data pertaining to the long-term impact of the survival of infants with complex congenital anomalies are less plentiful, but indicate an increased number of handicapped individuals who survive the neonatal/infancy period following successful life-prolonging treatment.
Do survivors and families think that aggressive care for very low birthweight is good?
A recent assessment of the attitudes of a large group of adolescents, former extra-low birthweight infants, demonstrated that their view of their quality of life was "quite satisfactory." Indeed, when compared to a comparable age group of normal controls there were few difference between the two groups in their perception of their quality of life.
Is it possible to predict which infants will not survive without aggressive medical/surgical care in the neonatal period?
Extremely immature infants (gestational age at birth of less than 25 weeks) and/or infants with congenital anomalies that involve vital organs (for example, intestinal atresia, renal agenesis, pulmonary hypoplasia, hypoplastic left heart) have 100% mortality without aggressive intervention.
However, a much larger group of infants with serious life-threatening conditions may not be so vulnerable to death as they are to severe morbidity in the absence of intervention. It is virtually impossible to predict which infants in the latter group will not survive without support; and which will survive but with more morbidity/suffering than they would have experience had there been aggressive intervention.
Who is the decision-maker regarding the nature of medical care administered to a newborn infant?
The biological parents (or parent) have authority regarding the decisions for their child. Notably, this is the case regardless of the parents' age, unless the parents are declared not competent or otherwise unfit to serve as the child's proxy (see also Parental Decision Making).
What is the accepted legal and ethical basis for decision-making regarding the nature of medical care in the newborn infant?
The child's best interest is legally and ethically primary and should be weighed over the family's well-being or societal concerns. However, there is considerable discussion in the literature about the need to include the family's interests when making life and death decisions regarding severely compromised infants who will be a significant burden. Societal concerns about excessive cost for aggressive care need to be addressed at the policy level, rather than on an individual or case-by-case basis.
Neonatal ICU Issues:
Case 1
M.S. is a married 35-year-old pregnant childless woman who has lost four previous pregnancies between 16 and 23 weeks gestation. She currently has reached 23 weeks and 3 days of gestation, her fetus is seemingly healthy, and has an estimated weight of 550 grams (+/-1.2 lbs). She has ruptured her bag of waters and is now having labor that seems unstoppable with tocolytics. Delivery seems inevitable.
What are the management options and who decides what form of care should be instituted following delivery?
Case 1 Discussion
This gestational age and estimated birthweight represent the "gray zone" in terms of viability vs. non-viability. Accordingly, the parents have a choice to make. They can choose a passive comfort care mode treatment (with non-survival being a virtual certainty) or alternatively, assisted ventilation, pressors, antibiotics, parenteral nutrition, etc. The role of the physician is to provide information and guide the parents through the decision-making process.
This situation 30 years ago would have presented no ethical dilemma. Indeed, the 1972 Roe v. Wade Supreme Court case defined the limit of viability as 28 weeks gestation. Any form of aggressive care involving newborn infants below this gestational was thought to be futile. Today, however, aggressive measures at birth are sometimes initiated with a modest degree of success achieved in terms of promoting survival (+/-25%). Notably, survival is accompanied by a long stay in the hospital following delivery (3-4 months), enormous costs(+/-$250,000), considerable suffering, and morbidity (in at least 50% of the cases there is significant handicap).
Case 2
B.R. is a term female infant from an unexpected pregnancy. She has Down syndrome (Trisomy 21) and also has a complex cardiac lesion that will require at least two major surgical procedures during early infancy for her to have a chance to survive beyond childhood. B.R.'s parents, ages 44 and 45, have three other children, all in college. They have considerable ambivalence as to what to do: continue to pursue potentially beneficial though burdensome and costly treatments, or forego such treatments in favor of a more conservative approach.
What are the issues involved?
Case 2 Discussion
That the child has Down syndrome should not be a factor in the decision-making process. Nor is it appropriate to allow financial issues to play a major role. The parents, who are the decision-makers, should be apprised of the medical facts (types of surgical interventions required, chances for success). They should also be given a good understanding of the amount of suffering the child will experience during aggressive intervention efforts. They should then come to a decision based on the child's best interests. That is to say, does the burden of care outweigh the benefits to be anticipated or vice versa.
Parental Decision Making
Adult patients have the moral and legal right to make decisions about their own medical care. Because young children are not able to make complex decisions for themselves, the authority to make medical decisions on behalf of a child usually falls to the child's parents.
Who has the authority to make decisions for children?
Parents have the responsibility and authority to make medical decisions on behalf of their children. This includes the right to refuse or discontinue treatments, even those that may be life-sustaining. However, parental decision making should be guided by the best interests of the child. Decisions that are clearly not in a child's best interest can and should be challenged.
What is the basis for granting medical decision making authority to parents?
In most cases, a child's parents are the persons who care the most about their child and know the most about him. As a result, parents are expected to make the best medical decisions for their children. Furthermore, since many medical decisions will also affect the child's family, parents can factor family issues and values into medical decisions about their children.
When can parental authority to make medical decisions for their children be challenged?
Medical caretakers have an ethical and legal duty to advocate for the best interests of the child when parental decisions are potentially dangerous to the child's health, imprudent, neglectful, or abusive. When satisfactory resolution cannot be attained through respectful discussion and ethics consultation, seeking a court order for appropriate care might be necessary.
What if parents are unavailable and a child needs medical treatment?
When parents are not available to make decisions about a child's treatment, medical caretakers may provide treatment necessary to prevent harm to the child's health.
Should children be involved in medical decisions even though their parents have final authority to make those decisions?
Children with the developmental ability to understand what is happening to them should be allowed to participate in discussions about their care. As children develop the capacity to make decisions for themselves, they should be given a voice in medical decisions.
What happens when an older child disagrees with her parents about a medical treatment?
The wishes of competent older children regarding their medical care should be taken seriously. If the medical caretaker judges a child competent to make the medical decision in question, she should first attempt to resolve the issue through further discussion. If that fails, the medical caretaker should assure that the child's voice has been heard and advocate for the child. In intractable cases, an ethics consultation or judicial hearing should be pursued.
Under what circumstances can minors make medical decisions for themselves?
Minors have the ethical and legal authority to make medical decisions for themselves when they have reached the legal age of majority or become "emancipated." Most states recognize an emancipated minor as a person who meets one of the following criteria:
self-supporting and not living at home
a parent
in the military
In addition, most states allow treatment without parental consent for sexually transmitted diseases, pregnancy, and drug or alcohol abuse.
Case 1
A 4-year-old with an obviously broken forearm is brought to the emergency department by her baby-sitter. Both the baby-sitter and emergency room staff have attempted to reach her parents without success.
Can you treat this child without parental permission?
Case 1 Discussion
Your first duty is to the health and welfare of the child. Having attempted to reach her parents for consent without success, you should proceed with x-rays and treatment of her fractured forearm. Rapid treatment of the child's pain and fracture are clearly in her best interest. When optimal treatment requires immediate intervention, treatment should not be delayed even if consent has not been obtained.
Case 2
An ill-appearing 2-year-old with a fever and stiff neck appears to have meningitis. His parents refuse a lumbar puncture on the grounds that they have heard spinal taps are extremely dangerous and painful.
What are your obligations in this case? How should you proceed?
Case 2 Discussion
A lumbar puncture is the only way to diagnose meningitis and a delay in treatment could cause significant harm to the child. Complications from the procedure are very rare, and the benefit in this case is likely to be substantial. There is not time to obtain an ethics consult or court order. The physician should attempt to address the parents' misconceptions about lumbar punctures and to reassure them about the safety of the procedure and perhaps offer to use appropriate pain control methods. A second opinion from another physician may prove helpful.
Should these efforts not result in parental permission, the physician is justified in proceeding with the procedure and treatment of the child. While parental authority to make medical decisions for their children is broad, it does not include choices that may seriously harm their children. As long as the physician has used reasonable clinical judgment in determining the need for the lumbar puncture, legal liability should be minimal.
Case 3
A 5-year-old child has just had his second generalized tonic-clonic seizure in a 4 month period. You have recommended starting an anticonvulsant. The parents have concerns about the recommended medication and would prefer to wait and see if their son has more seizures.
How should you respond to the parents request?
Case 3 Discussion
The parents have the authority to make a choice of this sort. In general, courts have been reluctant to overrule against parental wishes in most situations where that decision does not place the child at considerable risk. Though failure to start an anti-convulsant may increase the risk of further seizures, this does not pose a substantial enough risk to the child to justify overriding the parents' wishes, especially given the potential risks associated with the medication. Though you may not agree with their decision, the decision is a reasonable one that does not place their child at substantial risk of increased harm.
Physician-Assisted Suicide
Physician-assisted suicide (PAS) generally refers to a practice in which the physician provides a patient with a lethal dose of medication, upon the patient's request, which the patient intends to use to end his or her own life. (For related discussion, see also End of Life Issues.)
Is physician-assisted suicide the same as euthanasia?
No. Physician-assisted suicide refers to the physician providing the means for death, most often with a prescription. The patient, not the physician, will ultimately administer the lethal medication. Euthanasia generally means that the physician would act directly, for instance by giving a lethal injection, to end the patient's life. Some other practices that should be distinguished from PAS are:
Terminal sedation: This refers to the practice of sedating a terminally ill competent patient to the point of unconsciousness, then allowing the patient to die of her disease, starvation, or dehydration.
Withholding/withdrawing life-sustaining treatments: When a competent patient makes an informed decision to refuse life-sustaining treatment, there is virtual unanimity in state law and in the medical profession that this wish should be respected.
Pain medication that may hasten death: Often a terminally ill, suffering patient may require dosages of pain medication that impair respiration or have other effects that may hasten death. It is generally held by most professional societies, and supported in court decisions, that this is justifiable so long as the primary intent is to relieve suffering.
Is physician-assisted suicide ethical?
The ethics of PAS continue to be debated. Some argue that PAS is ethical (see arguments in favor). Often this is argued on the grounds that PAS may be a rational choice for a person who is choosing to die to escape unbearable suffering. Furthermore, the physician's duty to alleviate suffering may, at times, justify the act of providing assistance with suicide. These arguments rely a great deal on the notion of individual autonomy, recognizing the right of competent people to chose for themselves the course of their life, including how it will end.
Others have argued that PAS is unethical (see arguments against). Often these opponents argue that PAS runs directly counter to the traditional duty of the physician to preserve life. Furthermore, many argue if PAS were legal, abuses would take place. For instance, the poor or elderly might be covertly pressured to chose PAS over more complex and expensive palliative care options.
What are the arguments in favor of PAS?
Those who argue that PAS is ethically justifiable offer the following sorts of arguments:
Respect for autonomy: Decisions about time and circumstances death are very personal. Competent person should have right to choose death.
Justice: Justice requires that we "treat like cases alike." Competent, terminally ill patients are allowed to hasten death by treatment refusal. For some patients, treatment refusal will not suffice to hasten death; only option is suicide. Justice requires that we should allow assisted death for these patients.
Compassion: Suffering means more than pain; there are other physical and psychological burdens. It is not always possible to relieve suffering. Thus PAS may be a compassionate response to unbearable suffering.
Individual liberty vs. state interest: Though society has strong interest in preserving life, that interest lessens when person is terminally ill and has strong desire to end life. A complete prohibition on assisted death excessively limits personal liberty. Therefore PAS should be allowed in certain cases.
Openness of discussion: Some would argue that assisted death already occurs, albeit in secret. For example, morphine drips ostensibly used for pain relief may be a covert form of assisted death or euthanasia. That PAS is illegal prevents open discussion, in which patients and physicians could engage. Legalization of PAS would promote open discussion.
What are the arguments against PAS?
Those that argue that PAS should remain illegal often offer arguments such as these:
Sanctity of life: This argument points out strong religious and secular traditions against taking human life. It is argued that assisted suicide is morally wrong because it contradicts these beliefs.
Passive vs. Active distinction: The argument here holds that there is an important difference between passively "letting die" and actively "killing." It is argued that treatment refusal or withholding treatment equates to letting die (passive) and is justifiable, whereas PAS equates to killing (active) and is not justifiable.
Potential for abuse: Here the argument is that certain groups of people, lacking access to care and support, may be pushed into assisted death. Furthermore, assisted death may become a cost-containment strategy. Burdened family members and health care providers may encourage option of assisted death. To protect against these abuses, it is argued, PAS should remain illegal.
Professional integrity: Here opponents point to the historical ethical traditions of medicine, strongly opposed to taking life. For instance, the Hippocratic oath states, "I will not administer poison to anyone where asked," and "Be of benefit, or at least do no harm." Furthermore, major professional groups (AMA, AGS) oppose assisted death. The overall concern is that linking PAS to the practice of medicine could harm the public's image of the profession.
Fallibility of the profession: The concern raised here is that physicians will make mistakes. For instance there may be uncertainty in diagnosis and prognosis. There may be errors in diagnosis and treatment of depression, or inadequate treatment of pain. Thus the State has an obligation to protect lives from these inevitable mistakes.
Is PAS illegal?
In most states, including the state of Washington, aiding in a suicide is a crime, while suicide or attempted suicide itself is not illegal. The state of Oregon is the only state that currently has legalized PAS.
However, several major court decisions have been made regarding PAS. In the case of Compassion in Dying v. Washington, the Ninth US Circuit Court of Appeals held that individuals have a right to choose how and when they die. Later, the Second Circuit Court found a New York law on PAS in conflict with the 14th amendment, which says that no state shall "deny to any person within its jurisdiction the equal protection of the laws." The Court held that competent patients were being treated differently than incompetent patients. The US Supreme Court has ruled that there is no constitutional right to assisted suicide, and made a legal distinction between refusal of treatment and PAS. However, the Court also left the decision of whether to legalize PAS up to each individual state.
There have also been a couple of high-profile cases related to specific PAS incidents. Dr. Timothy Quill was investigated but not indicted for his participation in the suicide of a patient after he published his account of the incident. In November of 1998, 60 Minutes aired a tape of Dr. Jack Kevorkian administering a lethal injection. His patient, 52 year-old Thomas Youk, suffered from Amyotrophic Lateral Sclerosis (ALS), otherwise known as Lou Gehrig's Disease. As a result of the show, Kevorkian was tried for first degree murder in Oakland County, Michigan. Prosecutors argued that, in giving a lethal injection, Kevorkian stepped over the line of PAS into euthanasia, and that his actions amounted to murder. Kevorkian was convicted of second degree murder, and is currently serving a 10 to 25 year prison sentence.
What does the medical profession think of PAS?
Surveys of individual physicians show that half believe that PAS is ethically justifiable in certain cases. However, professional organizations such as the American Medical Association have generally argued against PAS on the grounds that it undermines the integrity of the profession.
Surveys of physicians in practice show that about 1 in 5 will receive a request for PAS sometime in their career. Somewhere between 5-20% of those requests are eventually honored.
What do patients and the general public think of PAS?
Surveys of patients and members of the general public find that the vast majority think that PAS is ethically justifiable in certain cases, most often those cases involving unrelenting suffering.
What should I do if a patient asks me for assistance in suicide?
One of the most important aspects of responding to a request for PAS is to be respectful and caring. Virtually every request represents a profound event for the patient, who may have agonized over his situation and the possible ways out. The patient's request should be explored, to better understand its origin, and to determine if there are other interventions that may help ameliorate the motive for the request. In particular, one should address:
motive and degree of suffering: are there physical or emotional symptoms that can be treated?
psychosocial support: does the patient have a system of psychosocial support, and has she discussed the plan with them? accuracy of prognosis: every consideration should be given to acquiring a second opinion to verify the diagnosis and prognosis.
degree of patient understanding: the patient must understand the disease state and expected course of the disease. This is critical since patient may misunderstand clinical information. For instance, it is common for patients to confuse "incurable" cancer with "terminal" cancer.
What if the request persists?
If a patient's request for aid-in-dying persists, each individual clinician must decide his or her own position and choose a course of action that is ethically justifiable. Careful reflection ahead of time can prepare one to openly discuss your position with the patient, acknowledging and respecting difference of opinion when it occurs. Organizations exist which can provide counseling and guidance for terminally ill patients. No physician, however, should feel forced to supply assistance if he or she is morally opposed to PAS.
Physician-Assisted Suicide:
Case 1
A recently divorced fifty-five-year-old man with severe rheumatoid arthritis comes in for a routine visit complaining of insomnia. He requests a specific barbiturate, Seconal, as a sleep aid, asking for a month's supply. On further questioning, he states that he wakes up every morning at four, tired but unable to go back to sleep. He admits that he rarely leaves his house during the day, stating that he has no interest in the activities he used to find enjoyable.
What is an appropriate course of action?
Case 1 Discussion
The request for a specific quantity of a specific barbiturate suggests that this patient is contemplating suicide. This concern should be addressed explicitly with the patient. His sleep pattern (early morning awakening) and lack of interest in previously enjoyable pastimes (anhedonia) suggest major depression. This should be fully evaluated and treated. In addition, pain management and long term care options should be fully revisited in a patient with complaints such as his.
Even if the patient were fully competent, most proponents of PAS would object to aiding his suicide as he is not terminally ill. This said, rheumatoid arthritis can be a painful and debilitating chronic condition and it is unclear whether there is any relevant ethical or legal distinction between such a patient and one who is terminally ill.
Physician-Patient Relationship
There is considerable healing power in the physician-patient alliance. A patient who entrusts himself to a physician's care creates ethical obligations that are definite and weighty. Working together, the potential exists to pursue interventions that can significantly improve the patient's quality of life and health status.
What is a fiduciary relationship?
Fiduciary derives from the Latin word for "confidence" or "trust". The bond of trust between the patient and the physician is vital to the diagnostic and therapeutic process. It forms the basis for the physician-patient relationship. In order for the physician to make accurate diagnoses and provide optimal treatment recommendations, the patient must be able to communicate all relevant information about an illness or injury. Physicians are obliged to refrain from divulging confidential information. This duty is based on accepted codes of professional ethics which recognize the special nature of these medical relationships.
How has the physician-patient relationship evolved?
The historical model for the physician-patient relationship involved patient dependence on the physician's professional authority. Believing that the patient would benefit from the physician's actions, a patient's preferences were generally overridden or ignored. For centuries, the concept of physician beneficence allowed this paternalistic model to thrive.
During the second half of the twentieth century, the physician-patient relationship has evolved towards shared decision making. This model respects the patient as an autonomous agent with a right to hold views, to make choices, and to take actions based on personal values and beliefs. Patients have been increasingly entitled to weigh the benefits and risks of alternative treatments, including the alternative of no treatment, and to select the alternative that best promotes their own values (for further discussion, see the topic page on Informed Consent).
Will the patient trust me if I am a student?
Students may feel uncertain about their role in patient care. However, it is crucial for building trust that you begin this relationship in an honest and straightforward manner. A critical part of this is being honest about your role and letting the patient know you are a physician-in-training. In some settings, an attending physician or resident can introduce the student to initiate a trusting relationship. In other settings, students may need to introduce themselves. One form of introduction would be "Hello, I am Mary Jones. I'm a third year medical student who is part of the team that will be caring for you during your hospitalization. I'd like to hear about what brought you into the hospital." (For further discussion of this issue, see the Student Issues topic page.)
Many patients will feel quite close to the student on the team. Students usually have more time to spend with a patient, listening to the patient's history and health concerns, and patients certainly notice and appreciate this extra attention.
How much of herself should the physician bring to the physician-patient relationship?
Many patients appreciate a physician who brings a personal touch to the physician-patient encounter. They may feel more connected to a physician whose extracurricular activities and interests make her seem more alive. Physicians choose to share parts of their life stories according to their level of comfort. However, it is essential that the patient, and the patient's concerns, be the focus of every visit.
What role should the physician's personal feelings and beliefs play in the physician-patient relationship?
Occasionally, a physician may face requests for services, such as contraception or abortion, which raise a conflict for the physician. Physicians do not have to provide medical services in opposition to their personal beliefs. In addition, it is acceptable to have a nonjudgmental discussion with a patient regarding her need for the service, and to ensure that the patient understands alternative forms of therapy. However, it is never appropriate to proselytize. While the physician may decline to provide the requested service, the patient must be treated as a respected, autonomous individual. Where appropriate, the patient should be provided with resources about how to obtain the desired service.
What can hinder physician-patient communication?
There may be many barriers to effective physician-patient communication. Patients may feel that they are wasting the physician's valuable time; omit details of their history which they deem unimportant; be embarrassed to mention things they think will place them in an unfavorable light; not understand medical terminology; or believe the physician has not really listened and, therefore, does not have the information needed to make good treatment decisions.
Several approaches can be used to facilitate open communication with a patient. Physicians should:
sit down
attend to patient comfort
establish eye contact
listen without interrupting
show attention with nonverbal cues, such as nodding
allow silences while patients search for words
acknowledge and legitimize feelings
explain and reassure during examinations
ask explicitly if there are other areas of concern
What happens when physicians and patients disagree?
One third to one half of patients will fail to follow a physician's treatment recommendations. Labeling such patients "noncompliant" implicitly supports an attitude of paternalism, in which the physician knows best. Patients filter physician instructions through their existing belief system; they decide whether the recommended actions are possible or desirable in the context of their everyday lives.
Compliance can be improved by using shared decision making. For example, physicians can say, "I know it will be hard to stay in bed for the remainder of your pregnancy. Let's talk about what problems it will create and try to solve them together." Or, "I can give you a medication to help with your symptoms, but I also suspect the symptoms will go away if you wait a little longer. Would you prefer to try the medication, or to wait?" Or, "I understand that you are not ready to consider counseling yet. Would you be willing to take this information and find out when the next support group meets?" Or, "Sometimes it's difficult to take medications, even though you know they are important. What will make it hard for you to take this medication?"
Competent patients have a right to refuse medical intervention. Dilemmas may arise when a patient refuses medical intervention, but does not withdraw from the role of being a patient. For instance, an intrapartum patient, with a complete placenta previa, who refuses to undergo a cesarean delivery, often does not present the option for the physician to withdraw from participation in her care (see the Maternal/Fetal Conflict topic page). In most cases, choices of competent patients must be respected when the patient cannot be persuaded to change them.
What can a physician do with a particularly frustrating patient?
Physicians will sometimes encounter a patient whose needs, or demands, strain the therapeutic alliance. Many times, an honest discussion with the patient about the boundaries of the relationship will resolve such misunderstandings. The physician can initiate a discussion by saying, "I see that you have a long list of health concerns. Unfortunately, our appointment today is only for fifteen minutes. Let's discuss your most urgent problem today and reschedule you for a longer appointment. That way, we can be sure to address everything on your list." Or, "I know that it has been hard to schedule this appointment with me, but using abusive language with the staff is not acceptable. What do you think we could do to meet everybody's needs?"
There may be occasions when no agreeable compromise can be reached between the physician and the patient. And yet, physicians may not abandon patients. When the physician-patient relationship must be severed, the physician is obliged to provide the patient with resources to locate ongoing medical care.
When is it appropriate for a physician to recommend a specific course of action or override patient preferences?
Under certain conditions, a physician should strongly encourage specific actions. When there is a high likelihood of harm without therapy, and treatment carries little risk, the physician should attempt, without coercion or manipulation, to persuade the patient of the harmful nature of choosing to avoid treatment.
Court orders may be invoked to override a patient's preferences. However, such disregard for the patient's right to noninterference is rarely indicated. Court orders may have a role in the case of a minor; during pregnancy; if harm is threatened towards oneself or others; with concern for mental incompetence; or when the patient is a sole surviving parent of dependent children. However, the use of such compulsory powers is inherently time-limited, and often alienates the patient, making him less likely to comply once he is no longer subject to the sanctions.
What is the role of confidentiality?
Confidentiality provides the foundation for the physician-patient relationship. In order to make accurate diagnoses and provide optimal treatment recommendations, the physician must have relevant information about the patient's illness or injury. This may require the discussion of sensitive information, which would be embarrassing or harmful if it were known to other persons. The promise of confidentiality permits the patient to trust that information revealed to the physician will not be further disseminated. The expectation of confidentiality derives from the public oath which the physician has taken, and from the accepted code of professional ethics. The physician's duty to maintain confidentiality extends from respect for the patient's autonomy.
Would a physician ever be justified in breaking a law requiring mandatory reporting?
Legal obligations to break confidentiality may pose difficult choices. While the physician has a moral obligation to obey the law, he must balance this against his responsibility to the patient. It is essential to balance the duty to protect the patient's confidence against the physician's responsibility to the members of the public at risk. (For a discussion on the limits of confidentiality, see the topic page on Confidentiality.)
What happens when the physician has a relationship with multiple members of a family?
Physicians with relationships with multiple family members must honor each individual's confidentiality. Difficult issues, such as domestic violence, sometimes challenge physicians to maintain impartiality. In many instances, physicians can help conflicted families towards healing. At times, physicians work with individual family members; other times, they may serve as a facilitator for a larger group. As always, when a risk for imminent harm is identified, the physician must break confidentiality.
Physicians can be proactive about addressing the needs of changing family relationships. For example, a physician might tell a preteen and her family, "Soon you'll be a teenager. Sometimes teens have questions they would like to discuss with me. If that happens to you, it's okay to tell your parents that you'd like an appointment. You and I won't have to tell your parents what we talk about if you don't want to, but sometimes I might encourage you to talk things over with them."
The physician-family relationship also holds considerable healing power. The potential exists to pursue options that can improve the quality of life and health for the entire family.
Physician-Patient Relationship:
Case 1
During a visit to her family physician, a 35-year-old woman discloses that she suffers from anorexia nervosa. She complains of fatigue, dizziness, depression, headaches, irregular menses, and environmental allergies. Each day, she uses 15 to 60 laxatives, exercises for several hours, and eats a salad or half a sandwich. At 5'2", she weighs 88 pounds. She demonstrates a good understanding of the diagnosis and the recommended therapy for anorexia. Despite receiving a variety of resource information, the patient refuses any medical intervention. She continues to present to the family physician, offering a variety of somatic complaints.
When a patient's preferences conflict with a physician's goal to restore health, which ethical principle should prevail, patient autonomy or physician beneficence? Does the patient's depression render her incompetent to refuse treatment for her anorexia?
Case 1 Discussion
Since this patient could rationally discuss her treatment options and her reasons for declining therapy, she could not be considered incompetent. Respect for autonomy is a central principle of bioethics, and it takes precedence in this case. Although the principle of beneficence could be used to argue for coercion towards treatment, compliance may be better improved by providing an ongoing partnership with the patient. Maintaining a therapeutic relationship with ongoing dialogue is more likely to provide this patient with the eventual ability to pursue therapy.
Case 2
A 16-year-old female presents to a family physician to obtain a referral for family therapy. She is estranged from her mother and stepfather, who see the same physician. For many years, this patient responsibly cared for her four younger siblings while their single mother worked. Since her mother's marriage, the family has become involved in a fundamentalist church. The patient moved out when she felt the social and moral restrictions of the family's religion were too burdensome for her. The patient seemed quite mature; she maintained a 3.5 GPA, along with a part-time job. She demonstrated a genuine desire for reconciliation, and the therapy referral was provided.
She also requested and obtained a prescription for contraceptives during the visit, with the assurance that her sexual activity would be kept confidential. In follow-up, she reported that the therapist had informed her that if she mentioned anything about being sexually active with her adult partner, he would be obliged to report her to the state. The patient was very concerned about the conflict between this statement and the family physician's prior assurance of confidentiality.
Should this patient's confidentiality be broken?
Case 2 Discussion
While the physician has a moral obligation to obey the law, he must balance this against his responsibility to the patient. In researching the Criminal Code of Washington, the physician learned that sexual intercourse with a minor, at least 16, but under 18, is a class C felony, and a reportable offense, if the offender is at least 90 months older than the victim. This patient's relationship did not actually meet the criteria for mandatory reporting. Had this not been the case however, the physician could be justified in weighing the balance of harms arising from the filing of such a report.
There is little justification for informing the family of the young woman's sexual activity. Due to the family's strong fundamentalist beliefs, significant damage would have occurred in the family reconciliation process with this discovery. Although they would clearly disapprove of the patient's actions, her choices carry no risk of harm to them.
Because medicine is a profession and physicians are professionals, it is important to have a clear understanding of what "professionalism" means. As a physician-in-training, you will be developing a personal sense of what it means to be a professional. This topic page outlines some common features. Please see the topic page on the Physician-Patient Relationship for further discussion of the professional responsibilities of physicians.
What does it mean to be a member of a profession?
The words "profession" and "professional" come from the Latin word "professio," which means a public declaration with the force of a promise. Professions are groups which declare in a public way that their members will act in certain ways and that the group and the society may discipline those who fail to do so. The profession presents itself to society as a social benefit and society accepts the profession, expecting it to serve some important social goal. The traditional professions are medicine, law, education and clergy.
The marks of a profession are:
competence in a specialized body of knowledge and skill;
an acknowledgment of specific duties and responsibilities toward the individuals it serves and toward society;
the right to train, admit, discipline and dismiss its members for failure to sustain competence or observe the duties and responsibilities.
What is the difference between a profession and a business?
The line between a business and a profession is not entirely clear, since professionals may engage in business and make a living by it. However, one crucial difference distinguishes them: professionals have a fiduciary duty toward those they serve. This means that professionals have a particularly stringent duty to assure that their decisions and actions serve the welfare of their patients or clients, even at some cost to themselves. Professions have codes of ethics which specify the obligations arising from this fiduciary duty. Ethical problems often occur when there appears to be a conflict between these obligations or between fiduciary duties and personal goals.
What are the recognized obligations and values of a professional physician?
The American Board of Internal Medicine has been working on a project to develop and promote professionalism since 1990. According to the report, Project Professionalism (1995), professionalism requires that one strive for excellence in the following areas which should be modeled by mentors and teachers and become part of the attitudes, behaviors, and skills integral to patient care:
Altruism: A physician is obligated to attend to the best interest of patients, rather than self-interest.
Accountability: Physicians are accountable to their patients, to society on issues of public health, and to their profession.
Excellence: Physicians are obligated to make a commitment to life-long learning.
Duty: A physician should be available and responsive when "on call," accepting a commitment to service within the profession and the community.
Honor and integrity: Physicians should be committed to being fair, truthful and straightforward in their interactions with patients and the profession.
Respect for others: A physician should demonstrate respect for patients and their families, other physicians and team members, medical students, residents and fellows.
While circumstances may arise that hinder adherence to these values, they should provide guidance for promoting professional behavior and for making difficult ethical decisions.
Is professionalism compatible with the restrictions sometimes placed on physician's judgments in managed care?
One of the principal attributes of professionalism is independent judgment about technical matters relevant to the expertise of the profession. The purpose of this independent judgment is to assure that general technical knowledge is appropriately applied to particular cases. Managed care may impose conditions on the clinical judgment of professionals who work in such settings but those conditions must be designed to enhance and improve professional judgment, not restrict it. Thus, requiring consultation may often be an obligation; restricting consultation may be ethically inappropriate. Also, requiring physicians to adhere to practice guidelines and to consult outcome studies may improve professional judgment; requiring blind adherence to those guidelines may be a barrier to the exercise of professional judgment.
Public Health Ethics
Public health practice concerns itself with issues of illness and disease of populations, and as such touches some unique ethical issues. In general, public health practices and policies seek to improve the overall health of the public, a position sometimes at odds with the autonomy of the individual. This conflict may be clinical, as in the case of immunization, or legal, as in the case of mandatory medical reporting and treatment of communicable diseases. Further, public health involved recognizing health and illness in the broader context of social, environmental, political, and economic factors. All health care providers share in public health practice, and have opportunities in their actions to shape public health policy.
When should diseases be reported to Public Health authorities?
Each state has specific statutes that identify specific diseases with public health implications, such as communicable diseases, which require reporting. Beyond this legal requirement lies the question of when it is justified to potentially violate confidentiality to protect the public's health. It is ethically justified to disclose a diagnosis to public health authorities if the risk to the public has the following features:
the risk is high in probability
the risk is serious in magnitude
the risk relates to an identifiable individual or group
For instance, if a food handling restaurant worker with acute hepatitis asks that his diagnosis be held in confidence, the physician should nevertheless disclose this diagnosis to the dining establishment or public health authorities, since the risk to the public is high, serious, and relates to identifiable persons (e.g., patron of the eating establishment).
Can patients refuse to undergo routine preventive health measures?
There are a number of preventive health interventions which provide minimal if any benefit to the individual yet provide substantial collective benefit to the public's health. For example, immunizations provide protection but involve some risk to the individual. However, if a public health program can achieve universal vaccination, the overall public health benefits. If a patient refuses a legally required immunization (e.g., in jurisdictions where immunization is legally mandated), this becomes a legal matter. If not legally mandated, an adequately informed refusal, expressing compelling personal or religious beliefs, may be respected.
Can a physician refuse to follow public health mandates that he opposes?
Most public health law and regulations reflect a public policy process that involved tradeoffs. There is seldom certainty in the final policy recommendations, which are often the result of compromise positions of divergent advocacy groups. As a result, physicians and other health care workers may find their own positions at odds with regulations or health care laws. Professionals have an obligation to exercise judgment and not follow laws that are grossly unjust or immoral. Most situations are not this extreme, however. Thus, the health care professional should find ways other than outright disobedience to try to influence health care policy with which she disagrees. No health care provider should be forced to provide a service he morally opposes, but he should also not obstruct others who support it. The best and most constructive way to affect health policy is to participate actively in the policy making process.
When can a patient be held for medical treatment against her will?
This is a controversial area in law, and the law varies by state. The ethical justification for treatment of a patient against his will is based on balancing of the risk to the public versus respecting the patient's personal freedom. If the magnitude of risk to the public is great, many states allow for involuntary treatment. For example, a patient with active pulmonary tuberculosis that is resistant to multiple anti-tuberculosis medications presents a grave risk to the public if her condition is untreated. This arises in part because of the high infectivity of active pulmonary tuberculosis and the relatively small risk to the patient from oral medications for TB treatment. Other conditions for which non-treatment poses little or no threat to the public, such as untreated acute leukemia, can rarely have involuntary treatment justified.
Public Health Ethics:
Case 1
MG is a 27-year-old graduate student, recently married, who comes into the student health clinic for a routine pelvic exam and PAP smear. During the course of the exam, the gynecology resident performing the exam obtains the PAP smear, but also obtains cervical cultures for gonorrhea and chlamydia. The examination concludes uneventfully.
Several weeks later, she receives a postcard indicating that the PAP smear was normal, with no evidence of dysplasia, but that the cervical culture for gonorrhea was positive. The card instructs her to come into the clinic to discuss treatment, and that "public health authorities" have been notified for contact tracing. The young woman is terrified that her husband will be contacted.
Does the woman have a right to be informed that the gonorrhea and chlamydia cultures were being obtained?
What should be done if she refuses?
Case 1 Discussion
The routine of obtaining cervical cultures for gonorrhea and chlamydia is motivated by the desire to have accurate information on the prevalence of gonorrhea in the population, and the hope that identification and treatment of asymptomatic carriers could reduce or eradicate gonorrhea as a public health problem. Yet, in this case the patient was not told about the culture being obtained. When health-related information is obtained from individuals, they should have an opportunity to consent to or refuse such collection. In some instances, individuals may conscript to having their rights disregarded, such as in the military. Similarly, other individuals do not have their rights recognized as a result of due process, such as prisoners. In this case, the physician should inform the woman what tests will be performed and why, and how that information will be handled. If she refuses to have the test obtained, her wish should be respected.
Research Ethics
The ethical issues in human subjects research have received increasing attention over the last 50 years. Institutional Review Boards for the Protection of Human Subjects (IRB's) have been established at most institutions that undertake research with humans. These committees are made up of scientists, clinical faculty, and administrators who review research according to the procedures set out in the Federal Regulations at 45 CFR 46.
What are the main ethical issues in human subjects research?
There are several ethical issues that must be considered when designing research that will utilize participants who are human beings.
The primary concern of the investigator should be the safety of the research participant. This is accomplished by carefully considering the risk/benefit ratio, using all available information to make an appropriate assessment and continually monitoring the research as it proceeds.
The scientific investigator must obtain informed consent from each research participant. This should be obtained in writing (although oral consents are sometimes acceptable) after the participant has had the opportunity to carefully consider the risks and benefits and to ask any pertinent questions. Informed consent should be seen as an ongoing process, not a singular event or a mere formality.
The investigator must enumerate how privacy and confidentiality concerns will be approached. Researchers must be sensitive to not only how information is protected from unauthorized observation, but also if and how participants are to be notified of any unforeseen findings from the research that they may or may not want to know.
The investigator must consider how adverse events will be handled; who will provide care for a participant injured in a study and who will pay for that care are important considerations.
In addition, before enrolling participants in an experimental trial, the investigator should be in a state of "equipoise," that is, if a new intervention is being tested against the currently accepted treatment, the investigator should be genuinely uncertain which approach is superior. In other words, a true null hypothesis should exist at the onset regarding the outcome of the trial.
What are the main ethical principles that govern research with human subjects?
There are three primary ethical principles that are traditionally cited when discussing ethical concerns in human subjects research. (A more complete enumeration of these principles is available in the Belmont Report, written by The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research in 1979.)
The first ethical principle cited by the influential Belmont Report is autonomy, which refers to the obligation on the part of the investigator to respect each participant as a person capable of making an informed decision regarding participation in the research study. The investigator must ensure that the participant has received a full disclosure of the nature of the study, the risks, benefits and alternatives, with an extended opportunity to ask questions. The principle of autonomy finds expression in the informed consent document.
The second ethical principle is beneficence, which refers to the obligation on the part of the investigator to attempt to maximize benefits for the individual participant and/or society, while minimizing risk of harm to the individual. An honest and thorough risk/benefit calculation must be performed.
The third ethical principle invoked in research with human subjects is justice, which demands equitable selection of participants, i.e., avoiding participant populations that may be unfairly coerced into participating, such as prisoners and institutionalized children. The principle of justice also requires equality in distribution of benefits and burdens among the population group(s) likely to benefit from the research.
What are the components of an ethically valid informed consent for research?
For an informed consent to be ethically valid, the following components must be present:
Disclosure: The potential participant must be informed as fully as possible of the nature and purpose of the research, the procedures to be used, the expected benefits to the participant and/or society, the potential of reasonably foreseeable risks, stresses, and discomforts, and alternatives to participating in the research. There should also be a statement that describes procedures in place to ensure the confidentiality or anonymity of the participant. The informed consent document must also disclose what compensation and medical treatment are available in the case of a research-related injury. The document should make it clear whom to contact with questions about the research study, research subjects' rights, and in case of injury.
Understanding: The participant must understand what has been explained and must be given the opportunity to ask questions and have them answered by one of the investigators. The informed consent document must be written in lay language, avoiding any technical jargon.
Voluntariness: The participant's consent to participate in the research must be voluntary, free of any coercion or promises of benefits unlikely to result from participation.
Competence: The participant must be competent to give consent. If the participant is not competent due to mental status, disease, or emergency, a designated surrogate may provide consent if it is in the participant's best interest to participate. In certain emergency cases, consent may be waived due to the lack of a competent participant and a surrogate.
Consent: The potential human subject must authorize his/her participation in the research study, preferably in writing, although at times an oral consent or assent may be more appropriate.
Is informed consent required by law?
According to 21 CFR 50.20,
"no investigator may involve a human being as a subject in research covered by these regulations unless the investigator has obtained the legally effective informed consent of the subject or the subject's legally authorized representative."
The potential participant must be given the opportunity to give full consideration regarding the decision whether or not to participate in the research study without undue influence from his or her physician, family, or the scientific investigator. No informed consent may contain any exculpatory language by which the participant waives any legal rights or releases the investigator or sponsor from liability for negligence.
Can I use deception when doing research?
As a general rule, deception is not acceptable when doing research with humans. Using deception jeopardizes the integrity of the informed consent process and can potentially harm your participants. Occasionally exploring your area of interest fully may require misleading your participants about the subject of your study. For example, if you want to learn about decision-making practices of physicians without influencing their practice-style, you may consider telling them you are studying "communication behaviors" more broadly. The IRB will review any proposal that suggests using deception or misrepresentation very carefully. They will require an in-depth justification of why the deception is necessary for the study and the steps you will take to safeguard your participants.
I'm just doing a simple survey! Do I need IRB approval?
Some research with humans is eligible for "exempt" status from the IRB. If your research is part of a routine educational experience, or if your participants will remain completely anonymous (with no identifying code to link them to their identity), you may apply to the IRB for a certificate of exemption. Your study proposal will still be reviewed by a member of the IRB, but the application process is considerably shorter.
Your study may also qualify for "expedited review" if an IRB reviewer determines that it meets assessment criteria for minimal risk, and involves only procedures that are commonly done in clinical settings, such as taking hair, saliva, excreta or small amounts of blood. A study that qualifies for expedited review is still held to the same standards used in full board review, but the approval process may take less time. Contact the University IRB if you have questions about the eligibility of your study.
Research Ethics:
Case 1
Mrs. Franklin, an 81-year-old Alzheimer's patient hospitalized under your care has been asked to participate in a clinical trial testing a new drug designed to help improve memory. You were present when the clinical investigator obtained a signed informed consent from Mrs. Franklin a few days ago. However, when you visit Mrs. Franklin today and ask her if she is ready to begin the study tomorrow, she looks at you blankly and seems to have no idea what you are talking about.
What should you do?
Case 1 Discussion
The competence of Mrs. Franklin to give an ethically valid informed consent is in doubt. You should contact the primary investigator to discuss Mrs. Franklin's participation in the trial. There may be a surrogate who can give consent for her participation if it is deemed to be in her best interests. Although she may be considered a vulnerable research subject because of her mental status, Mrs. Franklin does belong to the population the intervention is designed to assist, and her participation may benefit herself and other Alzheimer's patients. However, a careful balancing of risks and benefits should occur.
Resource Allocation
"Physicians should merit the confidence of the patients entrusted to their care, rendering to each a full measure of service and devotion." This is the first statement in the Principles of Ethics of the American Medical Association. Often it is difficult, if not impossible, to provide every patient everything each one needs for optimal medical care. When these conditions of scarcity occur, we look for guidance to make painful tradeoffs in a fair and compassionate manner. This topic page raises some issues to consider when facing these difficult allocation decisions.
What rules guide rationing decisions?
Rationing occurs when many persons are in need of an intervention but that intervention is in short supply for some reason. The reasons vary: there are many more patients with end stage cardiac disease or liver disease than there are cadaver organs available; expensive equipment may be lacking in a particular region; tertiary care hospital beds may be limited; a particular medication may be extremely costly; few personnel might be trained for a certain technical procedure, insurance coverage is unavailable or of prohibitive cost.
Every physician must "ration," at least his or her own time available to provide medical services. For the most part, this personal rationing is done by rules of common sense: I will take only as many patients as I can care for competently; I will assure that my attendance is sufficient to guarantee high quality medical care to my patients, etc. For other kinds of rationing, for instance rationing of ICU beds, these rules of thumb are not enough. More articulate principles are required.
In one highly publicized instance of resource allocation, the Seattle Artificial Kidney Center appointed a committee to decide who would receive dialysis treatments, in 1962 a rare and expensive resource. "Likelihood of medical benefit" was the first criteria used to determine eligibility. Even so, many more patients required dialysis than there were machines available. The committee turned to "social worth" criteria and began weighing the anticipated contributions the patients would make to society were their lives saved. Many have argued that a lottery or a "first-come, first-served" criteria would have been more equitable and ethically justifiable. We know from recent UNOS decisions that the criteria now in favor is "greatest (medical) need."
The allocation of organs for transplant was organized several years ago into a national system with criteria that strive for fairness. The criteria attempt to match available organs with recipients on presumed "objective" grounds, such as tissue type, body size, time on waiting list, seriousness of need. However, even in this system, it is obvious that such a criterion as "serious need" can be used in a manipulative way. Still, this system is preferable to the subjective use of criteria of social worth and status that would unfairly skew the distribution of organs.
Are there ethical criteria for making triage decisions?
Triage is one situation in which specific principles must be applied. Triage (which means "choice" or "selection") is required when many patients simultaneously need medical attention and medical personnel cannot attend to all at the same time. Again, the common sense rule is to serve persons whose condition requires immediate attention and, if this attention is not given, will progress to a more serious state. Others, whose condition is not as serious and who are stable, may be deferred. This sort of triage is often necessary in busy emergency departments.
A second sort of triage is indicated in disasters, such as earthquakes, or in military action. The rules of military triage, developed centuries ago, direct the physician to attend first to those who can be quickly and successfully treated in view of a speedy return to the battlefield, or to treat commanders before troops in order to assure leadership. This sort of disaster triage is applied to civilian disasters by treating persons, such as firefighters or public safety officers, who can quickly return to duty and help others. Disaster triage implies that the most seriously injured may be relegated to the end of the line and left untreated, even at risk of death, if their care would absorb so much time and attention that the work of rescue would be compromised. This is one of the few places where a "utilitarian rule" governs medicine: the greater good of the greater number rather than the particular good of the patient at hand. This rule is justified only because of the clear necessity of general public welfare in a crisis.
Can I make allocation decisions based on judgments about "quality of life"?
Under conditions of scarcity, the question may arise whether a patient's quality of life seems so poor that use of extensive medical intervention appears unwarranted. When this question is raised, it is important to consider a few questions. First, who is making this quality of life judgment, the care team, the patient, or the patient's family? Several studies have shown that physicians often rate the patient's quality of life much lower than the patient himself does. If the patient is able to communicate, you should engage her in a discussion about her own assessment of her condition.
When considering quality of life, you should also ask: What criteria are being used to make the judgment that the quality of life is unacceptable? These criteria are often unspoken and can be influenced by bias or prejudice. A dialogue between care givers and the patient can surface some underlying concerns that may be addressed in other ways. For example, residents on a medical floor in an urban public hospital may get discouraged with the return visits of a few chronically ill alcoholic patients and suggest that money is being wasted that could be used for prenatal care or other medically beneficial projects. While the residents' frustration is understandable, it would be helpful to consider other ways they might interrupt this vicious cycle of repeat admissions. How could this patient population be supported in ways that might improve health?
Quality of life judgments based on prejudices against age, ethnicity, mental status, socioeconomic status, or sexual orientation generally are not relevant to considerations of diagnosis and treatment. Furthermore, they should not be used, explicitly or implicitly, as the basis for rationing medical services.
What about "macro-allocation" concerns?
Some situations involve what is often called "macro-allocation," that is, broad policies to distribute resources across populations, as distinguished from "micro-allocation" decisions, such as in the above triage examples, to give priority to one patient over another.
Many of these reasons for shortage are the result of deliberate decisions to ration. Even such shortages as vital organs result from social policies that favor voluntary donation over routine salvaging or a commercial market in organs. Other shortages result from broad social and cultural institutions: our country has left health care largely in the private sphere and the availability of care for individuals is conditioned by their ability to pay or their employment status. The social "safety net" that acknowledges a moral duty to assure health care to those unable to pay is strengthened or weakened according to prevailing societal commitments.
The theoretical ethical question is: can a fair and just way of allocating health care resources be devised? The practical ethical question is: can a fair and just allocation be actually implemented in a particular social, economic and medical climate?
Can we ethically qualify a "right to health care"?
Several ethical theories have been elaborated to formulate criteria for fair and just distribution and to examine the arguments for a "right to health care." At present, little agreement exists on any of these issues. Ideally, all persons should have access to a "decent minimum" of health care necessary to sustain life, prevent illness, relieve distress and disability, so that, in the words of Norman Daniels, "each person may enjoy his or her fair share of the normal opportunity range for individuals in his or her society."
Debates over this issue have been lengthy and serious. Many policy proposals have been considered: some implemented and others rejected. However, as systems of managed health care are created, the question of fair and just allocation of resources must be raised and the various proposals, theories and criteria must be reviewed for their applicability to the policies of managed care organizations. Similarly, government policy must be formulated in ways that take into account the needs of those who are not served by such organizations in the private sector.
Some specific examples of public policy in devising an allocation system concentrate on the criteria of efficiency and cost-effectiveness. The state of Oregon is unique in having such a system for its Medicaid patients: a long list of medical procedures, ranked in terms of their cost/benefit ratio, determines the reimbursement policy. Even with such a system, ethical criteria must also be considered: what is to be done if life-saving and life-sustaining interventions rank low on cost-effectiveness? Is it ethical to omit the rescue of a person from death because their rescue by, say, bone marrow transplantation is less cost-effective than some preventive measures? How is cost-effectiveness to be applied to persons with shorter natural life expectancy, such as the elderly?
Resource Allocation:
Case 1
A 28-year-old male is admitted with bacterial endocarditis and needs a replacement of his prosthetic heart valve. After his first replacement, he continued to abuse intravenous drugs. The medical team feels it would be "futile" and a waste of medical resources to replace this heart valve yet again.
Is the team's judgment appropriate in this case?
Case 1 Discussion
While it is likely that this patient will require additional counseling and support services to improve his health outcomes, replacing the heart value is not "futile" in this case (see the topic page on Futility for further discussion). It is also likely that the medical team is using biased criteria to judge "wasted" vs. "properly used" medical resources. Thoughtful discussion may provide an opportunity for the team to voice their frustration and think through a treatment plan that will maximally support this patient's recovery.
Spirituality and Medicine
Religious beliefs and practices are important in the lives of many patients seeking medical care, yet many physicians are uncertain about whether, or how, to address spiritual or religious issues. Often physicians are trained to diagnose and treat disease and have little or no training in how to relate to the spiritual side of the patient. In addition, the physician's ethic requires that the physician not impinge her beliefs on patients who can be particularly vulnerable when supplicants for health care. Complicating it further, in our culture of religious pluralism, there is a wide range of belief systems ranging from atheism, agnosticism, to a myriad assortment of religions. No physician could be expected to understand the beliefs and practices of so many differing faith communities.
At first glance, the most simple solution suggests that physicians avoid religious or spiritual content in the doctor-patient interaction. As with many issues, however, the simple solution may not be the best. This topic page inquires into the possibility that within the boundaries of medical ethics and empowered with sensitive listening skills, the physician may find ways to engage the spiritual beliefs of patients in the healing process, and come to a clearer understanding of ways in which the physician's own belief system can be accounted for in transactions with patients. Appropriate referral to the hospital chaplain will be explored as well as ways in which the physician and clergy may best work together for the good of the patient.
How pervasive is religiosity in the United States?
Surveys of the US public in the Gallup Report consistently show a high prevalence of belief in God (95%) while 84% claim that religion is important to their lives.[1] Approximately 40% of Americans attend religious services at least once a week. One survey in Vermont involving family physicians showed that 91% of the patients reported belief in God as compared with 64% of the physicians.[2] A 1975 survey of psychiatrists showed that 43% professed a belief in God.[3]These surveys remind us that there is a high incidence of belief in God in the US public. It also appears from surveys that physicians as a group are somewhat less inclined to believe in God. Whereas up to 77 percent of patients would like to have their spiritual issues discussed as a part of their medical care [4], less than 20 percent of physicians currently discuss such issues with patients.[5]
Why is it important to attend to spirituality in medicine?
Regardless of their own belief system, physicians should not allow their own bias to blind them to the appreciation of the possibility that religion and spiritual beliefs play an important role for many of their patients. When illness threatens the health, and possibly the life of an individual, that person is likely to come to the physician with both physical symptoms and spiritual issues in mind. An article in the Journal of Religion and Health claims that through these two channels, medicine and religion, humans grapple with common issues of infirmity, suffering, loneliness, despair, and death, while searching for hope, meaning, and personal value in the crisis of illness.[6]
Persons may hold powerful spiritual beliefs, and may or may not be active in any institutional religion. Spirituality can be defined as ". . . a belief system focusing on intangible elements that impart vitality and meaning to life's events."[7] Many physicians and nurses have intuitive and anecdotal impressions that the beliefs and religious practices of patients have a profound affect upon their experiences with illness and the threat of dying. It is generally accepted that religious affiliation is correlated with a reduction in the incidence of some diseases such as cancer and coronary artery disease. For patients facing a terminal illness, religious and spiritual factors often figure into important decisions such as the employment of advance directives such as the living will and the Durable Power of Attorney for Health Care. Considerations of the meaning, purpose and value of human life are used to make choices about the desirability of CPR and aggressive life-support, or whether and when to fore-go life support and accept death as appropriate and natural under the circumstances.
How should I take a "spiritual history"?
In courses such as the "Introduction to Clinical Medicine," medical students learn the various components of the doctor-patient interview, often beginning with a history of the present illness, a psycho-social history, and a review of systems. Students-in-training are often hesitant to ask questions regarded as intrusive into the personal life of the patient until they understand there are valid reasons for asking about sexual practices, alcohol use, the use of tobacco or non-prescription drugs. Religious belief and practice falls into that "personal" category that students-in-training often avoid, yet when valid reasons are offered by teachers and mentors for obtaining a spiritual history, students can learn to incorporate this line of questioning into the patient interview.
Often, the spiritual history can be incorporated into what we may now want to call the "psycho-social-spiritual" patient history. Students are taught to make a transition by simply stating something like the following: "As physicians, (or, as physicians-in-training,) we have discovered that many of our patients have strong spiritual or religious beliefs that have a bearing on their perceptions of illness and their preferred modes of treatment. If you are comfortable discussing this with me, I would like to hear from you about any beliefs or practices that you would want me to know as your care giver." If the patient responds affirmatively, follow-up questions can be used to elicit the information. If the patient says "no" or "none" it is a clear signal to move on to the next topic.
In my experience as a tutor, students learning the patient interview have returned from a patient interview on many occasions with a sense of excitement and gratification in discovering that this line of questioning opened a discussion with the patient that disclosed the patient's faith in God as a major comforting factor in the face of a life-threatening illness. Some patients have described their gratitude to their church community for bringing meals to their family while at least one parent was at the hospital with a sick child. Others spoke of a visit from a priest, a rabbi, or a minister during their hospitalization as a major source of comfort and reassurance. One patient, self-described as a "non-church-goer," described his initial surprise at a visit from the hospital chaplain which turned into gratitude as he found in the chaplain a skilled listener with a deep sense of caring to whom he could pour out his feelings about being sick, away from home, separated from his family, frightened by the prospect of invasive diagnostic procedures and the possibility of a painful treatment regimen.
Todd Maugans offered a mnemonic in the Archives of Family Medicine as a technique to assist students in framing an approach to spiritual history taking:
S Spiritual Belief System
P Personal Spirituality
I Integration and Involvement in a Spiritual Community
R Ritualized Practices and Restrictions
I Implications for Medical Care
T Terminal Events Planning (advance directives)
The mnemonic is of course suggestive of a broader line of questioning that may follow from open ended questions organized around the topics identified above.
How can respect for persons involve a spiritual perspective?
The emphasis on listening to the patient and learning of the patient's beliefs and values as well as the signs and symptoms of illness is timely. A variety of features related to cost containment seem to work adversely against the patient's needs. The typical office visit grows shorter and more curtailed as physicians are pressured to see more patients within a working day. In managed care organizations the physician is responsible for a pool of patients, not just the individual patient who is standing before the physician at this particular moment. Increasingly, the physician is the "gatekeeper" in terms of referral to specialists and to expensive diagnostic procedures or hospitalization decisions. These pressures toward economy have been created by the upward spiraling of health care costs. However, they must not come at the sacrifice of respect for persons, a fundamental moral obligation in the profession of medicine.
The principle of respect for persons leads to actions designed to safeguard the autonomy of the patient, to limit the risks of harm while providing a medical benefit, and to treat persons fairly in the allocation of health care resources. Such respect for persons is a guiding principle of the healing profession and flows from the professions fundamental ethical commitment in serving the sick and injured. This principle is reinforced for the physician with a religious perspective, who in most religions, views the patient as a part of the creation of God. Likewise, it is reinforced in religious hospitals where the mission is to care for persons individually and equally as "children of God."
How should I work with hospital chaplains?
It is heartening to know that the physician is not alone in relating to the spiritual needs of the patient, but enjoys the team work of well trained hospital chaplains who are prepared to help when the needs of the patient are outside the competence of the physician. Consultation frequently may involve clergy serving the patient and his family. The onset of serious illness often induces spiritual reflection as patients wonder, "what is the meaning of my life now?". Others ponder questions of causation, or "why did this happen to me?". Still others are concerned as to whether the physician's recommendations for treatment are permissible within the faith community of the patient. Practical questions concerning the permissibility of procedures such as in vitro fertilization, pregnancy termination, blood transfusion, organ donation, or the removal of life supports such as ventilators, dialysis, or artificially administered nutrition and hydration, arise regularly for persons of faith. In many cases, the chaplain will have specialized knowledge of how medical procedures are viewed by various religious bodies. In each case, the chaplain will first attempt to elicit the patient's current understanding or belief about the permissibility of the procedure in question.
The chaplain is also a helpful resource in providing or arranging for certain rituals that are important for patients under particular circumstances. Some patients may wish to hear the assurances of Scripture, others may want the chaplain to lead them in prayer, and still others may wish for the sacrament of communion, baptism, anointing, or the last rites, depending upon their faith system. The chaplain may provide these direct services for the patient, or may act as liaison with the patient's clergy person. In one case, the surgeon called for the chaplain to consult with a patient who was inexplicably refusing a life-saving surgical procedure. The chaplain gently probed the patient's story in an empathic manner, leading the patient to "confess" to a belief that her current illness was God's punishment for a previous sin. The ensuing discussion revolved around notions of God's forgiveness and the patient's request for prayer. In this case, the chaplain became the "embodiment" of God's forgiveness as he heard the patient's confession, provided reassurance of God's forgiving nature, and offered a prayer acknowledging her penitence and desire for forgiveness and healing. In another case, the neonatologist summoned the chaplain to the NICU when it became apparent that a premature infant was not going to live and the parents were distraught at the notion that their baby would die without the sacrament of baptism. In this case, the chaplain was able to discuss the parents beliefs, to reassure them that their needs could be met, and to provide an infant baptism service with the parents, the neonatologist and the primary nurse all in attendance. The chaplain also notified their home town pastor and helped make arrangements for the parents to be followed back home in their grieving process.
What role should my personal beliefs play in the physician-patient relationship?
Whether you are religious, or areligious, your beliefs may affect the doctor-patient relationship. Care must be taken that the nonreligious physician not underestimate the importance of the patient's belief system. Care must be taken that the religious physician who believes differently than the patient, not impose his or her beliefs onto the patient at this time of special vulnerability. In both cases, the principle of respect for the patient should transcend the ideology of the physician.
It is clear that religious beliefs are important to the lives of many physicians. Some physicians attest to a sense of being "called" by God to the profession of medicine, a definite sense of vocation in the religious sense of a calling. In fact, in a much earlier time in the history of the world, the priest and the medicine man were one and the same in most cultures, until the development of scientific medicine led to a division between the professions. Modern physicians wonder whether, when and how to express themselves to patients regarding their own faith.
In one study reported in the Southern Medical Journal in 1995, physicians from a variety of religious backgrounds reported they would be comfortable discussing their beliefs if asked about them by patients.[8] The study shows that physicians with spiritual beliefs that are important to them integrate their beliefs into their interactions with patients in a variety of ways. Some devout physicians shared their beliefs with patients, discussed the patients beliefs, and prayed either with or for the patient. These interactions were more likely in the face of a serious or life-threatening illness and religious discussions did not take place with the majority of their patients.
Four guidelines are offered for physicians regarding religious issues:
physicians may enter such a dialogue, but they are not obligated to do so.
the dialogue must be at the invitation of the patient, not imposed by the physician.
physicians must be open and nonjudgmental in claiming that their beliefs are personally helpful, without claiming ultimate truth
the guiding principle should be "do no harm," the purpose of the dialogue should be burden-lifting, not burden-producing.[9]
Some physicians find a number of reasons to avoid discussions revolving around the spiritual beliefs, needs and interests of their patients. Reasons for not opening this subject include the scarcity of time in office visits, fear of imposing upon the patient, lack of familiarity with the subject matter of spirituality, or the lack of knowledge and experience with the varieties of religious expressions in our pluralistic culture. On the other hand, some physicians do incorporate spiritual history taking into the bio-psycho-social-spiritual interview, and others find opportunities where sharing their own beliefs or praying with a particular patient in special circumstances has a unique value to that patient. Certainly issues in modern medicine raise a host of questions such as whether or not to prolong life through artificial means, whether it is licit to shorten life through the use of pain medications, or what duty one has to a new born with fatal genetic anomalies. These and a myriad of other questions have religious and spiritual significance for a wide spectrum of our society and deserve a sensitive dialogue with physicians attending to patients facing these troubling issues.
How can I approach spirituality in medicine with physicians-in-training?
In one approach at the University of Washington School of Medicine, the course "Spirituality in Medicine" goes beyond teaching the spiritual history taking. The purpose of the course is to provide an opportunity for interactive learning about relationships between spirituality and the practices in medicine and health care. Some of the goals of the class are as follows:
To heighten student awareness of ways in which their own faith system provides resources for encounters with illness, suffering and death.
To foster student understanding, respect and appreciation for the individuality and diversity of patients' beliefs, values, spirituality and culture regarding illness, its meaning, cause, treatment, and outcome.
To strengthen students in their commitment to relationship-centered medicine that emphasizes care of the suffering person rather than attention simply to the pathophysiology of disease, and recognizes the physician as a dynamic component of that relationship.
To facilitate students in recognizing the role of the hospital chaplain and the patient's clergy as partners in the health care team in providing care for the patient.
To encourage students in developing and maintaining a program of physical, emotional and spiritual self-care which includes attention to the purpose and meaning of their lives and work.
Until recently, there were all too few medical schools that offered a formal forum to discuss humanistic aspects of medicine for medical students and residents. This situation is changing. Like the University of Washington, some thirty medical schools around the country have recently added new courses addressing spirituality in medicine. Increasingly, residency programs, particularly those with a primary care focus, are also incorporating this view in the training of residents. In addition, CME has been offered to practicing physicians through three annual conferences on "Spirituality in Medicine," the first of which was hosted by Harvard Medical School with Herbert Benson, MD, as facilitator.
Student Issues
As a medical student, you may encounter some troubling issues specifically related to your position as a physician-in-training. Often, these issues can arise unexpectedly or in time pressured settings. It can be helpful to think through what you will do (and become familiar with some respected opinions) before you feel you are stuck between a rock and a hard place. This topic page address some of these concerns and allows you the opportunity to think through what you might do in these situations.
If you are particularly troubled with any of these issues,
please contact our counseling office (616-3023) or
feel free to post a "case" to the discussion forum on this website by sending an e-mail.
What should I do when my preceptor introduces me as "Dr. Miller"?
Some community preceptors prefer to introduce their medical students as "doctor" because they feel it encourages patient trust. However, it is important to recognize that by calling yourself "doctor," you are misrepresenting yourself to the patient. As with other truth-telling and informed consent issues, it is appropriate to disclose to the patient what he or she needs to know. In this case, the patient needs to know you are a physician-in-training! Students have found themselves in awkward situations once the patient begins asking questions that a physician should know how to answer. At this stage, even if you clarify, "Actually, I'm a medical student, not yet a physician," patient trust may be damaged.
It can be a difficult conversation to have with your preceptors, but it is best to discuss this matter in advance. Find out what his or her expectations are. If they feel strongly about introducing you as "doctor," it remains your responsibility to explain tactfully that you cannot misrepresent yourself to patients. In the long run, patients' trust will be secured if they realize you are both being straightforward. If the preceptor insists, you may need to find polite ways to reintroduce yourself to the patient, modeling for the preceptor that direct communication is often the best foundation for a strong physician (and student-physician) patient relationship. For example, you might say, "Yes, I am a physician-in-training from University of Washington."
How should I respond when an intern asks if I want to practice a procedure on a patient who just died?
Practicing procedures on newly dead patients is a highly contentious issue. For some procedures, like intubation, students can benefit from practicing first on a cadaver. Weighing the risks and benefits, the student is more likely to harm a living patient were she to try to intubate without practicing first. No physical harm can occur to the cadaver. However, some are appropriately concerned about the disrespect that "practicing" procedures may show to the deceased patient or to the patient's family. It remains your responsibility to assure that your interactions with the cadaver are respectful and only as invasive as necessary. Most likely, the time you take to practice a simple procedure will not add significantly to the usual amount of time needed to prepare the patient's body for viewing by the family if they are waiting nearby. This is important to be cognizant of, however. (See our reference list for further discussion of this difficult issue.)
What if I see my resident or attending doing something "unethical"?
You will encounter many positive role models during your medical training. However, you will also see some behaviors and actions that are downright troubling or offensive. Because of the "team hierarchy," you may feel unable to confront someone who is "above" you or, more concerning, in control of your evaluation. However, you do still have several duties in this case. Ideally, you could talk with your resident about what you observed. Everyone has a unique perspective and your resident may have a rationale for his behavior that was unknown to you. Approaching him honestly, with simple questions, may allow him the benefit of the doubt and open up a dialogue between you.
The nature of the observed 'unethical' act determines what your obligations are. In simpler cases, it can be a matter of treating it as a negative lesson in how NOT to be a physician. In more complex instances, patient care may be in jeopardy and you may have an obligation to report the resident's behavior if he refuses to discuss it with you directly. Your attending physician or clerkship coordinator can be valuable resources as you make these judgment calls. Discussing these instances with your peers can also be helpful.
Is it ever appropriate to do a procedure for the first time without supervision
The "see one, do one, teach one" model of medical training has become something of a urban legend. However, on a busy service, you will be probably be asked to "go consent Mr. Jones" or "just start a line on Mrs. Smith." If you have never done either of these activities before, it is your responsibility to ask for appropriate supervision before beginning the procedure. Emphasize your interest in learning the new skill as well as your interest in learning it under the best conditions possible.
I'm not sure how I feel about "using" vulnerable patients as teaching patients. Are we taking unfair advantage of people?
A necessary part of learning to be a physician, "practicing" on people sometimes feels uncomfortable. You can keep a few things in mind to minimize the discomfort you might feel. First, as with all your future patients, treat them with respect and ask permission before doing any observations, tests, or procedures. Second, remember that it is a privilege to learn medicine. When appropriate, convey your gratitude to the patients, acknowledging the crucial role they play in your education.
Listen to your instincts as well. Sometimes it may not be appropriate to do an unnecessary duplicate examination or, for example, try more than three times to start an IV line in a patient. If the patient is uncomfortable with your presence, you must respect that and ask a more senior person on your team to complete the procedure or the exam. Unfortunately, you may notice a difference in how some housestaff or attending physicians treat patients from different socioeconomic classes. It is your responsibility to attend to these patients needs with respect and compassion. The homeless man in the ER could be very lucky to have you be the one to stitch his lacerations if you are the one who will be gentle and kind. Sometimes you can put a patient at ease if you convey that you are the member of the team with the most time and attention at the moment.
Other students have (unauthorized) access to last year's killer exam. Should I look at it?
In a survey of students from the late 1980's. 58% reported cheating at least once during medical school. There have been disincentives for reporting cheating, and perhaps a general sense that "this is just the way it is." On the contrary, cheating in class is an example of unprofessional behavior. It represents a lack of fairness, lack of integrity, and can foreshadow lying in other contexts during your medical training.
As a member of a profession, you are accountable for your own behavior and for the behavior of your colleagues. The Assistant Dean for Student Affairs or the Medical Student Association (MSA) representative can field your concerns and help you develop a plan for confronting your classmates.
I'm noticing what looks like addictive behavior in one of my classmates. What should I do?
Impaired students become impaired physicians. You are entering a profession that carries an obligation to its members for self-regulation. As a student, your classmate has an opportunity to seek help before serious harm comes to himself or herself, or to one of his or her patients.
Once licensed, you will have a legal obligation to report colleagues to the medical board if they are "unable to practice medicine with reasonable skill and safety to patients by reason of illness, drunkenness, excessive use of drugs, narcotics, chemicals, or any other type of material, or as a result of any mental or physical conditions (Revised Code of Washington 18.72.165)." The UW Counseling Office or the Assistant Dean for Student Affairs can help you arrange an intervention if you have these concerns.
Termination of Life-Sustaining Treatment
On the medicine wards, you will have patients who are receiving treatments or interventions that keep them alive, and you will face the decision to discontinue these treatments. Examples include dialysis for acute or chronic renal failure and mechanical ventilation for respiratory failure. In some circumstances, these treatments are no longer of benefit, while in others the patient or family no longer want them.
When is it justifiable to discontinue life-sustaining treatments?
If the patient has the ability to make decisions, fully understands the consequences of their decision, and states they no longer want a treatment, it is justifiable to withdraw the treatment.
Treatment withdrawal is also justifiable if the treatment no longer offers benefit to the patient.
How do I know if the treatment is no longer "of benefit?"
In some cases, the treatment may be "futile"; that is, it may no longer fulfill any of the goals of medicine. In general, these goals are to cure if possible, or to palliate symptoms, prevent disease or disease complications, or improve functional status. For example, patients with severe head trauma judged to have no chance for recovery of brain function can no longer benefit from being maintained on a mechanical ventilator. All that continuation would achieve in such a case is maintenance of biologic function. In such a case, it would be justifiable to withdraw mechanical ventilation.
Do different standards apply to withholding and withdrawing care?
Many clinicians feel that it is easier to not start (withhold) a treatment, such as mechanical ventilation, than to stop (withdraw) it. While there is a natural tendency to believe this, there is no ethical distinction between withholding and withdrawing treatment. In numerous legal cases, courts have found that it is equally justifiable to withdraw as to withhold life-sustaining treatments. Also, most bioethicists, including the President's Commission, are of the same opinion.
Does the patients have to be terminally ill to refuse treatment?
Though in most cases of withholding or withdrawing treatment the patient has a serious illness with limited life expectancy, the patient does not have to be "terminally ill" in order for treatment withdrawal or withholding to be justifiable.
Most states, including Washington State, have laws that guarantee the right to refuse treatment to terminally ill patients, usually defined as those having less than 6 months to live. These laws do not forbid other patients from exercising the same right. Many court cases have affirmed the right of competent patient to refuse medical treatments.
What if the patient is not competent?
In some cases, the patient is clearly unable to voice a wish to have treatment withheld or withdrawn. As with DNR orders, there are two general approaches to this dilemma: Advance Directives and surrogate decision makers.
Advance Directive:
This is a document which indicates with some specificity the kinds of decisions the patient would like made should he/she be unable to participate. In some cases, the document may spell out specific decisions (e.g. Living Will), while in others it will designate a specific person to make health care decisions for them (i.e. Durable Power of Attorney for Health Care). There is some controversy over how literally Living Wills should be interpreted. In some cases, the document may have been drafted in the distant past, and the patient's views may have changed. Similarly, some patients do change their minds about end-of-life decisions when they actually face them. In general, preferences expressed in a Living Will are most compelling when they reflect long held, consistently stable views of the patient. This can often be determined by conversations with family members, close friends, or health care providers with long term relationships with the patient.
Surrogate decision maker:
In the absence of a written document, people close to the patient and familiar with their wishes may be very helpful. (See Advance Care Planning.) The law recognizes a hierarchy of family relationships in determining which family member should be the official "spokesperson," though generally all close family members and significant others should be involved in the discussion and reach some consensus. The hierarchy is as follows:
Legal guardian with health care decision-making authority
Individual given durable power of attorney for health care decisions
Adult children of patient (all in agreement)
Parents of patient
Adult siblings of patient (all in agreement)
What if I'm not sure if the patient is competent?
Sometimes the patient is awake, alert, and conversant, but their decisions seem questionable or irrational. First, it is important to distinguish an irrational decision from simple disagreement. If you feel strongly that a certain course of action is "what's best" for the patient, it can seem irrational for them to disagree. In these situations, it is critical to talk with the patient and find out why they disagree.
Patients are presumed to be "competent" to make a treatment decisions. Often it's better to say they have "decision making capacity" to avoid confusion with legal determinations of competence. In the courts, someone's competence is evaluated in a formal, standardized way. These court decisions do not necessarily imply anything about capacity for making treatment decisions. For example, an elderly grandfather may be found incompetent to manage a large estate, but may still have intact capacity to make treatment decisions.
In general, the capacity to make treatment decisions, including to withhold or withdraw treatment, is considered intact if the patient:
understands the clinical information presented
appreciates his/her situation, including consequences with treatment refusal
is able to display reason in deliberating about their choices
is able to clearly communicate their choice.
If the patient does not meet these criteria, then their decision to refuse treatment should be questioned, and handled in much the same way as discussed for the clearly incompetent patient. When in doubt, an ethics consultation may prove helpful.
Is a psychiatry consult required to determine decision making capacity?
A psychiatry consult is not required, but can be helpful in some cases. Psychiatrists are trained in interviewing people about very personal, sensitive issues, and thus can be helpful when patients are facing difficult choices with fears or concerns that are difficult to talk about. Similarly, if decision making capacity is clouded by mental illness, a psychiatrist's skill at diagnosis and potential treatment of such disorders can be helpful.
Does depression or other history of mental illness mean a patient has impaired decision making capacity?
Patients with active mental illness including depression should have their decision making capacity evaluated carefully. They should not be presumed to be unable to make treatment decision. In several studies, patients voiced similar preferences for life-sustaining treatments when depressed as they did after treatment of their depression.
Depression and other mental disorders should prompt careful evaluation, which may often be helped by psychiatry consultation.
Is it justifiable to withhold or withdraw food or fluids?
This question underscores the importance of clarifying the goals of medical treatment. Any medical intervention can be withheld or withdrawn, including nutrition and IV fluids. At all times, patients must be given basic humane, compassionate care. They should be given a comfortable bed, human contact, warmth, and be kept as free from pain and suffering as possible. While some believe that food and fluids are part of the bare minimum of humane treatment, both are still considered medical treatments. Several court cases have established that it is justifiable to withhold or withdraw food and fluids.
Is it justifiable to withhold or withdraw care because of costs?
It is rarely justifiable to discontinue life-sustaining treatment for cost reasons alone. While we should always try to avoid costly treatments that offer little or no benefit, our obligation to the patient outweighs our obligation to save money for health care institutions. There are rare situations in which costs expended on one terminally ill patient could be clearly better used on another, more viable patient. For instance, a terminally ill patient with metastatic cancer and septic shock is in the last ICU bed. Another patient, young and previously healthy, now with a self-limited but life-threatening illness, is in the emergency room. In such cases, it may be justifiable to withdraw ICU treatment from the terminally ill patient in favor of the more viable one. Even so, such decisions must be carefully considered, and made with the full knowledge of patients and their surrogate decision makers.
Termination of Life-Sustaining Treatment:
Case 1
Mr. S is a 70-year-old man with end-stage COPD, admitted last month with pneumonia. His course was complicated by respiratory failure needing mechanical ventilation, and multiple efforts to wean him have been unsuccessful. Awake and alert, he now communicates through written notes that he wants the ventilator taken off.
What do you think his prognosis is? What else do you want to know before making this decision? If he is competent, will you honor his request?
Case 1 Discussion
The prognosis of full recovery from long-term mechanical ventilation is poor, particularly in patients like Mr. S with minimal pulmonary reserve. The approach to his request should start with an evaluation of his decision making capacity. Even though he is awake and alert, you should carefully probe the reasons for his request, with particular attention to making sure he understands the consequences of his decision. If you're concerned about depression or other mental illness affecting his thinking about this decision, you might request a psychiatry consultation. You should ask Mr. S if he's discussed this with his spouse or family. If his decision making capacity is intact, you should honor his request.
Case 2
Mrs. H is a 62-year-old woman with metastatic breast cancer. She was admitted with dehydration and weakness. Her cancer treatments have failed, as she now has a recurrence. The oncologists are contemplating some new palliative chemotherapy. The nutrition team is concerned about her cachexia and recommends total parenteral nutrition (TPN).
Should the patient be started on TPN?
Case 2 Discussion
Patients with metastatic cancer often suffer from profound cachexia, attributable to the metabolic effects of their cancer and their inability to get adequate caloric intake from eating alone. TPN is able to provide protein and nonprotein nutrients to reverse the catabolic effects of illness. TPN has a number of potential complications, such as those related to infection from the central line catheter site.
In this case, you should carefully evaluate the goals of therapy as they relate to TPN. Is TPN likely to offer the patient any benefit? If her life expectancy can be prolonged with additional chemotherapy, it may be reasonable to give TPN to allow the patient to enjoy that benefit. If additional chemotherapy offers no substantial increase in quantity or quality of life, TPN could become another burden for the patient without any meaningful benefit, and ought to be withheld.
Truth-telling and Withholding Information
When physicians communicate with patients, being honest is an important way to foster trust and show respect for the patient. Patients place a great deal of trust in their physician, and may feel that trust is misplaced if they discover or perceive lack of honesty and candor by the physician. Yet there are situations in which the truth can be disclosed in too brutal a fashion, or may have a terrible impact on the occasional patient. The goal of this summary is to be able to discern the difference. (For related discussions, see Confidentiality, Cross-Cultural Issues, and Physician-Patient Relationships topics.)
Do patients want to know the truth about their condition?
Contrary to what many physicians have thought in the past, a number of studies have demonstrated that patients do want their physicians to tell them the truth about diagnosis, prognosis, and therapy. For instance, 90% of patients surveyed said they would want to be told of a diagnosis of cancer or Alzheimer's disease. Similarly, a number of studies of physician attitudes reveal support for truthful disclosure. For example, whereas in 1961 only 10% of physicians surveyed believed it was correct to tell a patient of a fatal cancer diagnosis, by 1979 97% felt that such disclosure was correct.
How much do patients need to be told?
In addition to fostering trust and demonstrating respect, giving patients truthful information helps them to become informed participants in important health care decision. Thus, patients should be told all relevant aspects of their illness, including the nature of the illness itself, expected outcomes with a reasonable range of treatment alternatives, risks and benefits of treatment, and other information deemed relevant to that patient's personal values and needs. Treatment alternatives that are not medically indicated or appropriate need not be revealed. Facts that are not important to the patients ability to be an informed participant in decision making, such as results of specific lab tests, need not be told to the patient. Also, complete and truthful disclosure need not be brutal; appropriate sensitivity to the patient's ability to digest complicated or bad news is important.
What if the truth could be harmful?
There are many physicians who worry about the harmful effects of disclosing too much information to patients. Assuming that such disclosure is done with appropriate sensitivity and tact, there is little empirical evidence to support such a fear. If the physician has some compelling reason to think that disclosure would create a real and predictable harmful effect on the patient, it may be justified to withhold truthful information.
What if the patient's family asks me to withhold the truth from the patient?
Often families will ask the physician to withhold a terminal or serious diagnosis or prognosis from the patient. Usually, the family's motive is laudable; they want to spare their loved one the potentially painful experience of hearing difficult or painful facts. These fears are usually unfounded, and a thoughtful discussion with family members, for instance reassuring them that disclosure will be done sensitively, will help allay these concerns. In unusual situations, family members may reveal something about the patient that causes the physician to worry that truthful disclosure may create real and predictable harm, in which case withholding may be appropriate. These occasions, however, are rare.
When is it justified for me to withhold the truth from a patient?
There are two main situations in which it is justified to withhold the truth from a patient. As noted above, if the physicians has compelling evidence that disclosure will cause real and predictable harm, truthful disclosure may be withheld. Examples might include disclosure that would make a depressed patient actively suicidal. This judgment, often referred to as the "therapeutic privilege," is important but also subject to abuse. Hence it is important to invoke this only in those instances when the harm seems very likely, not merely hypothetical.
The second circumstance is if the patient him- or herself states an informed preference not to be told the truth. Some patients might ask that the physician instead consult family members, for instance. In these cases, it is critical that the patient give thought to the implications of abdicating their role in decision making. If they chose to make an informed decision not to be informed, however, this preference should be respected.
What about patients with different specific religious or cultural beliefs??
Patient with certain religious beliefs or ethnic or cultural backgrounds may have different views on the appropriateness of truthful disclosure. For instance, Carrese and colleagues found that many people with traditional Navajo beliefs did not want to hear about potential risks of treatment, as their beliefs held that to hear such risks was to invite them to occur. Thus, dialogue must be sensitive to deeply held beliefs of the patient. One should not, however, assume that someone of a particular ethnic background holds different beliefs. Rather, a culturally sensitive dialogue about the patient's role in decision making should take place.
Is it justifiable to deceive a patient with a placebo?
A placebo is any substance given to a patient with the knowledge that it has no specific clinical effect, yet with the suggestion to the patient that it will provide some benefit. The placebo effect is powerful, in many cases providing measurable improvement in symptoms in 20-30% of patients. In general, the deceptive use of placebos is not ethically justifiable. Specific exceptions should be rare and only considered if the following conditions are present:
the condition is known to have a high placebo response rate
the alternatives are ineffective and/or risky
the patient has a strong need for some prescription
Truth-telling and Withholding Information:
Case 1
A 65-year-old man comes to his physicians with complaints of abdominal pain that is persistent but not extreme. Workup reveals that he has metastatic cancer of the pancreas. The man has just retired from a busy professional career, and he and his wife are about to leave on a round-the-world cruise that they've been planning for over a year.
Should you tell him his diagnosis?
Case 1 Discussion
Several factors tempt one to withhold the diagnosis, and these should be recognized. One would be the concern that the patient would suffer psychological harm that would interfere with his planned trip. There is little empirical evidence that this occurs, and lacking some compelling reason to think it would occur with this man, it is insufficient grounds to withhold information. To the contrary, sensitive disclosure would allow the patient and his wife to decide if the trip is still important to them, versus seeing their grandchildren, for instance, and would spare the patient the inconvenience of suffering advancing symptoms while traveling, perhaps necessitating emergency care in a foreign locale. Finally, physicians should not confuse discomfort at giving bad news with justification for withholding the truth. In this case, the man should be told his diagnosis, prognosis, and treatment options.
Case 2
An 80-year-old Asian woman is hospitalized with weight loss, generalized weakness, and a pulmonary mass. Work-up reveals that she has pulmonary tuberculosis. Her family approaches the physician and asks that the patient not be told, stating that in her upbringing in mainland China tuberculosis was considered fatal and to tell her would be like giving her "a death sentence."
Should you respect the family's concerns?
Case 2 Discussion
Some cultures hold different beliefs about truth-telling in the medical encounter. Some assert that in some Asian cultures, members of the family unit may withhold the truth about terminal illness from elders out of respect and a desire to protect them from harm. If a patient and their family members hold such beliefs, they should be respected, and a mechanism for informed decision making in collaboration with the family negotiated. One must not, however, assume that every patient of Asian ancestry holds the beliefs described here. The physician should make an attempt to explore the patient's belief system. If he finds that the patient does hold such beliefs about the harmful nature of truthful disclosure of the truth, then it would be justifiable to withhold the diagnosis of tuberculosis.
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* Re:exam experience
  mamu - 02/24/06 14:49
  can you post the link of the washington university website for ethics..

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* Re:exam experience
  rdb - 02/24/06 14:15
  to daner90007,

dont worry daner90007, all of us suffer from PTSD(Post TEST Stress Disorder) after taking step 3. You will surely pass. Keep on praying GOD. He will surely help all of us.GL
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* Re:exam experience
  rdb - 02/24/06 14:07
  To perk,

I took the step 3 nbme FREE trail exam. I took in november
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  rdb - 02/24/06 14:11
  T dik and lucy01

Aster's USMLE Step3 Notes

Page 1 of 94
May 19, 2003
ASTER's USMLE Step3 Notes
Recommended Study Material for Step3
1.Crush the Boards [5 days]
2.Swanson's Family Practice [15-20 days]
3.Ethics in Medicine (U of W site) [1 day]
4.Biostatistics [2 days]
5.Blueprints in OBG [2 days]
6.Blueprints in Peds [2 days]
7.Compass Surgery & Trauma Notes [1 day]
1.USMLE 2003 CD (Software Tutorial + Sample Cases)
3.VETAN'S LIST OF CCS CASES (list of recent cases)
1.Swanson's Family Practice
2.USMLE 2003 CD – sample MCQs
3.Kaplan Step3 CD – 200 sample MCQs
4.NMS Review – 750 questions
5.Kaplan Qbank for Step3
Aster's USMLE Step3 Notes
Page 2 of 94
May 19, 2003
Critical aortic stenosis: virtually zero chance of successful CPR.
Gout with h/o peptic ulcer disease: Rx of choice – colchicine (not indomethacin)
<6w: external rainage >6w: internal drainage
St. John's Wort: is a herbal medication with some efficacy in treatment of depression
(no FDA Approval)
Vaginal d/c pH < 4.5 : Consider Candida
ph > 4.5 : Consider Bacterial Vaginosis
Maternal Smoking / Alcohol: Symm IUGR
Maternal HTN: Symm IUGR
Physiological Jaundice / Exaggerated Physio / Breast Milk Jaundice: no risk of
Kernicterus occurs @ 1% x Birth Wt. (in grams) [Bilirubin Level]
PKU screen can be negative at 48hrs of life
(requires a repeat screen after 48 hrs. to confirm)
Maternal SLE: Congenital Lupus & 3rd degree Ht. Block (Anti-Ro)
Respi Failure: <60 mmHg O2 >60mHg CO2
Maternal Solvent Abuse: assoc. with nail hypoplasia
PDA closure achieved by Indomethacin
NEC: Pneumatosis Intestinalis
Neonatal CMV: confirm by isolation of virus from urine
Transplacental spread is highest in primary HSV,
Aster's USMLE Step3 Notes
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May 19, 2003
very low in recurrent HSV
Breast Milk (cf. Cow's Milk)
high carboydrate
low protein
low iron, but more bioavailable
inadequate Vit. D, Vit. K
supplement Iron @ > 6 m in exclusively breast fed
Infants of Diabetic Mothers with proteinuria, hematuria:
? Renal Vein Thrombosis (ass. with maternal DM)
Transfusion Reactions:
Febrile Reaction: WBCs in Donor Blood (Acetaminophen)
Anaphylaxis: Proteins in donor blood (Antihistaminics, SQ Epinephrine)
Hemolysis: Mismatch (Hydration & Diuresis)
Infantile Colic: (Wessel Criteria)
3 m child; 3 hrs/day; >3 days/week; > 3 wks. duration
1.Methylphenidate / Dextroamph / Mg Pemoline
2.TCA / SRI (second line)
3.Don't use Benzodiazepines
4.consider “drug holiday” on weekends
ACEIs contraindicated in preg.
HyperTG Rx: Gemfibrozil
Hypercholesterolemia (Drug Rx):
>190: 0-1 risk factors
>160: >= 2 risk factors
>130: CAD equivalent / CAD
if > 15% reduction reqd: “statins”
if < 15% reduction reqd: (Low HDL) Niacin
(normal HDL) Cholestyramine
Obesity in Children Triceps Skin Fold Thickness
OCP induced hepatic adenomas : tendency to rupture
(Surgical resection)
Aster's USMLE Step3 Notes
Page 4 of 94
May 19, 2003
ELISA â-hCG (Urine) is (+) 14 d post conception
RIA â-hCG (Serum) is (+) 14 d post conception
Symptomatic Gallstones: Lap Cholecstectomy
Ca. Tail of Pancreas: Poorest Prognosis
Lobular Ca in situ is not premalignant
Digitalis Toxicity is enhanced by:
HYPERcalcemia, HYPOkalemia, HYPOmagnesemia
Infant of HIV + mother (steps to derease transmission)
1.Intrapartum I/V AZT
2.LSCS delivery
3.AZT prophylaxis to child x 6 m
4.No breastfeeding
5.HIV test at 6m - 12 m
Finkelstein Test: Chr. Stenosing Tenosynovitis (deQuervain's Disease)
Rx for Chlamydial Ophthalmia: ORAL Erythromycin
(to prevent chlamydial pneumonia)
Commonest Hernia: Indirect Inguinal Hernia
T4 / RTU / FT4-I move up or down together unless there is a derangement in TBG
CPK-MM is increased in hypothyroidism (proximal myopathy)
Fetal Weight Determination:
Fetal Age Determination:
Transcerebellar Diameter
RA: associated with atlanto-axial subluxation
(“drop” attacks)
PTE: (A-a) O2 gradient is always abnormal
even if PaO2 is normal [highly sensitive]
Aster's USMLE Step3 Notes
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May 19, 2003
Fever 24-48 hrs. Postop: #1 Atelectasis
(D)EH / (B)CP / BR
Pneumococcal Vaccination is required in CSF Leak
Nephrotic Syndrome: Fatty Casts
Pyelonephritis: WBC Casts
Cystitis: WBCs
GN (PSGN): RBC Casts
CRF: Broad Casts
Cold Antibody: IgM - Inravascualr Hemolysis
Warm Antibody: IgG - Extravascular Hemolysis
Addison's: ACTH Simulation Test
Cushing's: Dexamethasone Suppresion Test
Conn's: Salt Loading Response
Diabetes Insipidus: Water Deprivation Test
Hemophilia A: aPTT increased, BT normal
vWD: aPTT increased; BT increased
(Ristocetin Cofactor Assay)
Factor VII def.: PT increased, BT normal
Aspirin: prolonged BT, no effect on CT
spiking fever despite antibiotics, 1 wk. postLSCS
?Septic Pelvic Thrombophlebitis (Mx: i/v Heparin)
Mx of Myesthenia Gravis: PYRIDOSTIGMINE
(not PHYSOSTIGMINE cuz of CNS effects)
vWD & Aortic Stenosis: ass. with Angiodysplasia
Alcoholic Cirrhosis: â-gamma bridge
d-xylose test: abnormal in small bowel malabsorption, normal in pancreatic disease
screening for malabsorption: 24 hour fecal fat
? Penicillamine increases survival in Scleroderma
Aster's USMLE Step3 Notes
Page 6 of 94
May 19, 2003
Congenital Syphilis may be associated with severe osteochondritis. Child may refuse to
move limbs (Pseudoparalysis of PARROT)
Abciximab: decreases restenosis rates post-PTCA
PTCA: no effect on morbidity or mortality
Diabetes Mellitus : assocation with hyperTG
First line management of newly diagnosed diabetic: DIET (not drugs)
Hypercalcemia: I/V Hydration + Loop Diuretics
Obesity: BMI>27g/m2 or 120% of ideal body weight
Caloric Intake increase:
300 Cal (Pregnancy); 50 Cal (Lactation)
Pulmonary Embolism: i/v Heparin
COPD excacerbation: H.flu, Pneumo., Moraxella
Long term stabilization of exercize induced asthma: Salmetrol & Zafirlukast
Severe acute asthma: < 50% best PEFR
Moderate acute attack: 60-80% best PEFR
Mild acute attack: >80% best PEFR
#1 community acq. pneumonia: S. pneumoniae
Ideal sputum sample: <10 epi./HPF & many PMNs
GERD: Transient relaxation of LES
Always perform an EKG for any adult with chest pain (esp. with risk factors for CAD)
Esophageal Ca.: most common type is AdenoCa. (Barrett's Esophagus)
effective in UC & Crohn's colitis / ileocolitis
Aster's USMLE Step3 Notes
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(not small-bowel Crohn's)
Celiac Sprue:
villous atrophy & reactive crypt hyperplasia
Dermatitis Herpetiformis (Mx: Dapsone)
H. pylori association:
.Serology (Past or Present Infection)
.Fecal Antigen Detection (False [-] with PPI)
.Urease Breath Test (False [-] with PPI)
Triple Therapy, esp. for non-NSAID ass. ulcers
1st episode of PUD: emperical therapy (H2 -> PPI)
Recurrent PUD: H. pylori eradication
Infectious mononucleosis
EBV, Sore Throat, LN, Splenomegaly
Atypical Lymphocytes (also in CMV)
Monospot (+): positivity wanes with time
Serology: increased Anti-EA; increased Anti-VCA IgM
â blockers decrease variceal bleed in portal HTN
Ascites: Salt Restriction, Diuretic: Spironolactone
narcotic analgesic switching
use 1/5 equianalgesic dose
Graves': Rx – Radioactive Iodine
children & pregnant: Propylthiouracil
WHO analgesic stepladder
1st LINE
Aspirin, Acetaminophen, NSAIDs
2nd LINE
3rd LINE
Aster's USMLE Step3 Notes
Page 8 of 94
May 19, 2003
Morphine Sulfate
Ca. ass. cachexia & anorexia: Prednisone, Magestrol
Agitated Depression Rx: sedating TCA (not SSRI)
Rx of choice for narcotic induced costipation: Lactulose
Nephropathy Incidence: IDDM (40%) > NIDDM (20%)
but #1 cause of Diab. Nephropathy is NIDDM
('cuz NIDDM prevalence is much higher than IDDM)
Prevalence Inreases: PPV of test increases
(NPV of negative test decreases)
Screening for GDM
Oral 50g Glucose: Bl. Glu. @ 1 hr. > 140mg% (+)
F/U with Oral 100g Glu. 3 hour GTT
values > 105 (0h) / 190 (1h) / 165 (2h) / 145 (3h)
Obese Diabetic: Diet/Wt.Loss -> Metformin
(ass. With Lactic Acidosis)
Insulin in DM
Initial dose: 15-20 U
2/3 of total : AM dose (2/3 regular, 1/3 intermediate)
1/3 of total : PM dose (2/3 regular, 1/3 intermediate)
Conn's syndrome Mx
Adenoma: Sx resection
B/L hyperplasia: Spironolactone
"cold nodules" on thyroid scan: ? Malignant
#1 Thyroid Study: Serum TSH (yields max. info.)
Multiple Sclerosis:
2 attacks more than 24 hours apart
> 1 area of damage (Oligodendrocyte damage)
m/c variant: relapsing-remitting type
Aster's USMLE Step3 Notes
Page 9 of 94
May 19, 2003
CSF mononuclear pleocytosis, CSF IgG increase
Oligoclonal Banding of CSF IgG
Myelin Breakdown Metabolites
Headache on stopping NSAIDs:
Analgesic withdrawl headache
Jaw Claudication & Scalp Tenderness: GCA
ESR increased
Visual Loss
Start Glucocorticoids without waiting for Bx results
Aspirin in febrile children: Reye's Syndrome
Continue anticonvulsants till seizure free for 4 years
Menorrhagia with hemodynamic compromise:
i/v conjugated estrogen
normal Hb in women: 12.0
normal Hb in pregnancy: 11.0 (1st & 3rd trimester)
10.5 (2nd trimester)
m/c variant of Hodgkin's : Nodular Sclerosis
Hodgkin's: Supraclav. node
NHL: epitrochlear node / likely to be extranodal
Joint space narrowing
subchonral cysts
osteophytes (mere osteophytes are not OA)
OA: Isometric exercizes are better than isotonic
CFS: T cell activation -> CNS effect of cytokines
nonREM sleep anomaly
(also seen in Fibromyalgia)
Gout prophylaxis: required for recurrent attacks
(not indicated after first attack)
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Strep Sore Throat Rx: can prevent Rh. Fever
Potassium sparing diuretics can cause severe hyperkalemia in CRF
SULINDAC: NSAID with no nephrotoxicity
Asymp. Bacteruria in Pregnancy : Treat with antibiotics [Amoxycillin is safe] (high risk of
Give Chlamydia Rx in Gonorrhea
-> i/m Ceftriaxone + PO Doxycycline
Biophysical Profile : TBMAN
Tone, Body Movements, Breathing, AFI, NST
Early Deceleration: Head Compression
Variable Deceleration: Cord Compression
Late Deceleration: Uteoplacental insufficiency
GU+NGU: 1 g Azithromycin stat
.Benzoyl Peroxide
.Topical Tretinoin
.Topical Antibiotics
.Systemic Antibiotics
.Systemic Isotretinoin
Acne Rosacea Mx
Topical Metronidazole -> Systemic Antibiotic
[Benzoyl peroxide & Tretinoin can aggravate rosacea]
Female Infertility (Hormonal)
Hyper-estrogenic: CLOMIPHENE CITRATE
Hyper-PRL: Bromocriptine (PIH)
Narcotic Dependence: Methadone replacement
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External Hemorrhoids: Excision with elliptical incision
Internal Hemorrhoids: Banding
2nd trimester eclampsia: Molar pregnancy
Molar pregnancy: hyperemesis gravidarum
Most important obstetric measurement:
Diagonal Conjugate (at least 11.5 cm)
Amniotomy: perform after enagement of fetal head
Rx of HTN in preg.: á-methyldopa, hydralazine
BP reduction goal in pre-eclampsia:
Lower diastolic to 90-100 mmHg (lowering to 80mmHg could jeopardize placental
#1 maternal disease causing IUGR: Maternal HTN
#1 cause for 1st tri. abortions: Chromosomal ab(n)
Postpartum Blues: < 2 weeks
Postpartum Depression: > 2 weeks
Major Depression: >= 5 symptoms for > 2 weeks
Mania: >= 3 symptoms for > 1 week
Primary Type 1 Osteoporosis: # vertebrae
Primary Type 2 Osteoporosis: # neck femur
Progesterone required only if uterus is present
Estrogen: dec. LDL, inc. HDL
Progesterone: inc. LDL, dec. HDL
Estrogen's cardioprotective effects of estrogen are not mediated through cholesterol.
Estrogen promotes EDRF synth. In vascular endothelium
Repeat Pap: if reqd., no sooner than 6 weeks
Hormonal contraception if h/o DVT/PE (+):
Norplant & DMPA (Progesterone based), not OCPs
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Jarisch Herxheimer reaction: Syphilis Rx (chills)
HPV: condyloma acuminata
HPV 18: fastest progression to Ca. Cx
Acute Epididymitis:
#1 cause: Chlamydia trachomatis
#1 bacterial cause: E. coli (m/c in >40 y age)
Depression: Cognitive Psychotherapy + SSRI
Drug Rx of Bipolar Disorder:
Li, Carbamazepine, Valproate,
Gabapentin, Lamotrigine (ass. With SJS)
Lithium: Hypothyroidism, NDI
Atypical Antipsychotics are especially useful for negative symptoms of Schizophrenia
Mx of DTs
.Intermediate acting BZDs (Diazepam)
.IV saline (no glucose containing fluids)
.IV thiamine
BZD in Hepatic Enceph.: Oxazepam
Fluid Deficit in Burns
= 4mL/kg x %BSA (Parkland Formula)
1st degree:
2nd degree: clean, sulfadizine, nonadhesive dressing
3rd degree: refer to plastic surgeon for escharotomy
Heat Cramps: ORS
Heat Exhaustion: IV Fluids
Heat Stroke: neurological dysfunction & absence of sweating (may not be
Hypothemia: Osborne (J) wave on EKG
Mild: (32-35 C) Passive External Rewarming
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Moderate: (27-32 C) Active External Rewarming
Severe: (< 27C) Active Core Rewarming
Depression: Cognitive Psychotherapy
Anxiety Dsorders: Behavioral Psychotherapy
Adjustment Disorder: Supportive Psychotherapy
Social phobia: bea blockers & assertive training
Specific phobia: systematic desensitization
Panic: SSRI & Alprazolam (short T1/2)
.Na Lactate can mimic a panic attack
.use alprazolam for panic, not GAD
.may be associated with rebound anxiety
OCD: (associated with anxiety) SSRI
OC PD: insight-oriented psychotherapy
Somatization Disorder:
4 Pain, 2 GI, 1 sexual symptoms
(associated with abuse in childhood)
Depression: SSRI + Cognitive Psychotherapy
“Atypical” depression: MAOIs are first-line
Generalized Anxiety: Buspirone (selective anxiolytic)
Sexual Dysfunction
Young Males: Premature Ejaculation
(Mx: start and stop penile stimulation, not SSRIs)
Older Males: #1 Erectile Dysfunction
Females: #1 Hypoactive Sexual Desire
Young males with sexual dysfunction: Psychogenic
Older males with sexual dysfunction: Organic
The PATIENT is the head of the healthcare team
ADHD associated with:
Conduct Disorder and Oppositional Defiant Disorder
(also with Tourette's Syndrome)
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ADHD with (+) h/o or F/H tics
Phototherapy isomerizes bilirubin to a state that can be excreted in urine & bile
unchanged. (does not enhance conjugation)
Water Supply > 1 ppm fluoride: No supplementation
Retrocecal Appendicitis: poorly localized pain
#1 cause : lymphoid hyperplasia
Mx: Surgery
Yersnia enterocolitis can mimic appendicitis
Painkillers & antibiotics can alter presentation
Preg. With appendicitis: atypical location of pain
Elderly: higher chances of perforation
Appendiceal abscess: Delay surgical intervention
If on lap., some other cause is found – do an appendectomy anyway, to prevent
confusion in future
Oral Dissolution of Gallstones
single floating cholesterol stones in functioning g.b.
Asymp. Gallstones: DO NOTHING
Symptomatic Gallstones: Lap. Cholecystectomy
#1 complication of Lap Chole: Bile Duct Injury
Choledocholithiasis: ERCP with sphincterotomy
idications of ERCP:
.small stones
.dilated CBD
.palpable stones in CBD
Plantar Warts: Cryosurgery
Venereal Warts: Podophyllin (not in pregnancy)
Cullen's Sign: periumbilical discoloration
Grey Turner Sign: flank discoloration
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#1 radiological signs in pancreatic disease
acute pancreatitis: sentinel bowel loop
chronic pancreatitis: pancreatic calcification
Crucifer intake reduces Colon Ca.
Ca. risk of polyps is dependent on villous content
#1 risk factor for pancreatic ca. : smoking
#1 cause for chronic low back pain: idiopathic
.bed rest has no role
.no need for imaging (X-Ray / CT / MRI)
.prescribe an exercize program (can temporarily excacerbate symptoms)
Acetohydroxamic acid: urease inhibitor
(acidifies urine in patients with struvite stones)
HTN with BPH: Terazocin (á blocker)
Vestibular Neuronitis: NO hearing loss
Meniere's Diseass: Tinnitus, Vertigo, Hearing Loss
Ac. Labrynthitis: Ac Hearing Loss, Nystagmus, Vertigo
Acute Bacterial Sinusitis:
no role of imaging (Dx by h/o & PE)
? antibiotics – PO Amox x 7-10 days
Antidep. of choice in depresion in elderly: TCA (Nortryptaline) - minimal side effects cf.
other TCAs
Alzheimer's Rx: DONEPEZIL (OD) & Tacrine Cholinesterase Inhibitors
Polymyalgia Rheumatica: Oral Steroids
GCA: I/V Seroids
Elderly black HTN: CCB & Thiazide Diuretics
Parkinson's with Tremor has a better prognosis than pts. with symptoms of
Postural Instability & Gait Disturbance
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Perform Postvoid Residual Urine measurement on every elderly patient with Urinary
incontinence to r/o Urinary Retention
Alzheimer's & Parkinson's cause Detrusor Hyperreflexia : URGE INCONTINENCE
@ high risk for pressure ulcers: reposition q2h
low-risk patients: reposition q6h
.prenatal ultrasound not mandatory
.? role of PSA & DRE in screening of asymptomatic individuals
Hyperlipidemia screening:
if elevated: do a FASTING LIPID PROFILE
á-FP estimation at 5-17 weeks to r/o NTD
.increased: ultrasound (can detect 80% anomalies)
.decreased: does not necessarily indicate Downs'
QUIT SMOKING before starting Nicotine replacement
Transdermal Nicotine Replacement:
21mg -> 14mg -> 7mg
[Pts. with CAD, start with 14 mg.]
[Nicotine is vasoconstrictor, risk of MI]
Pesticide exposure has been linked to Prostate Cancer
HTN increases the risk of stoke > CAD
2% reduction in CAD for every 1% decrease in serum cholesterol
Cancer mortality is increasing
stroke/CAD mortality is decreasing
HAART drug interactions
“statins”, Antihistaminics, Ergot alkaloids
AIDS in infants: better prognosis cf. adults
d/o/c for malaria prophylaxis: MEFLOQUIN
once-a-week (1 w before travel & 6 weeks after)
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Influenze A: adults
Influenza B: children
Influenza epidemics: Influenza A
Influenza vaccine: A & B
Amantidine protects only against “A”
(Rimantidine preferred in patients with renal failure)
Oseltamivir (Tamiflu®) protects against both “A” & “B”
Annual influenza vaccination for age > 65 y
#1 cause of traveler's diarrhea: ETEC
Cardiac Arrest: 1st step – initiate 911 call
Cardiac Arrest in Children: Assess, 1 min. on CPR
Initiate 911 call
Mx of Respiratory Acidosis: Increase Ventilation
(Use of NaHCO3 is not wise to Mx Respi. Acidosis)
1-person CPR: 15:2
2-person CPR: 5:1
symptom to treatment time: <60 minutes
ED to needle time: <30 minutes
A. Fib.: (Unstable): Sync. Cardioversion
V. Fib.: Async. Defib. [200 -> 300 -> 360 mJ]
SVT: Vagal Maneuvres -> Adenosine
V.Tac.: Lidocaine, Procainamide, Bretylium
V.Tac.: (Unstable): Cardiovert
V. Fib:
Defibriallate again
2nd line antiarrhythmic
Immediate transcutaneous pacing
Epinephrine -> Atropine -> Consider Bicarbonate
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Use intra-osseous route in age < 6 years
Insulin 0.1U/kg/hr + NS
Add K+
when Blood Glucose approaches 250, shift to 5%D
m/c cause of abdo. Pain in elderly: CONSTIPATION
Use activated charcoal with 70% sorbitol in poisonings
Cuffed ETT for age > 7yrs
#1 Poisoning: OTC Analgesics
Naloxone: Short acting
Naltrexone: Long acting
(used in rehab programs, not acute overdose)
Urticaria: Subcutaneous edema
Angioedema: Mucosal edema
Colles' #: Dinner Fork abnormality
(Splint in Neutral position)
Suspected Scaphoid # & X-Ray (-)
Ankle Inversion Injury
- Lateral Ligament Sprain
- Anterior Talofibular Ligament
McMurray Test:
.Meniscal Tear
.Joint Line Tenderness
Lachman Test:
Anterior Cruciate Ligament Injury
Dislocation of Shoulder:
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.associated with axiallry artery injury
NBT (-) : CGD (SXR) -> IFN-gamma
(Bone Scan is useless, does not detect lytic lesions)
#1 cause of death in myeloma: Pulmonary or UTI
Duration of Maintenance Pharmacotherapy for depression (even for single episode)
should be at least 6 months.
Desert Rheumatism: C immitis
Mx – Conservative
Rx required only for dissemination / lung lesions
#1 Kidney stones: Calcium Oxalate (radiopaque)
[Square Crystals]
URIC ACID stones are radiolucent
CYSTINE crystals in urine are always pathological
Crohn's: associated with gallstones & kidney stones
[increased absorption of oxalates from the gut]
#1 complicatin of chickenpox: 2º skin infection
Postop Fever @ 24 hours: atelectasis
Postop Fever @ 5-10 days: wound infection
(early wound infection: clostridia / pesudomonas)
Neonatal Meningitis: S. agalactiae (Gp B Strep)
C1 esterase inhibitor deficiency:
.hereditary angiodema
.depleted C4 levels
.Mx: FFP/e-ACA/Stanozolol
.Maintain: ANDROGENS (inc. synthesis)
Suspect endometrial cancer:
gynecological referral for enometrial biopsy
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Pap misses 60% of endometrial Ca.
Cryoprecipitate: replaces Fibrinogen & Factor VIII
FFP: replaces all coagulation factors
Reversal of warfarin action: FFP (chronic: Vit. K)
Reversal of heparin action: Protamine
sterile subdural effusions: H. influenzae meningitis
pneumonia with effusion / empyema: Staph. aureus
Lipase is more sensitive and specific than amylase
Serum amylase elevated for 2-4 days
Urinary amylase elevated for 7-10 days
#1 cause of sensorineural hearing loss:
#1 cause of conductive hearing loss: OTOSCLEROSIS
osteomyelitis after foot puncture wound:
.Inability to supress glucose
.no stimulation of GH with levodopa
.paradoxical increase of GH with TRH
#1 intracranial mass lesion: METASTASIS
#1 brain malignancy (adult): Glioblastoma multiforme
#1 brain malignancy (child): Astrocytoma
adult: supratentorial
children: infratentorial (#1 supratentorial in children is craniopharyngoma)
SVC Syndrome: Think Bronchogenic Ca.
AML with DIC: M3 variant of AML
AML with gum chloromas: M5 variant of AML
Hairy Cell Leukemia: TRAP+ (Rx: Cladribine)
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Port Wine Stain: Sturge Weber Syndrome
CSF has a higher Cl- content compared to plasma
Rocky Mountain Spotted Fever:
Dx – Indirect IF
Rx – DOXYCYCLINE (< 8y: Chloramphenicol)
> 6 cafe au lait spots [or 1 spot > 5cm]
Tuberous Sclerosis:
Cardiac Rhabdomyomas
Angiomyolipoma of Kidney
Subungal Fibromas
Decreased Haptoglobin:
Intravascular Hemolysis
Very Severe Extravascular Hemolysis
3- are normal
Testicular Torsion: affected testis lies horizontally
Mx – Surgical Fixation of BOTH Testes
Torsion of Testicular Appendix: BLUE DOT
Mx – Exploration of other scrotum not required
m/c Thyroid Malignancy: Papillary Ca. Thyroid
MEN Syndrome: Medullary Syndrome
Hematogenous Spread: Follicular Ca.
Patella dislocates laterally
Mx PTSD with Group Psychotherapy
(not BZD : high risk of BZD abuse)
Fever without Focus:
#1 cause: Occult Bacteremia
due to Pneumococcus
due to Otitis Media
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Signs of Occult Bacteremia:
Temp > 40C
WBC < 5000 or WBC > 15000
Acute Otitis Media: Strep. pneumoniae (Amoxicillin)
#1 Pediatric Gastroenteritis: Rotavirus
#1 Pediatric (Bacterial) Gastroenteritis: C. jejuni
Recurrent Otitis Media:
.definition: >3 in 6 months or >4 in 1 year
.Amox prophylaxis -> Myringotomy & Tubes
Indications of Tonsillectomy:
.1 episode of Quinsy (Peritonsillar abscess)
.> 7 proven streptococcal pharyngitis
.airway obstruction
decreases recurrent sore throat, not URI
Suspected Strep Sore Throat:
Sore throat, fever, cervical LN, tonsillar exudates
Only 15% of sore throats are streptococcal
Rapid Strep. Test (HIGH SPECIFICITY)
even If (-), start treatment & perform a throat swab
Simple Diarrhea
No role of Stool Culture:
Stool Culture indicated only if:
.bloody diarrhea
.persistent diarrhea
.(+) tenesmus
.h/o foreign travel
Mx: Oral Rehydration Solution
(not juices or carbonated beverages)
Children with no dehydration – age-appropriate diet
Gp A â-hemolytic Streptococci are usually susceptible to Penicillin (this is not the case
with Staphylococci)
Strep viridans sensitive to Ampicillin + Gentamycin
German Measles (Rubella)
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Measles (Rubeola)
Roseola infantum (Exanthem subitum) HHV 6
high fever, rash appears after fever subsides
Lead levels > 10 : environmental abatement
start chelation therapy @ higher levels (? > 25)
single umbilical artery associated with renal ab(n)
Caput crosses midline; cephalhematoma does not
HbS Disease: Prophylactic Penicillin till 5y age
Stranger Anxiety: 6-9m
Separation Anxiety: 12-15m
Encopresis: >4 y
Enuresis: >5 y
Simple Febrile Seizures:
.Single Seizure
.< 15 minutes durations
.associated with high fever
.Rx: antipyretics (NOT ANTICONVULSANTS)
.F/H (+)
.Can recur
Meningococcal Contacts: Rifamp/Cipro prophylaxis
(#1 cause) Seasonal Allergic Rhinitis-Ragweed
(#1 cause) Perennial Allergic Rhinitis-House Dust Mite
Choanal Atresia
.cyanosis with feeding
.relieved by crying
Dog & Cat Bite: P multocida (Rx: Amox-Clav)
Cat scratch disease: Bartonella henselae
Cushing's Syndrome: #1 Iatrogenic
Cushing's Disease: #1 Pituitary Microadenoma
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Dx: 24 hour urinary free cortisol
to diff. Pituitary & adrenal cause: Overnight DST
Pick's Disease:
Dementia / atrophy of frontal & anterior temporal lobes
[early psychiatric manifestations]
Dementia with Lewy bodies:
(Alzheimer's + Parkinsonism features)
[they can excecerbate parkinsonism features]
Dialysis Dysequilibrium Syndrome:
associated with rapid correction of uremia
HTN in elderly African Americans: CCB + Diuretics
HTN in young African Americans: Diuretics
Paget's Disease of the bone:
extent is delineated by Tc 99 scan
Wounds < 12 hours old, clean: primary closure
Wounds > 12 hours old, contaminated: debridement and secondary closure
concomitant use of I/v heparin with thrombolysis:
Ac. anterior MI & Left Venticular Thrombus
Pts. with non-Q wave MI & previous CABG do not benefit considerably from
High risk features post-MI
1. Post MI angina
2. Non Q Wave MI
3. CHF
4. LVEF < 40%
5. > 10 PVCs / min
e/o Significant Ischemia on Exercize Stress Test:
1.ST segment depression
2.< 6 METS work
3.@ < 70% predicted maximum heart rate
4.Hypotensive Response
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LDL is the most important “lipid” risk factor for CAD
Cholesterol: < 200, 200-240, > 240
LDL: < 130, 130-160, > 160
treatment of choice for hypercholesterolemia: DIET
Basilar & Hemiplegic Migraine
(also c.i. in IHD/MI, Pts on SSRI/MAOI/Li)
Acute A. Fib.:
(Stable) â-blockers & CCB
(Unstable) Sync. Cardioversion
Obesity is a risk factor for Endometrial Ca.
Surgical intervention for obesity : BMI > 40 kg/m2
Heparin: keep PTT 1.5-2.0 x control
Warfarin: keep PT 1.5-1.8 x control
Enoxaparin (LMWH): No PTT monitoring required
COPD : smooth muscle hyperplasia (as in asthma), but Methacholine challenge test is
REID INDEX: ratio of thickness of bronchial glands to bronchial wall thickness
(increased in chronic bronchitis)
Nicotine enhances growth of H. flu
Most effective long term pharmacotherapy for COPD: Ipratropim bromide
COPD excecacerbations: H. flu, Pneumococcus, Moraxella
Only Rx in COPD that enhances survival
.Resting PaO2 < 55 mmHg
.Resting PaO2 < 60 mmHg with tissue hypoxia
(cor pulmonale / polycythemia)
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Acute Bronchitis in healthy non-smoker:
no Investigations, no treatment (no antibiotics)
Early phase of asthma: primary mediators
Late phase of asthma: secondary mediators
Prophylaxis of exercize induced asthma: Albuterol
Long term stabilization of exercize induced asthma: Salmetrol (long acting) +
Mycoplasma pneumonia:
.minimum physical findings
.B/L lower lobe infiltrates
.Cough (+)
.Mx: Macrolide
Cold Agglutinins (IgM) Inravascular hemolysis
Pnenumonia in elderly debilitated alcoholic:
Lower Lobe: Strep pneumoniae
Upper lobe: Klebsiella
(currant jelly sputum, hemoptysis, cavitatory lesion)
Normal Semen analysis
vol. 2-5 mL
sperm conc. > 20 million / mL
morph > 30% normal
motile > 50% motile
#1 cause of dysphagia: lower esophageal ring
(in the absence of risk factors for esophageal cancer)
Systemic Sclerosis associated with severe GERD
UC (Dx): Colonoscopy
Crohn's (Dx) : air contrast barium enema
Alcoholic Hepatitis: AST >> ALT (ratio > 2.0)
Malignant Neuropathic Pain
Sharp Stabbing: Rx anticonvulsants (Carbamazepine)
Dull Aching: Rx TCA (Desipramine)
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Mx of Chemotherapy induced Emesis: ONDANSETRON
Pain control : round-the-clock dosing > cf. PRN
TPN: no mortality/morbidity benefit in cancer pts.
Vestibular Nausea Rx: Cyclizine
Radiotherapy assoc. diarrhea: Loperamide / Codeine
Narcotic induced constipation: LACTULOSE
#1 symptom in avanced cancer is weakness (ASTHENIA)
SSRIs can make agitated depression worse
(Use sedating TCA & Anxiolytic PRN)
#1 metabolic derangement with advanced malignancy:
.hyperCa++ (long PR, decreased QT, wide T waves)
Type 1 DM is HLA DR3/DR4 associated
Type 2 DM - Obesity & Family History
decrease Glucose production & increase peripheral utilization (Metformin)
stimulate Insulin release (Glibenclamide)
.á-glucosidase inhibitors
decrease carbohydrate absorption (Acarbose)
.pts. are normal to underweight
.< 40 years age
.AD inheritance
.F/H (+) in 50%Dx of DM
Diagnosis of Diabetes Mellitus
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.FBS (2 values) > 126 mg%
.RBS (1 value) > 200 mg%
.GTT (100g oral glucose): 2 hour value > 200 mg%
Li induced NDI : stop Li -> start Carbamazepine
#1 feature of Cushing's: Truncal Obesity (90%)
Pathophysiology of Migraine:
CNS Platelet aggregation with Serotonin release
Very Severe Migraine (abortive): SUMATRIPTAN
Moderately severe Migraine (abortive): DHE
Status migrainous: migraine lasting > 72 hours
Cluster Headaches: Sumatriptan / O2 inhalation
New onset seizure
< 40 y age: #1 Idiopathic
> 40 y age: #1 Brain Tumor
Discontinue anticonvulsants after seizure-free for 4y
(confirmed by absence of epileptiform activity on EEG)
Grand mal: Phenytoin
Petit mal: Ethosuximide
Thrombotic Stroke: slow and continuing (m/c variety)
Embolic Stroke: sudden
#1 risk factor for CVA: HTN
CEA for Symptomatic Carotid Artery stenosis > 70%
Fe deficiency anemia (most sensitive Ix): S. Ferritin
#1 inherited bleeding disorder: vWD
Inherited hypercoagulable state
Factor V Leyden (most common)
Prot C def. / Prot. S def.
Anti-thrombin III deficiency
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Anti-PL antibodies: can cause arterial thrombosis
TTP: do NOT give platelet transfusion
vWD: Factor VIII (cryoppt.)
COX-2 (Celecoxib): less GI side effects cf. NSAIDs
Exercize program in OA
Graded, Active Exercize, Isometric
.tenderness in 11 of 18 defined points
.r/o comorbid depression
.ass. with sleep disorder
(á-nonREM sleep anomaly) -> also in CFS
Mx of Chronic Fatigue Syndrome:
.nonsedating TCAs
GOUT prophylaxis: only for recurrent attacks
(> 2-3 attacks) [not after first atack]
#1 cause of Chr. Renal Failure: DM
Mx of uncomplicated UTI: 3 days of TMP-SMX
Artificial Donor Insemination
.Store semen for 6 months
.Check donor for HIV @ 6 m
.If still (-), proceed with insemination
#1 step in Obstructive Sleep Apnea: Weight Reduction
BZD can worsen Obstructive Sleep Apnea
Narcolepsy Mx:
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.Mazindol (TCA)
Long T1/2 BZD are associated with lower incidence of rebound anxiety (e.g.
Oral - to be taken in the morning on empty stomach with 8 oz of water (to prevent
Alendronate (FDA approved)
Etidronate (less efficacious)
Pamidronate (I/V infusion)
SERMs (Raloxfene):
.Estrogenic on Bone / Lipids
.Anti-estrogenic on Uterus & Breats
Marjolin Ulcers: squamous cell ca. in old scars
Immunosuppression is a risk facor for Sq Cell Ca.
PRCA (Pure red cell aplasia) may be associated with thymoma
Aplastic Anemia causes <3% fall in Hct / week
[>3% fall in Hct / week: Hemolysis / Hemorrhage]
Hereditary Spherocytosis:
.increased MCHC, increased Osmotic Fragility
.Lifelong FOLATE supplementation
.acquired defect in DAF
.Dx: Sugar Water Test
.prone to hepatic & mesenteric vein thrombosis
.may progress to Aplastic Anemia / AML
Blody Nipple d/c: DUCT EXCISION
(no role of ductography)
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G6PD def.: older RBCs are deficient in enzyme, hemolysis is self-limited
G6PD def. (Mediterranean Variant): all cells are deficient - severe and chronic
.giant abnormal platelets
.dry bone marrow tap
“Clustered Polymorphic Microcalcification” on Mammography is s/o Breast Cancer
Mammography is never a substitute for BIOPSY. Mammo is for detection of other
lesions and screening the contralateral bereast. It does not rule-in or rule-out cancer
HbSC disease:
.increased incidence of Proliferative Retinopathy
.decreased vaso-occlusive and pain crisis
Fever in Neutropenia: consider infectious
Rx of acute promyelocytic leukemia: RETINOIC ACID
Serum LDH is a prognostic marker in Lymphomas
multiple myelomas with no paraprotein : 1%
(very aggressive)
TTP & HUS: normal coagulation studies (cf. DIC)
Uremia is asscoaited with qualitative platelet defect
Hemophilia with low platelet count:
??? HIV associated immune-thrombocytopenia
Hemophilia with no improvement with Factor VIII infusion: ??? suspect Factor VIII
Inhibitor activity
[Serum Mixing Test]
Mx: Steroids or Cyclophosphamide
Vit. K dep. factors:
Factor II, VII, IX, X
(Vit. K def.: corrected by Vit. K administration)
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Liver Disease:
decreased vit. K dependent factors & Factor V
(coagulopathynot corrected by Vit. K administration)
1 Unit of Packed Red Cells
300 mL volume = 200 mL of Red Cells
raises Hc by 4%
When Typo “O” blood is being used (universal donor): use packed red cells, not
whole blood
<50y: increase fiber or osmotic laxatives
>50y: FOBT
If (+), Colonoscopy (Sigmoido/Ba enema)
Mayonnaise/Salad Dressing: S. aureus food poisoning
Small Bowel Diarrhea: Voluminous, Bloating
Large Bowel Diarrhea: small volume, LLQ Cramps
Methylene Blue stain of stool detects Fecal Leukocytes
Follow-up Rx of DKA with ANION GAP
(not serum Ketones)
.ketone estimation detects only acetate and acetoacetate
.the predominant ketone in DKA is b-HAP
.as DKA Rx progresses, b-HAP converts to acetoacetate and estimation of serum
ketones might suggest "paradoxical" worsening ketonemia
Osmotic Diarrhea: decreases with fasting
Fecal Fat > 10g/24hours : s/o Malabsorption
#1 Peptic Ulcer
#2 Variceal Bleed (#1 cause of death from UGIH)
#1 (>50y) Diverticulosis (#2: Angiodyslasia)
<50y: Anoscopy or Sigmoidoscopy
>50y: Colonoscopy (Sigmoido/Ba enema)
Aster's USMLE Step3 Notes
Page 33 of 94
May 19, 2003
Ascitic Flluid: SAAG > 1.1 [Portal HTN]
Spontaneous Bacterial Peritonitis
.> 500 cells / ìL
.> 250 PMNs / ìL
.Total Protein < 1g / dL
.Mx: i/v Ceftriaxone (no anaerobic cover required)
.prophylactic FLUOROQUINOLONES to
prevent recurrences
Familial Mediterranean Fever:
.Turks, Armenians, Arabians
.recurrent abdominal pain (resembles acute surgical abdomen)
.attacks resolve in 24-48 hours
.associated with serositis & pleuritis
.recurrent attacks cause secondary amyloidosis
Uncomplicated GERD: H2 blockers (1st line) -> PPI
Complicated GERD: PPI (1st line)
Preferred procedure for portal decompression is TIPS (Transvenous Inrahepatic
Portosystemic Shunt)
.associated with maximum decrease in rebleeding rate (> banding, sclerotherapy, âblockers)
Non-invasive tests for H. pylori
.serology (past & present infection)
.fecal antigen detection
.urea breath testing
PPI can cause False (-) fecal antigen & breath test
Duodenal ulcers heal faster than gastric ulcers
Long term PPI Rx not required in PUD
Long term PPI Rx required in GERD
H. pylori eradication: PPI / Amox / Clarithromycine
50% of H pylori isolates are Metronidazole-resistant
.10-14 days of H. pylori eradication followed by 4-8 weeks of PPI for Rx of PUD
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May 19, 2003
Rx of Whipple's Disease: TMP-SMX for 1 year
Giardiasis can cause Lactase deficiency
Ogilvie's: acute colonic pseudo-obstruction
Gastric malignancy
#1 Gastric adenocarcinoma
#2 B-cell lymphoma
Celiac Sprue
increased incidence of intestinal T-cell lymphomas
Carcinoid Syndrome: small bowel carcinoid with hepatic metastasis (increased urinary
.increased right sided valvular lesions
Abdominal Pain relieved by defecation: IBS
Cl. difficile: watery diarrhea (Dx: Toxin Assay)
high potency steroid
low systemic side efects
(due to high first pass metabolism)
useful in nflammatory bowel disease
When UC/CD diff. is difficult
UC: pANCA (+)
CD: ASCA (antbodies to s. cerevisiae)
UC: assoc. with PSC (PSC is an independent risk factor for colonic malignancy in UC)
APC Gene:
.Polyps -> Adenomatous Polyps -> Ca
.small bowel polyps (low malignant potential) & gastric polyps (no malignant potential)
may also be found
FPC: begin screening colonoscopy @ 12-20 y age
Peutz Jeghers:
.colonic polyps have no malignant potential
.increased extraintestinal malignancies
Aster's USMLE Step3 Notes
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May 19, 2003
(Breast, Gonads, Pancreas)
.Colorectal Ca (+)
(few, flat, fast-progressing adenomas)
.40% lifetime risk of endometrial cancer
Right sided Colon Ca: Bleeding
Left sided Colon Ca: Obstruction
Hep D superinfection is more severe than co-infection
HAV infection: may have relapses
Acute Hepatic Failure: Encephalpathy in < 8w
Subacute Hepatic Failure: Enceph. in 8w - 6m
Chr. Hepatitis: > 6m
Anti-HCV: EIA -> if (-) -> confirmatory test RIBA
Chronic HCV infection:
ass. with cryoglobulinemia and Type2 DM (NIDDM)
Individuals with Hemachromatosis are susceptible to V. vulnificus, Listeria, Y
enterocolitica infections
Dx of Budd Chiari syndrome: Duplex Doppler U/S
Left Heart Failure:
increased liver enzymes (ischemic injury)
Right Heart Failure:
increased Bilirubin & Ascites (>> periph. edema)
Gastric Varices without Esophageal Varices: Splenic Vein Thrombosis
Mx: Splenectomy
#1 organism causing pyogenic liver abscess: E. coli
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May 19, 2003
OCP associated Liver Adenoma
(Mx: RESECTION even for asymptomatic cases)
Meperidine: least Sphincter of Oddi spasm
UC with pruritus: consider PSC
S. amylase can be increased in MUMPS ue to salivary gland involvement without
involvement of pancreatic gland [but S. Lipase would be normal in cases of
extrapancreatic elevation of amylase]
Antibiotic of Choice in Pancreatic Infections: IMIPENEM
decreases Breast Ca. / increases Endometrial Ca.
SERMs (Raloxifene):
decreases Breast Ca. / decreases Endometrial Ca.
Medical Adrenalectomy
Aminoglutethemide + Corticosteroids
HRT after Breast Ca. -> Raloxifene
IgE is not involved in anapylactoid reactions
(e.g. radiocontrast allergy)
CD3 : pan B cell marker
CD19: pan T cell marker
Dx of CREST syndrome is clinical
(not based on anti-centromere antibody)
Of all HLAs - HLA-DR compatibility is essential for long term graft survival
decreases CMI & decreases IL-2 (T-cell activation)
Steroids: decrease CMI
Cyclophosphamide: decreases CM as well as HMI
IFN-á: HCL, HepB & C, Kaposi's, CML
IFN-â: Multiple Scerosis
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Page 37 of 94
May 19, 2003
Acidosis due to Organic Acids is not assoc. with HyperK+ (cuz they freely permeate the
cell membrane)
Renal Glycosuria, Hyphosphatemia, Hypouricemia: FANCONI's
Commonest TA: Type IV RTA
(Hyperchloremic Hyperkalemic metabolic acidosis)
Thyroid Scan: I-123
Thyroid Ablation: I-131
Prerenal Azotemia: BUN/Cr > 20.0
L4: Knee Jerk & Sensory on Medial Calf
S1: Akle Jerk & Lateral Foot
PIVD L5 compression:
DORSIFLEXION of foot affected
PIVD S1 compression:
PLANTAR FLEXION of foot affected
[Ca][PO4] > 64 : predictive of metastatic calcification
Mx of Myedema Coma:
300-500 microg bolus of i/v thyroid hormone
followed by 50 microgram daily
Panhypoptuitarism presenting with Myxedema coma:
(to prevent Adrenal Crisis)
Allopurinol potentiates the action of Azathioprine: if used together, reduce
Azathioprine dose by 75%
Routine PIVD: MRI not indicated
(conservative Mx – resolve in 1-4 weeks)
PIVD with neurological deficits: MRI
Aster's USMLE Step3 Notes
Page 38 of 94
May 19, 2003
Lumbar Spinal Stenosis:
.Discomfort in Thighs on walking / standing
.pedal pulses preserved (PSEUDOCLAUDICATION)
.Ix: MRI
Urinary Catecholamines: sensitive
Urinary Metanephrine: specific
Urinary VMA: least useful
Mx of Fibromyalgia: TCA (NSAIDs are ineffective)
#1 functional pituitary adenoma: PROLACTINOMA
Pain in sole of foot after getting up in he morning: Plantar Fascitis (Mx: Arch Support /
ANA- sensitive
Anti-Sm: specific
Ant-dsDNA: correlates with disease activity
#1 vitamin deficiency: Vit. D
Polymyositis associated dysphagia:
oropharyngeal (striated muscle)
Scleroerma associated dysphagia:
esophageal (smooth muscle)
Muscle Biopsy findings in Dermatomyositis:
lymphoid infiltrate AROUND muscle fascicles
Muscle Biopsy findings in Polymyositis:
lymphoid infiltrate INSIDE muscle fascicles
Ix of choice: Muscle Biopsy (not EMG/NCV)
Woman with Joint Pains and Dental Caries : Sjogren's syndrome
GCA: associated with increased incidence of
Thoracic Aortic Aneurysms
Aster's USMLE Step3 Notes
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May 19, 2003
Ank. Spond. vs. SI joint involvement in Psoriasis:
lack of calcification in Psoriasis
Prompt Rx of NGU:
associated with decreased indcidence of REITER's
Whipple's: Joint symptoms precede GI symptoms
Synovial Fluid WBC count
< 200 normal
< 2000 noninflammatory (OA)
2000-50000 Rheumatoid Arthritis
50000-100000 Septic / Gout
> 100000 Septic
#1 Septic Arthritis: N gonorrheae
#1 non-gonococcal arthritis: S. aureus
#1 with IVDU/arthroscopy/prosthesis: S epidermidis
Recurrent Gonococcal Arthritis:
? C5-C8 deficiency
#1 cause of Osteomyelitis: S. aureus
#1 renal involvement after URI:
IgA nephropathy (1-2 days after URI)
PSGN occurs 1-3 weeks after Strep. infection
Nephrotic Syndrome:
#1 (Children): MCD
#1 (Adults): MGN
Dialysis :acquired renal cysts (? malignant pot.)
inflammation of Ligaments / Tendons
(Ankylosng spondylosis / Reactive Athritis)
Polycystic Kidney Disease:
associated with Berry aneurysms in circle of Willis
Multile Myeloma & Kidney:
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Page 40 of 94
May 19, 2003
Myeloma Kidney - LIGHT CHAIN Renal Toxicity
(light chains are not detected by urine protein dipstick)
Renal Amyloidosis - Heavy Chains excreted
(heavy chains are detected by urine protein dipstick)
Aging: decreasd GFR but S. Cr. remains constant ('cuz Lean Body Muslce Mass
decreases too)
Initial Hematospermia: Prostate
Terminal Hematospermia: Seminal Vesicle
RBCs: Hematuria
WBCs: Cystitis
RBC Cast: GN
WBC Cast: APN, Pyelonephritis
Acute Bacterial Prostatitis:
NO Prostatic Massage or Catheterization
Chronic Bacterial Prostatitis:
Prostatic massage -> C/S of expressed secretions
Ureteral Stones < 6mm:
Conservative Mx for 6 weeks
Asymptomatic Renal Stones: Conservative
F/U with serial X-Rays
Symptomatic Renal stones (Fever/Pain/UTI):
.< 3cm: ESWL
.> 3cm: PCNL
Urinary Incontinence:
Total: Sx
Stress: Sx is curative (Kegel/Pessary/Estrogen)
Urge: Antispasmodic / Anti-Ach / TCA
Overflow: Catheterize
Sildenafil (Viagra) c.i. in patients on Nitroglycerine
Right Ventricular Infarction:
Nitroglycerine precipitates HYPOTENSION
Aster's USMLE Step3 Notes
Page 41 of 94
May 19, 2003
Mx: I/V Fluids
70y old man with urinary obstruction and backache:
? Prostatic Ca with mets
Prostatic Biopsy: U/S guided biopsy > finger-guided
Prostatic Ca: Transrectal U/S = MRI for staging
(CT has no role)
Prostatic Mets: Radionuclide Bone Scan > X-Ray
Ix for suspected Bladder Ca.: CYSTOSCOPY
MEN II: hyperparathyroidism is due to HYPERPLASIA, not PARATHYROID
Testicular Neoplastic Mass:
Children: Embryonal Cell Ca.
Adult: Seminoma
> 50y: Lymphoma
Intracranial H'age (< 48h. duration):
CT without contrast is superior to MRI
Cerebellar Vermis:
Axial ataxia
Cerebellar Hemisphere:
“IPSILATERAL” Appendicular Ataxia
Frontal Lobe Lesions:
Personality Changes
Temporal Lobe Lesions:
Hallucinations/ deja vu / emotional changes
Parietal Lobe Lesions:
cortical sensory loss (astereognosis)
Occipital Lobe Lesions:
macular sparing field defects &
Aster's USMLE Step3 Notes
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May 19, 2003
Acoustic Neuroma:
first symptom is IPSILATERAL hearing loss
To measure severity of ASTHMA attack:
Peak Expiratory Flow Rate [PEFR] (not ABG)
Alcohol can temporarily decrease symptoms in BENIGN ESSENTIAL TREMOR
(intention tremor)
Myerson's Sign:
2 per second tap on nose -> sustained blinking
(seen in Parkinsonism)
Parkinsonism + Autonomic Insufficiency + Neurological Deficits
Progressive Bulbar Palsy (CN Motor nuclei): TONGUE WASTED
Pseudobulbar Palsy (UMN):
Peripheral Neuropathy:
AXONAL (NCV normal)
TT Leprosy: Neuropathy in area of skin lesions
LL Leprosy: Neuropathy > Skin Lesions
Tarsal Tunnel Syndrome
Pain, Paraeshesiae on bottom of foot
(Sparing of the HEEL)
Cervical Rib:
.Thenar Wasting
.Pain & Numbness on medial 2 fingers
(ulnar side of forearm)
Myotonic Dystrophy:
Aster's USMLE Step3 Notes
Page 43 of 94
May 19, 2003
Mx - Quinine, Phenytoin, Procainamide
Neuropathy: DISTAL ± Sensory Loss
NM Junction: Fluctuating Deficits
Myopathy: PROXIMAL weakness (NO sensory loss)
non-enhancing white matter lesions without mass effect (in AIDS): PML
Ix of Valvular Ht. Disease:
ECHO foll. by Catheterization (definitive Dx)
.Non-productive Cough
.Exertional Dysnea
.Fine Expiratory Crackles
.decreased DLCO
.increased A-a gradient
.gold standard for diagnosis: LUNG BIOPSY
Dx of Malignant Mesothelioma: Pleural Biopsy
100% of small cell ca. occur in smokers
Complicated Parapneumonic Effusions
.Gross Pus
.Gram Stain (+)
.Glucose < 50 mg%
.Pleural Fluid pH < 7.0
Severe Hyperkalemia Mx: Calcium Gluconate
Mx of Mg toxicity: Calcium Gluconate
1st test in asymptomatic hematuria:
1st test in suspected pneumonia:
CXR -> Sputum C/S
Currant jelly sputum: Klebsiella
Rusty sputum: Pneumococcus
Smokers / COPD: H. influenzae
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Page 44 of 94
May 19, 2003
Interstitial infiltrates: Mycoplasma
Empyema / Rapidly progressive: Staph. aureus
Pneumonia Rx:
Community acquired: Macrolide
> 60y or COPD/smoker: 2nd gen cephalosporin
Nosocomial: 2nd / 3rd gen cephalosporin
ICU (severe): Macrolide + Antipseudomonadal
Uncomplicated UTI: 3 day course of TMP-SMX
Native Valve Endocarditis - S. viridans
[â-lactam + aminoglycoside]
Prosthetic Valve Endocarditis (Early) - S. epidermidis [Vancomycin + Aminoglycoside]
Prosthetic Valve Endocarditis (Late) - S. viridans [Vancomycin + Aminoglycoside]
IVDU - S. epidermidis / S. aureus
[Vancomycin + Aminoglycoside]
IE prophylaxis:
- Amox 2g 1 hr. before Dental / GI / GU procedures
- penicillin allergy -> Clarithromycin
Don't delay antibiotics in Meningococcal meningitis
(even if LP is not done)
HAART: AZT+3TC & Indinavir
AIDS - avoid all live vaccines except MMR
Abdo. Pain: 1st investigation - AXR
UC: Pseudopolyps, Crypt Abscesses
CD: Skip Lesions, Fistulae
ddI can cause Pancreatitis
Aster's USMLE Step3 Notes
Page 45 of 94
May 19, 2003
RA: PIP involvement (DIP sparing)
OA: DIP involvement
Ix of choice in Osteoporosis: DEXA scan
Vaginal Candidiasis:
Topical Miconazole / Systemic Fluconazole (recurrent)
(Oral agents eliminate rectal reservoir of yeast)
PO Metronidazole 2g stat (Rx male partner also)
Bacterial Vaginosis:
PO Metronidazole 250-500mg x 7 days
(cf. single dose in Trichomoniasis)
Pap shows LGSIL (F/U reliable):
repeat Pap 4-6 months later
Women Smokers should always have annual Pap
Primary Dysmenorrhea: within 2 years of menarche
.inreased Prostaglandins
.arteriolar spasm
.uterine hypoxia
.Mx: (sexually active): OCP's
.Mx (sexually inactive / OCP c.i.): NSAIDs
#1 cause of DUB: Anovulatory Cycles
Mx: Hormonal Therapy===>Endometrial Ablation
Severe acute DUN with orthostatic hypotension
I/V Conjugated Estrogen
#1 STD: Chlamydia trachomatis
Ectopic (hemodynamically stable / no rupture):
Ectopic (Unstable / rupture):
Aster's USMLE Step3 Notes
Page 46 of 94
May 19, 2003
Salpingectomy or Salpingotomy
decrease Gonococcal STD
may increase Chlamydial STD (cervical ectropion)
Vaginal Spermicides:
decrease Gonococcal & Chlamydial STD
(no effect on HIV transmission)
Breastfeeding & OCPs: can use. Use low-dose OCPs
('cuz of effect on milk production, not because of infant safety consideration. Estrogens
do pass into milk in small quantity, but they are safe)
Hormonal Contraception for h/o DVT/PE:
Norplant & Depo-Provera [no OCP's]
I/V Cefoxitin or Cefotetan + Doxycycline
I/M Ceftriaxone + PO Probenecid + PO Doxycycline
Depression: Cognitive Psychotherapy
Adjustment Disorder: Supportive Psychotherapy
Anxiety Disorder: Behavioral Psychotherapy
Antidepressant Ladder:
.another antidepressant (except MAOIs)
.best tolerated agent + LiCO3
Lab Test for Cocaine:
Urine Benzoylecgonine (Cocaine metabolite)
Genital Herpes transmission occurs even in asymptomatic state
(Acyclovir decreases freq. of recurrences)
H'agic crust on "molluscum" like lesions in HIV pts. : Cutaneous Cryptococcosis
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May 19, 2003
HPV (Genital Warts)
Heaperd up lesions flesh colored lesions on penis
female partner has increased risk of Ca. Cx
Leprosy with painful red patches on extremities that become nectrotic and ulcerate:
LUCIO REACTION (seen in unreated leprosy, responds to Steroids)
Excessive use of Aluminium containin laxatives:
risk factor for postmenopausal osteoporosis
KOH Prep "meatball-and-spaghetti" appearance: Tinea versicolor
binge eating and purging behavior
(even without depression) : SSRI
Factitious Disorder : assoc. with child abuse
Somatoform Pain Disorder:
limit analgesic use
best managed in a multi-disciplinary pain clinic
Rx of choice for Panic Disorder: PAROXETINE [dependence might develop with
Mx of Social Phobia:
Mx of OCD: SSRI [Fluvoxamine]
Clomipramne is no longer the first line drug
Mx of PTSD: >1m; assoc. with life-threatening event
Group Psychotherapy
Anorexia nervosa:
75% have Depression, 25% have OCD
Buckman's 6 steps of Breaking Bad News
1. Getting started
2. find out how much the pt. knows
3. find out how much the pt. wants to know
4. share the info. a) Give Warning Shot
5. respond to pt.'s feelings
6. Plan F/U - give hope
Aster's USMLE Step3 Notes
Page 48 of 94
May 19, 2003
Skew: depends on direction of tail (not hump)
± 1 SD 68%
± 2 SD 95%
± 3 SD 99.7%
To increase power of a test: inrease sample size
Nominal or Ordinal Data:
Non-parametric Tests [Chi Square]
Interval or Ratio Data:
Parametric Tests [T-test, Z-test, F-test]
Correlation coefficient
Ordinal Data: Spearman Rank Order
Interval or Ratio Data: Pearson product-moment
r=correlation coeeficient
r2 (square)=coefficient of determination
(proportion of variation in one variable explained by variation in other)
Causality is only proven by properly conducted experimental studies
A test can only be 100% sensitive and specific if there is no overlap between
measurements in normal and diseased states
Higher the prevalence of a disease:
Higher the PPV of a (+) test
Lower the NPV of a (-) test
Untreated apendicitis in young female can cause infertility (peritoneal adhesions)
Appendiceal abscess: delay
Sx till inflammation has subsided
[the acute process has been walled off]
Cholangitis (ass. with CBD stones):
ERCP with Sphincterotomy + Lap Chole.
Skin Suture: cutting needle
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May 19, 2003
Deeper Layer Suture: Taper Needle
Ingrown Toe Nail
first episode:
antibiotics, elevation of edge -> wedge resection
Nail Removal
Anal Fissure: Local Steroid Cream / Sitz Bath
Anaesthetic of choice for skin lesion removal: Lidocaine + Adrenaline
(No Adrenaline for fingers and nails)
#1 type of breast Ca.: Infiltrating Ductal Ca. (80%)
Mx of Fibrocystic Disease: Low Dose OCP
Mx of Fibroadenoma: Biopsy (Excisional)
Danger Signs in Chronic Low Back Pain
- Bowel or Bladder dysfunction
- Impotence
- Ankle clonus
- Weight Loss
- Lymph Node enlargement
- Buttock claudication
- New Onset in age > 50 y
No imaging for routine chronic low back pain
Mx of Chronic LBP:
TCA's have the best cost/benefit ratio
[Muscle relaxants and NSAIDs have low effectiveness]
Dx of Childhood PCKD: > 2 cysts in EITHER Kidney
Dx of Adult PCKD: > 5 cysts in EACH Kidney
C/I to thrombolysis
- Sx < 2 weeks
- Unconrolled HTN
- Aortic Dissection
- h/o CVA / 'aic stroke / CNS tumor / AVM
- prolonged traumatic CPR
- allergy to thrombolytic agents
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May 19, 2003
- pregnancy
Risk Stratification in Unstable Angina
(Outpt.) Low - Onset < 2 weeks
(Telemetry) Medium - Onset < 2 weeks, Pain > 20 minutes but resolved @ present
(CCU) High - Rest Pain > 20 minutes and not resolved @ present
(CHF / Pulm. Edema / ST changes / Mitral Regurg.)
1st episode of syncope / low risk of heart disease:
Emperical Rx for IE:
Nafcillin + Ampi + Genta
(add Rifampin for Prosthetic Valve)
IE prophylaxis not reqd. for:
1. small ASD of secundum type
2.MVP without Mitral Regurg.
Acute Asthma:
Give Albuterol, O2, steroids -> assess response (PEFR, O2 sat.)
Good Response
PEFR > 80% of best (discharge with â-agonist)
Moderate Response
PEFR 60-80% of best
(hospitalize and continue medications, O2)
Poor Response
PEFR < 50% of best
(ICU admission)
(prepare for Intubation if silent chest, altered sensorium, respiratory failure)
Chronic Asthma
Mild Intermittent:
<2/week, nocturnal symp. < 2/month
(Inh â2-agonist)
Mild Persistent:
>2/week, nocturnal symp. >2/month
(Inh â2-agonist + Anti-LT)
Moderate Persistent:
Daily, PF 60-80%
(Inh â2-agonist + Inh. Steroids/Inh. long acting â2-agonist)
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Severe Persistent:
Continuous, PF<60%
(Inh â2-agonist + Inh. Steroids + Inh. long acting â2 / Anti LT)
SPN: Conservative Mx
Age < 45, nonsmoker, no inrease in size, size < 4cm
.Emollients / Keratolytics / Corticosteroids
.Tar / Calcipotriol / Anthracin
.Methotraxeate / Cyclosporin
Rx of Onychomycosis: PO Terbinafine
Acute Mastoiditis develops 2-3 w after acute otitis
Mx: Ceftriaxone / Sx drainage
Acute Bacterial Sinusitis: Pneumococcus
Chronic Bacterial Sinusitis: S. aureus
most serious form of sinusitis: FRONTAL sinusitis
d/o/c for Alzheimer's :
DONEPEZIL (OD dosing, no liver toxicity)
Upper Lips: BCC > SCC
Lower Lips: SCC > BCC
RCA stenosis: Saphenous grafts
Anterior Duodenal Ulcers: Perforation
Posterior Duodenal Ulcers: Bleeding
Acute Meseteric Ischemia: Embolization
Chronic Mesenteric Ischemia: Atherosclerosis
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Carcioid: Appendix > Ileal
(Ileal have higher chances of metastasis)
#1 GI malignancy: HCC (not colorectal Ca.)
#1 Liver neoplasm: Cavernous hemangioma
#1 Breast Lesion: Fibrocystic Disease
#1 Breast Malig.: Infiltrating Ductal Ca.
Indications for Hormonal Therapy for Breast Ca.
- Postmenopausal
- Nodes -
- ER +
Aortic Aneurysms
Type A: Sx
Type B: Sx if > 6 cm
Sx if > 5cm
#1 Congenital Heart Disease: VSD
#1 Cyanotic Heart Disease: TOF
ASD: Fixed Splitting of S2
Biliary Atresia:
Jaundice @ 2 wks of life, dark urine & acholic stools
Rx: Surgery (Roux-en-y portoenterostomy)
Neck Injuries:
Zone I : Arteriography -> Sx
Zone II : Sx
Zone III : Arteriography -> Sx
Mortality in Burns = Age + % BSA
1st degree: Leave Open
2nd degree: Clean,Sulfadiazine,nonadhesive dressing
3rd degree: Escharotomy + Skin Grafting
Sprain: Ligament Pull
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Strain: Muscle Pull
# Neck Humerus: Axillary Nerve Damage
# Shaft Humerus: Radial Nerve Damage
Quick Neuro Exam
Responds to Verbal Stimulus
Responds to Pain
O2, 2 large bore IV lines, IV fluids, EKG
- 100 mg Thiamine
- 1 amp 50% Dextrose
- 0.4 mg Naloxone
C/I to Foley's Catheter: (do retrograde urethrogram)
1. Blood at tip of urethral meatus
2. Perineal Eccymoses
Abdo. Trauma
#1 Injury in Blunt Trauma: Spleen
#1 Injury in Penetrating Trauma: Small Bowel
Indications for Exploratory Laparatomy in Abdo. trauma
1. Shock with Abdo. Injury
2. Pneumoperitoneum
3. Gunshot
4. (+) DPL
- Blood
- RBC > 100,000/mL
- WBC > 500/mL
- Food
- Bile
- Bacteria
Referral for Burns
- 3rd degree burns > 10% BSA, < 10 y, > 50 y
- 2nd degree burns > 20% BSA
- Electrical burns / Chemical burns
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May 19, 2003
- Inhalation Injury
- Perineal burns
- Radiation burns
#1 symptom of Parkinsonism: Tremor (Resting)
Benign Essential Tremor
.Intention Tremor
.Head Nodding
.temporary decrease with alcohol intake
S. pneumoniae: Rx - Macrolide or newer Quinolone (Levofloxacin / Gatifloxacin)
Majority of elderly patients with sepsis:
URINARY TRACT is the culprit
#1 cause of death in hospitalized elderly: UTI
#1 cause of death in institutionalized pts.: Bacterial Pneumonia
#1 cause of Urinary Incontinence: Urge Incontinence
Clean pressure ulcers with Normal Saline
(avoid Povidone-Iodine, Hydrogen Peroxide etc.)
Unimmunized with infected wounds
3 TT + 1 ATS
Stroke mortality is higher in WHITES than in BLACKS
indications for pneumococcal vaccine
1. Splenectomy
2. Sickle Cell
3. > 65 y
4. Chr. Cardio / Pulmonary / Renal Disease
4. Hodgkin's Disease
Continued Gastric Lavage for : PCP overdose
#1 Foods causing angioedema: Nuts / Seafood
#1 Drug causing allergy: Aspirin
Electronic Fetal Monitoring & Intermittent Auscultation of Fetal Heart have similar
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NST (Non-stress Test)
> 2 accelerations (in 20 minutes)
15 bpm lasting > 15 sec
>= 3 consecutive late decelerations in 10 minutes
< 20w. POG with HTN: Essential HTN
(not PIH or pre-eclampsia)
Bed Rest / (L) lateral position /
pharmacotherapy [á-methyldopa / labetalol]
#1 indicator of perinatal outcome in IUGR is:
presence of vertical pocket of Amniotic Fl > 3 cm
0-8 weeks : Embryo
8w-term : Fetus
0-14 weeks: 1st Trimester [Routine Ix]
14-28 weeks: 2nd Trimester [GDM Screen]
28-40 weeks: 3rd Trimester [GBS Culture]
<24 weeks: Previable
24-27 weeks: Preterm
37-42 weeks: Term
> 42 weeks: Post-term
Cervical Incompetence:
- Cerclage @ 12-14 weeks, till 36-38 weeks POG
Bishop Score:
<= 5: Prime (with Prostaglandins)
> 8: Induce Labor
#1 cause of PPH: Uterine Atony
Preterm ROM: @ < 37 weeks POG
Aster's USMLE Step3 Notes
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Premature ROM: > 1 hr before onset of labor
Prolonged ROM: > 18 hours before onset of Labor (Mx: Antibiotics)
Mastitis in breasftfeeding:
continue breastfeeding, Cloxacillin
Early Breast Milk Jaundice
.Exaggerated Physiological Jaundice
.Onset < 4 days of life
Late Breast Milk Jaundice
.Breast Milk Jaundice
.Onset 4-14 days
.competitive inhibition of glucuronyl ransferase by nonesterified long chain fatty acids in
reast milk
.Mx: Stop breastfeeding for 2-3 days /
Give Formula Milk [Jaundice comes down quickly] -> Resume Breastfeeding
Any jaundice @ Birth is PATHOLOGICAL
Success of Contraceptives
Norplant > OCPs > Barrier
Norplant: quick return to fertility
DMPA: 18 months for fertility to return
Complete Mole:
Diploid; 46, XX; has higher malignant potential
Kernicterus never occurs with:
.physiological jaundice
.exaggerated physiological jaundice
.breast milk jaundice
Features of Pathological Jaundice:
.present @ birth
.increase in bili. > 5 mg/dL/day on first day
.Bili. >12 mg/dL [term] or Bili. >14mg/dL [preterm]
.persists > 1 week of life
.Conjugated Bili. > 1 mg/dL @ any time
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May 19, 2003
Wessel Criteria for Infantile Colic
Unexplained Crying:
.> 3 hr/day,> 3 d/week, > 3 weeks, 3 m old child
.Do Urinanalysis
.No treatment necessary
.Bottle-fed infants have higher incidence
.Dicyclomine: risk of apnea
After a feed, allow "burping" and lay the child on
(R) side of abdomen
Introduce Solid Foods @ 6 months age
Vaginal pH < 4.5: Candida
Vaginal pH > 4.5: Bacterial Vaginosis
Transfusion Reactions
Fever: Leukoagglutination (donor WBCs)
Mx: acetaminophen
Anaphylaxis (donor proteins,severe in IgA-deficiency)
Mx: Epinephrine, Steroids
Hemolysis (ABO mismatch)
Mx: stop transfusion, hydration & diuresis
Familial Short Stature: NORMAL BONE AGE
Constitutional Delay: DELAYED BONE AGE
Short Stature with Webbed Neck is seen both in Turner's (XO) & Noonan's (normal
Sex chromosomes)
Budesonide has proven to be beneficial in Croup (along with racemized epinephrine)
Rx of choice for AOM in primary practice:
Amox ===> Cefaclor (if no response to Amox)
Transmission of Common Cold:
Indirect Spread is more important than Aerosol spread
Absolutely no antibiotics in common cold
(even if patient demands it!)
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May 19, 2003
Erysipelas: Gp. A â-hemolytic Srep.
Impetigo: Staph. or Strep. [Bullous - Staph.]
Coxsackie A16: Hand Foot Mouth Disease
Pitryasis rosea: Herald Patch
2 wks: GBS
2 wks - 4 m: Chlamydia trachomatis
#1 Bacterial: Strep. pneumoniae
4 months - 4 years: Mycoplasma pneumoniae
#1 Bacterial: Strep. pneumoniae
> 4 years: VIRAL
#1 bacterial: Strep. pneumoniae
Antibiotic Rx of Occult Bacteremia
does not decrease the occurence of meningitis
Yersenia entercolitica: can mimic acute appendicitis (no Rx necessary - self limiting)
ROTAVIRUS G/E is preceded by URI symptoms
Rec. Abdo. Pain Syndrome
- 10% prevalence
- school phobia
- no organic signs
- no Rx necessary
Growing Pains
- B/L deep pains
- can awaken child from sleep
Mx: exercize program
.overweight and sedentary "teenage" BOY
.Groin Pain/ Knee Pain
Dx: X-Ray
Mx: Surgical fixation
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.Avascular necrosis of femoral head
.hip pain or referred knee pain
(knee is NOT TENDER to palpation)
Osgood Schlatter
.tenderness over tibial tubercle
.aggraveated by activity
.occurs in pysically actve males around puberty
Mx: Limit activity, NSAIDs;
(if severe) Knee immobilization splint
Teenager with knee pain aggravated by climbing stairs: Patellofemoral Syndrome
Child with Limp / Hip Pain
- preceded by URI
- Fever (+)
- normal ESR
TOXIC SYNOVITIS [Sterile Hip Effusion]
Foot dorsiflexes easily
banana shaped sole: Congenital calcaneovalgus
kidney bean shaped sole: Metatarsus adductus
patella points forward: Internal Tibial Torsion
patella points medially: Excessive Femoral Anteversion (#1 cause of intoeing in
CTEV: inability to dorsiflex
Mx: progressive serial casts,
posteromedial release of heel cord
#1 substance of abuse: Alcohol
Nocturnal Enuresis
.> 4 years
.majority of children do NOT have any physical or psychiatric disorder
.Mx: Behavioral modification
Bell / Buzzer system
d/o/c: dDAVP (no longer IMIPRAMINE)
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Encopresis: > 4 y.
Enuresis: > 5 y.
Allergic Rhinitis:
.Hyperemic Nasal Mucosa
.Clear Discharge
.Bluish-purple rings around eyes (SHINERS)
.Ix: Nasal smear for Eosinophils
.Mx: elimination / inra-nasal corticosteroids
Child with rash on introduction of "whole milk":
Atopic Dermatitis
Mx: Cow Milk ----> Formula Milk ----> Soy Milk
(Cow milk allergic might show allergy to soy milk, too)
Diaper Rash
.Candidal: Satellite lesions
.Primary Irritant Dermatitis:
maceration with sparing of henitocrural folds
(Mx: frequent changing, washing,
no occlusive plastic pants, ZINC OXIDE,
Innocent Murmur in Children
.prevalence: 50%
.accentuated by sitting, anxiety, fever, tachycardia
.mid to low sternal border
.no thrill
.vibratory or musical in quality
[Still's Murmur]
Common Cold: Steam Inhalation provides superior relief of nasal congestion cf.
.Decongestants (sympathomimetics) :
can cause CNS overstimulation
.Cough Suppressants (Dextromethorphan) :
can cause respiratory depression in children
#1 complication of sickle cell disease
Painless Hematuria (Paillary Necrosis)
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Priapism in Sickle Cell Disease
> 6 hrs. : Hospitalize
no effect on future erectile function
may respond to Nifedipine / NTG
Complications of Sickle Cell Disease
- Hemolytic Crisis
- Vaso-occlusive crisis
- Aplastic Crisis
- Splenic sequestration crisis
- Renal Papillary Necrosis
- LOwer extremity skin ulcers
- Proliferative retinopathy
Mx of HbS disease
.Pneumococcal vaccination
.FOLATE supplementation
.Prophylactic antibiotics (Penicillin till age 5)
.Narcotic analgesia for pain crisis
.CVA: Exchange transfusion
.Painless Massive Hematuria: e-ACA
.HydroxyUrea for frequent vaso-occlusive crisis
.Bone Marrow Transplantation
(Age < 16, availability of Bone Marrow Donor)
STROKE / TIA in Sickle cell disease is an indication for exchange transfusion to keep
the HbS < 50%
HbS disease 'per se' can lead to restrictive lung disease -> hypoxemia -> increased
sickling tendency
Avoid use of MEPERIDINE in severe chronic pain (short T1/2)
Malignant Hyperthermia:
Symp. AORTIC STENOSIS: high perioperative risk
In preop pts. with A. Fib. : achieve rate control
In preop pts. on Diuretics : Get Electrolyte Levels
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May 19, 2003
Avoid elective surgery in patients with
significant hepatic dysfunction
Indications for Intra-op Insulin
- IDDM : any surgical procedure
- NIDDM on Insulin : any surgical procedure
- NIDDM on OHA : major surgical procedure
Prophylactic preop antibiotics only decrease the incidence of wound infection
(no effect on postop pneumonia, UTI, sepsis) : CEFAZOLIN is a good choice
elderly with repeated falls with dementia / seizures:
look for chronic SDH
stool impaction can cause urinary incontinence
Breast Cancer with BRCA1 gene: Better prognosis
Breast Cancer with HER2/neu gene: POOR prognosis
Kaposi's: HHV8 (Male Homosexuals)
Cyclophosphamide: Mesna
Methotrexate: Leucovorin
Cisplatin: Amifostine
Doxorubicin: Dexrazoxane
Mx of chemotherapy induced dry mouth:
Pilocarpine Hcl 5-10 mg PO TDS
Assessment of Doxorubicin toxicity: MUGA scan
requires antibiotic prophylaxis for G(-) / fungus
Competent individuals @ the end of life have right to refuse nutrition and hydration
Cutaneous absorption of drugs is 3 times more in children than in adults
Topical drugs c/i in pregnancy
1. Podophyllin
2. Isotretinoin
3. Lindane
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most appropriate initial investigation in â-Thalassemia: CBC with red cell indices
SLE: decreased C3/C4
Dumping Syndrome post-Bilroth II
- Dietary modification
- Octrotide
- (fails) Bilroth I conversion
75%-95% of AAAs are infra-renal
- Dx: U/S abdo.
Food poisoning: < 6 hrs. after food intake
- S. aureus (mayonnaise / salad dressing)
- B. cereus (fried rice)
> 16 hours / poultry consumption: C. jejuni
Carbamazepine intoxication
- QRS prolongation : predisposes to
- QT lengthening
Defib. followed by pulseless electrical activity
- Hypovolemia
- Hypoxia
- cardiac tamponade
- pneumothorax
- massive pulmonary embolism
- drug toxicity
- hyperkalemia
- acidosis
- massive MI
Coarctation of aorta is associated with
Bicuspid aortic valve in 70% cases
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May 19, 2003
#1 cause of GI h'age following AAA repair is:
Colonic Ischemia (not stress gastritis)
Early onset wound infections: Strep / Clostridium
Visuospatial: Alzheimer's
Gait disturbance / Urinary Incontinence: NPH
Delayed DTR: Hypothyroidism
Myoclonus: CJD (Creutzfeld Jacob Disease)
Alzheimer's with agitation: use HALOPERIDOL
(not BZDs -> they can aggravte agitation)
Testicular tumors
.#1 seminoma
.increased incidence in cryptorchidism
.metastatize to retroperitoneal nodes
.inguinal nodes involved only with scrotal spread
.Children: Embyonal Cell Ca.
.Adults: Seminoma
.> 50 y: Lymphoma
.Dx: Testicular Ultrasound (no BIOPSY)
Mx: Inguinal exploration & cross clamping of cord
& Orchiectomy
.increased tidal volume
.decreased BP (decreased TPR – progesterone)
.Hb decreases (dilutional effect)
TV U/S > sensitive cf. Abdo. Scan for ectopic preg.
Fat Embolism: associated with Eosinophilia & Lipiduria
Shoulder Pain
Rotator Cuff Injury:
best elicited by positioning of the reater tubercle of humerus beneath acromion
Subacromion bursitis:
elicited by palpation over deltoid
Biceps tendinitis:
aggravated by flexion or supination of elbow
Acromioclavicular arthritis:
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elicited by crossed arm adduction against resistance
at admn. @ 48 hours
Age > 55 Fall in Hct > 10%
WBC > 16000 Fluid deficit > 6L
Bl. Glu > 200 S. Ca++ < 8.0
LDH > 350 PaO2 < 60 mmHg
AST > 250 BUN increase > 5 mg/dL
Base deficit > 4 mEq/L
Rx of sigmoid volvulus: Sigmoidoscopy
(Sx required if s'copy fails)
Hemodialysis in CRF
.Unresponsive Volume Overload
AIDS Chemoprophylaxis
CD4 < 200: PCP
CD4 < 100: Cryptococcus
CD4 < 50: MAIC
Cryptococcal Meningitis: very high CSF pressure
(serial lumbar punctures may be warranted)
#1 cause of inracranial mass lesions:
Metastasis (not primary brain tumor)
#1 benign liver neoplasm:
HEMANGIOMA (not Hepatic Adenoma)
Propylthiouracil: can cause agranulocytosis
smoking is a relative c.i. to OCPs - not absolute
#1 cause for osteomyelitis: S. aureus
Bed Rest has no proven benefit in chronic low back pain & threatened abortion
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Significant Hematuria: > RBCs/HPF
Significant Pyuria: > 10 WBCs/HPF
increased PEEP causing hypotension/hypoxemia -> consider pneumothorax
Confirm erythema nodosum by SKIN BIOPSY (Conservative Mx) -> Steroids for
persistent Pain
Change in Antipsychotics should be done
within 2-4 weeks, if no desired effect
Ice should not be applied on snake bite site ->
can delay efflux of venom by causing vasoconstriction
Severity of AS: late peaking murmur & delayed and weak carotid upstroke
Hymenoptera anivenom is not available
Even after treating anaphylaxis with S/Q Epinephrine -> monitor patient in ED
(patient is not risk-free, complications can develop)
#1 cause of fever in AIDS, without overt symptoms: MAC (Rx Ethambutol +
#1 cause of Seizures in AIDS: TOXOPLASMOSIS
#1 cause of dysphagia in AIDS:
Candidal Esophagitis
Suspected child abuse:
inform child protective services
(Hospitalize only if child's conition requires it)
ITP : improvement with splenectomy but platelet counts falls again (Ix:
radionuclide spleen scan for splenic remnant)
HSP: usually remits in 1 week (Mx is conservative) - Leukocytoclastic vasculitis
#1 cause of hematuria after URI: IgA nephropathy
ABI < 0.4 - sever vaso-occlusive disease
Mx: surgical revascularization
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Oliguria in hospitalized pt. -> assess pulmonary wedge pressure (to diff. hypovolemia
and ATN)
Fibrinogen is the most abundant acute phase reactant (responsible for increased ESR)
Age, Myeloma, Macroglobulinemia, Hypoalbuminemia increase ESR
Number-needed-to-screen is reciprocal of absolute risk reduction
Celiac Sprue: dermatitis herpetiformis Mx: Dapsone
Localization of extra-adrenal phaeo: MIBG scan
suspected phaeo
1.catecholamine levels
2.if levels elevated, Imaging
(imaging, done first, will lead to detection of incidental adrenal masses – high
Preop prep in Phaeo
full á blockade followed by â blockade (not vice versa)
Antidote for Mg toxicity is Calcium Gluconate
Mild pre-eclampsia: Bed Rest and Monitoring
Severe pre-eclampsia: Hospitalization,
Control of HTN, MgSO4 infusion
Dx of Hemachromatosis (Gold Standard):
Hepatic Iron Index (not HFE Gene analysis)
#1 cause of TEN : Adverse Drug Reaction
Rapid Correction on HypoNa: CPM
Frozen shoulder = adhesive capsulitis
takes months to regain full function
(steroid injections can hasten recovery)
Orchiopexy in Cryptorchidism @ 1 year age
Orchiopexy deceases the proportion of seminomatous malignancies - but total risk of
malignancy stays the same
Aster's USMLE Step3 Notes
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Urine dipstick only detects albumin,
24 urinary protein assessment detecs all proteins
(Myeloma light chains will not be detected by dipstick)
Bone scan has no role in lytic lesions of myeloma
Hypotension in Meningococcemia:
Waterhouse-Frederrikson syndrome
Macrolide antibiotics prolong QT interval:
Sinusitis / Bronchiectasis / Infertility / Situs inversus
Disulfiram : slow excretion from the ody. Adverse reactions can occur even 1-2 weeks
after cessation of therapy. Disulfiram is not an option for long term alcohol abstinence
Statin therapy: monitor LFTs regularly
(CPK only if rhabdmyolysis is suspected)
Intravascular Catheter related infection :
Staph. epidermidis / S. aureus
(use Vancomycin, cultures pending)
Arterial Clots: Anti-PL antibody
Venous Clots: #1 inh. cause: Factor V Leyden
Postcoital contraception: is not 100% effective
(Progestin-only Pills are safer than OCPs)
HIRUDIN: is a direct thrombin inhibitor approved for use in pts. with Heparin-induced
Pulmonary Embolism: CXR is usally NORMAL
#1 finding on EKG: Sinus Tachycardia
- Hampton's Hump: seen in Pulmonary Infarction
- Westermark's Sign: sign of Pulmonary Oligemia
Meningococcemia: seen in C5-C8 deficiency
Meningococcal vaccine: Polysaccharide vaccine (A,C,Y,W135)
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Neutropenia with Fever: (Neutropenia = < 500/mcL)
suspect Pseudomonas
Piperacillin/Tazobactam & Gentamycin
(or Ceftazidime)
if central line is present: Add Vancomycin
[Continue antibiotics even if cultures are negative]
Indomethacin: can decrease amniotic fluid production
Indications for CONIZATION
1. non-visualization of transformation zone
2. "pap" worse than bopsy
3. AdenoCa.
4. (+) endocervical cuerettage
5. Microinvasion on Bx
(+) F/H is not a risk factor for Ca. Cx
Neuroblastoma metastasis:
can cause periorbital ecchymosis / proptosis
- increased urinary VMA
- N-myc gene
PEPTO-BISMOL: affects platelet function
(can prolong bleeding time)
"popcorn" calcification in SPN : Hamartoma
Mx of SIADH: Fluid Restriction
Mx of malignant SIADH: Demeclocycline
"pop" or snap in knee : ACL tear
[Knee Immobilization / Crutches]
post-URI abdo pain / vomiting / RUQ mass in a child: ? Intussusception [Barium Enema
- Rx & Dx]
Legitimate Vanco. use :
â-Lactam resistant Staph. epidermidis
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Vit. A toxicity can cause Hypercalcemia
Gatsric ulcers: located on lesser curvature
within 1cm of gastric antrum
Adrenal Mass > 4cm & High Hounsfiled Values:
high chance of being malignant
Most ensitive test for Cushing's:
24 hour urinary cortisol
(levels are subject to diurnal variation)
Bilroth II:
Afferent Loop Syndrome (Pain after meal ingeston) Mx: Bilroth I conversion, roux-en-y
Blind Loop syndrome (bacerial overgrowth, malabs.) Mx: antibiotics
â-Thalassemia major: HbF increased
â-Thalassemia trait: HbA2 increased
Risk of Postop DVT
#1 Elective Knee Arthroplasty
#2 Elective Hip Arthroplasty
#3 Hip # Repair
Cocaine use assoc. MI:
combination of spasm and plaque rupture
(don't assume spasm is the cause, do angiography)
Pappenheimer's Bodies: Iron inclusions in RBCs
Hypocalcemia, Hyperkalemia, Hyperphosphatemia
Diverticulosis: #1 complication - BLEEDING
85% bleeds stop spontaneously
(#1 complication is not Diverticultis)
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.Broad spectrum antibiotics
.no barium enema / colonoscopy
h/o Malig. Hyperthermia with succinylcholine:
use NITROUS OXIDE in future anesthesia
Chronic Fatigue with normal physical exam: DEPRESSION INVENTORY -> Thyroid
IE -> Mycotic Aneurysm -> Bleeding -> SAH
[embolization of bacteria to the brain)
IFN-â: decreases relapse frequency in MS
First Episode of DVT:
Heparinize -> Warfarin for 3-6m (INR 2.0-3.0)
Recurrent DVT:
Lifelong "Warfarin"
[if Warfarin is not tolerated : ENOXAPARIN]
Fever / Sore Throat / Atypical Lymphocytes
(without LN / Splenomegaly / MonoSpot) : CMV
Colles' #: splinting in NEUTRAL postion
(not in FLEXED position)
PSA levels in Prostatic Ca. correlate with lymphatic spread
Antibiotics in postpartum endometritis:
I/V Imipenem / Cilastatin
Vaginal Delivery in Breech
2. Fetal Weight between 2000-3000g
3. Gynecoid Pelvis
Rx of Catatonia: Lorazepam
Incisions done for pre-existing infections and abscesses are considered INFECTED
Severe Depression with Psychosis: Mx with ECT
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Hypertensive Heart Disease: S4 Gallup (LVH)
Depo-provera: - associated with Irregular bleeding
(use conjugated estrogen x 7 days to control bleeding)
Peak CPK levels:
give idea about size of an infarct
(no prognostic value)
Nephrolithiasis with increased Creatinine:
IVP can not be done
(No I/V CONTRAST in the setting of renal dysfn.)
Renal and Bladder Ultrasound Scan, instead
HTN in Graves' disease: Rx with â-blockers
Anti-Ro: associated with neonatal Lupus
(resolves in 6 months) and Congenital Heart Block
Lupus anticoagulant
.recrrent abortions
.thrombotic state (arterial + venous)
."in vitro" increased PTT
(doesn't correct with mixing)
.Russel Viper Venom Time
Doxepin (a TCA) is useful in chronic urticaria
suspected ADHD: get psychometric tests
Misleading Low Sodium is caused by Hyperglycemia
Mx of acute mountain sickness: acetazolamide
Dx of Sarcoidosis:
.Kveim test is obsolete
.ACE levels are elevated in 50% pts.
Rx of Brown Recluse Spider Bite: DAPSONE
Middle Ear Effusion persisting for 4-6 months following an adequate course of
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antibiotics, with significant hearing loss (especially bilateral), is an indication for
myringotomy and insertion of tympanostomy tubes.
Chlamydial Ophthalmia:
(to prevent chlamydial pneumonia)
Appropriate Initial Test for suspected B12 def:
Serum B12 levels
(many patients have normal CBC and normal indices)
fruity breath odor: ketosis
prolonged latent phase of labor :
.therapeutic rest & sedation (usually morphine).
.No Oxytocin / No Amniotomy
DtaP contra-indications:
1.previous febrile reaction: fever > 105 F
2.h/o seizures
(F/H of seizures is not a contra-indication)
Rx of choice for SVC syndrome:
First HiB vaccine @ 2 months age
Female > 40y with abnormal vaginal bleeding Endometrial Bx to r/o Endo. malig.
Atrial Flutteris not a serious arrhythmia, but cardioversion should be attempted in the
presence of CHF.
Atrial Flutter due to Digitalis toxicity:
Anorexia nervosa:
BUN increase
Low Platelet Count
Leukopenia with relative lymphocytosis
elevated serum carotene levels
Legionaire's disease:
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Person-to-person spread has not been documented
Childhood obesity is not a predictor for adult obesity
long-term Rx of obesity in children : usually fails
Thoracic outlet syndrome:
appearance on numbness and paraesthesiae
with arm abducted to 90 degrees and externally rotated
(not defined by the disappearance of radial pulse)
Postmenopausal with stress incontinence:
Kegel exercizes, pessary, estrogen replacement
Retractile Testes:
.exaggerated cremasteric reflex
.resolves in adolescence
.no increased risk of malignancy
Flail Chest: Intubation & Assisted ventilation
(Strapping of Chest may lead to hypoxia & atelectasis)
Vaginismus is involuntary contraction
Behcet's: cutaneous hypersensitivity
60-70% will develop a sterile pustule within 48 hours of any aseptic injection
epidydimitis -> check age of pt.
< 35: Chlamydia, Gonococcus
> 35: E.coli
Gold stadard for diagnosis of melanoma:
Treatment of alcoholism in wife-batterers does not treat battering behavior
Pt. with hemoptysis and normal chest film:
Fibre-optic bronchoscopy
(PPD is not indicated)
F/U COPD progression with FEV1
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Tick paralysis (neuro-toxin mediated): 10% mortality
prompt resolution if tick is identified and removed
Let children attend funerals, if they want to. They should be accompanied by adults who
can provide comfort and support
Hyperparathyroidism: inc. incidence of Pseudogout
NIACIN: can be associated with hepatotoxicity
rear-facing infant seats should be on the back seat.
< 12 y children: ride secured on car backseat
Headache onset with exertion, such as weight-lifting:
serios sign (look for CNS malformations & vascular malformations)
Minocycline: has anti-inflammatory action
(has been used in Rheumatoid Arthritis)
Gynecomastia in adolescence: Observation
Long standing Gynecomastia: SURGERY
HCM: EKG is abnormal (LVH, WPW, abnormal Q wves)
Ticlopidine: has been associated with neutropenia
Immediate gastric lavage is ot indicated in strychnine poisoning
Continuous gastric lavage: PCP overdose
Not all persons with anaphylaxis will have a repeat
reaction when exposed again to the agent. Repeat reactions are usually less severe.
Head, Neck, Face sutures:
leave in place for 3-5 days (rapid healing)
Eclampsia: MgSO4
(no role of anticonvulsants)
Clonidine withdrawl: Hypertensive Crisis
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May 19, 2003
The woman's need for physical intimacy often increases during pregnancy.
Abstention from intercourse in the last month of normal pregnancy is not necessary
Valsalva maneuver decreases the venous return to the heart, thereby decreasing
cardiac output. This decreases murmurs due to AS, MR, PS, but increases the
murmur due to HCM
FOBT testing does not decrease the mortality from colorectal carcinoma
#1 symptom in vaulvar carcinoma: Pruritus
Of the anticonvulsant, VAPROATE has the least effect on hepatic enzymes and
therefore has the least impact on decreasing the efficacy of OCP's
Gilbert's syndrome: lower levels of unconjugated bilirubin cf. Crigler Najjar (6-45 mg/dL)
Menopause: Serum FSH increased
Estradiol decreases, and Estone becomes predominant estrogen.
Infiltration of local anesthetic agents (less pain):
.warm solution
.small needles
.slow infiltration
.addition of bicarbonate to the mixure
Mg-containing antacids in CRF:
can cause magnesium toxicity
Postherpetic neuralgia: higher incidence in older pts.
ANA titre < 1:160 is common in healthy older people
Orthostatic hypotension:
Drop in Systolic > 20 mmHg
Drop in Diastolic > 10 mmHg
Mx: discontinue any drugs that might be responsible
-> arise slowly -> elastic stockings -> Fludrocortisone
B pertussis is being recognized as a cause of
persistent cough in adults. (associated with dysnea, tingling sensation in throat)
d/o/c for Giardiasis in children: Furazolidone
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Tinea capitis: Oral Griseofulvin
poor response to topical medication
Males with impotence, decreased libido & decreased testosterone: order a prolactin
(r/o pituitary adenoma)
Pre-term infants: normal response to immunization
(although they have relative immunodeficiency)
Drug indiced LE: anti-histone antibodies
[ANA (+), Anti-dsDNA absent]
.hydralazine, isoniazid, procainamide, penicillamine
.Mx: discontinue medication + short-course of glucocorticoids
.disease lasts < 6 months
.ANA may remain (+)
.most lupus inducing drugs can be safely used in SLE, if no alternative exists
HCM: sudden death in athletes
Dx: Echo Rx: â-BLOCKERS
Valsalva maneuver increases murmur
ITP: low platelet, BM aspiration shows numerous megakaryocytes
Risk of suicide: Female Physicians > general females
Physicians' risk of suicide
Psychiatrists > Ophthalmologist > Anesthesiologist
Anaphylaxis: Epinephrine
Juvenile Rheumatoid Arthritis:
very few patients are left with disabilty / deformity. At least 50% remit fully and majority
regain normal function
Urticaria > 48 h :
Skin Biopsy to r/o Urticarial Vasculitis
Mobitz Type II Heart Block: Mx is PACEMAKER
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Stage IA Hodgkin's: Radiotherapy alone is effective
Total Hip replaement:
.immediate relief
.perioperative anticoagulation
.successful (no need for revision in 90%)
.bone resorption is a major concern for long-term stability of implant
Pressure Ulcers:
Stage I: Nonblanching Erythema
Stage II: Broken Skin with partial thickness skin loss
Stage III: Full tickness skin loss (extension into subcutaneous fat)
Stage IV: Extension into Muscle or Bone
"kennel cough" is produced by a canine Bordetella
Risk factor for domestic abuse: female gender
Trochanteric bursitis
.presents with a deep, dull, aching pain
.burning & tingling in lateral upper thigh
.worse with activity
.excacerbated by sitting cross-legged with affected leg
The mortality rate for pneumococcal pneumonia is same for the past 50 years
SKIN SWELLING with Bee sting: local reaction
[not anaphylaxis]
Rx of Restless Leg Syndrome: Clonazepam
Alendronate: Pill-induced esophagitis
TCA withdrawl symptoms (cholinergic symptoms) : best managed with Benzotropine
Aspartame is c.i. in children with PKU
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Diaphragm & spermicidal jelly:
insert upto 2 hrs before intercourse
and leave in place for 6 hrs after intercourse
(for repeated intercourse, re-apply jelly)
Asthmatics who require â2-agonists > once/day; can be prescribed inhaled
Psoriasis in infancy: begins n diaper area (the area of greatest trauma)
Labia minora adhesions:
.not present @ birth
.acquired condition
.no urinary retention
.not assoc. with other anomalies
.surgical correction has a 100% recurrence rate
.estrogen cream can lyse the adhesions
Carbidopa/Levodopa do not alter the progression of Parkinson's disease
Chronic Choleystitis with Cholelithiasis is frequently non-visualized on ultrasound.
Umbilical hernia in a child < 6m
Mx: Conservative [Strapping is ineffective]
(usually disappear by 1 year of age)
Surgery for strangulated hernia; persisting beyond 4y
Increased Postop Cardiac Death
.S3 Gallop
.h/o MI in the past 6 months
.Frequent PVCs
.Aortic Stenosis
Supression of lactation: breast inder & cold pack
[Bromocriptine is not approved for this purpose]
Cardiac Pacemaker: does not warrant IE prophylaxis
Pubertal development in an adolescent girl:
Thelarche, Pubic Hair, Growth spurt, Menarche
(Growth spurt precedes Menarche)
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Most sensitive and specific means of diagnosing appendicitis is history and physical
(not CT or U/S)
In stroke, overzealous antihypertensive medications can reduce cerebral perfusion and
increase tissue damage.
Scabies in young children:
[Lindane not approved]
Wheezing in children may also be due to GERD
A single sexual encounter with a person with genital warts carries a 60% chance of
transmission. Transmission occurs in asymptomatic state too.
Hydrocephalic children:
.increased developmental disabilities
.lower IQ
.learning deficits
.defective verbal abilities
.memory and visual problems
Chlamydial infections:
Azithromycine & Doxycycline have equal efficacy
#1 cause of hematemesis in healthy newborn:
comiting of swallowed maternal blood
Clinical privileges to physicians are granted by the GOVERNING BODY of the hospital
New onset LBBB may be an indication for thrombolysis even in the absence of
characteristic ST elevation of MI
Dexfenfluramine: 1º Pulmonary Hypertension
Transdermal NTG Patches: Rapid Tolerance
Oropharyngeal dysphagia in elderly:
? early Parkinson's
Paget's disease of bone:
.Head Enlargement
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.Nerve compression
.increased urinary hydroxyproline
.increased alkaline phosphatase
HIDA scan: Cholecystitis (+)
.nonvisualization of the GB
.visualization of CBD & Bowel
Leading cause fo mental retardation in US:
Fetal Alcohol Syndrome
Rotavirus G/E: decreased incidence in breast fed infants. None of the antibodies that
develop after the first attack are protective
Grade 1 Vesico ureteral reflux:
prophylactic antibiotics and double voiding of urine
Sodium Nitroprusside infusion:
may increase Thiocyanate levels to toxic range (delirium, tinnitus, blurred vision)
Allergic bronchopulmonary aspergillosis is treated by corticosteroids (not
Childhood autism:
Echolalia, minimal eye contact, repetitive behavior
serum digoxin levels elevation can be seen in pts. treated with oral verapamil
Recurrent Zoster is rare
Cocaine > Coronary Spasm
(free basing can lead to loss of eyebrows/eyelashes)
Measles vaccine significantly reduces the chances of developing SSPE
Influenza A is usually sensitive to Amantidine
(resistance occasionally seen in institutionalized pts.)
Synovial Fluid in OA : High Viscosity
Children with diarrhea who are not dehydrated should be give age appropriate diet
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Loperamide: contra-indicated in children
Secondary Amenorrhea: give Progestin Challenge
Rapidly Progressive Periodonitis (with good dental hygiene) might be suggestive of
Hyperosmolar nonketotic coma:
.require less insuin for correction (cf. DKA)
.Fluid deficit is larger (cf. DKA) (10 L)
.patients are older
.can also occur in Type 1 DM
The hypochondriac believes that his fears about disease are totally realistic. He also
believes that physicians are not acting in his best interests by disputing the reality of
these fears.
poor response to antidepressants
Old age:
Vital Capacity decreases
Functional Residual Capacity increases
Arterial Oxygen Tension slowly declines with age
Pasturella multocida:
Rx Amox-Clav
(Pn allergy: Doxycycline) [NOT ERYTHROMYCIN]
Place PPD on all individuals being admitted to a nursing home. Persons with doubtful
reactions should be tested a second time within 1-2 weeks (boosted reaction). This
second reading should be taken as the baseline reading for that person.
Tennis Elbow : Lateral Epicondylitis
(usually acquired occupationally)
Obesity lowers aminoglycoside volume of distribution necessitating decrease in
Primary indication of joint replacement in OA:
Severe Pain
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Postcoital test : best done in midcycle
Adhesive bands are now the most common cause of intestinal obstruction for all age
(strangulated hernias are the m/c cause in children)
Rx for ANUG (acute necrotizing ulcerative gingivitis) PENICILLIN
Vasoldilators of choice for CHF
Use of TCAs in patients with glaucoma can precipitate acute angle-closure attacks (antcholinergic
The only absolute contra-indication to breast feeding is
Major abdominal trauma in 3rd trimester pregnancy:
evaluate for placental abruption & preterm labor
[electronic fetal monitoring: obtain reactive NST]
Transient cortical blindness due to mild head traums usually recovers (benign outcome)
Pneumococcal vaccine: not before 2 years of age
#1 cause of microscopic hematuria in elderly is BPH
Polychlorinated Biphenyls: skin rash called Chloracne
Ludwig's angina: infection of the deep fascial space of the submandibular space (early
airway compromise)
Mx: Intravenous steroid cover
Wilson's disease confirmed by inability to incorp. a copper isotope into Ceruloplasmin
Patients with procaine allergy usually tolerate Lidocaine (amide group) well
Always inject insulin in skin of non-exercized areas (to prevent exercize-induced
hypoglycemia). If the lefg is used as injection site, insulin absorption will be enhanced
with running leading to hypoglycemia.
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Celecoxib: not to be used in patients with SULFA allergy
Passengers with stable medical conditions requiring low-flow oxygen cannot bring their
own oxygen on aircrafts according to Federal Air Regulations concerning hazardous
cargo. Most air carriers will provide O2 for a fee
Do not fly within 3 weeks of a MI
No air travel with term pregnancy
.Response prevention & in vitro exposure
Don't give OPV to a child whose sibling is immunodeficient
Post MI Risk Stratification is done with an Exercize Stress Test (for patients who can
exercize). For patients who can not exercize, a Pharmacological stress testing or
Dobutamie Echo is indicated (both are less sensitive than Exercize Stress Testing)
Continue ASPIRIN in the post-MI period
Antiplatelet agent Post-stent placement:
Clopidogrel (ADP receptor inhibitor)
Abciximab (anti-IIb/IIIa)
(decrease restenosis rates)
The choice of agents in asthma therapy is determined by frequency of asthma
The presentation & management of acute cholecystitis in pregnant patients is the same
as in non-pregnant population (Lap Cholecystectomy). Fetal otcome is the best in 2nd
Hyperactive children: hypoperfusion in frontal lobes
NPH: order CT scan head to r/o ICSOL
(confirm NPH by documentation of improvement in symptoms with serial lumber
Severe pre-eclampsia:
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.delivery @ term
.MgSO4 for seizure prophylaxis
.antihypertensives for BP control
.MgSO4 is not an antihypertensive.
.Control of BP alone does not obviate the need for seizure prophylaxis
Suspected PCP in AIDS: Obtain a Chest X-Ray
Migraine prophylaxis: â-blockers
Migraine treatment: Sumatriptan
Somatization disorders: 1st step in Mx
avoid un-necessary Ix & medical/surgical treatment
Community acquired pneumonia: S pneumoniae
Rx: Macrolide (Clarithromycin)
Patient presents to the office with unstable angina:
1st step: Chew & Swallow Aspirin
Vaginal douching > 3-4 times / month:
associated with alteration of vaginal flora and increased incidence of PID
Prolonged survival in CHF: ACEI's
A fecal gram stain is always positive for bacteria and is not indicative of any pathology.
Inflammatory Bowel Disease: Fecal Leukocytes(+)
Gold standard for Dx of IBD: COLONOSCOPY
Critical Aortic Stenosis: Valve Repair Surgery
(Valvuloplasty in high risk due to other co-morbidity)
Spinal metastasis: Emergent Radiotherapy
COPD patient who still smokes:
#1 step is smoking cessation
(immediate effect on declining lung function)
COPD patients should receive annual influenza vaccine (not HiB vaccine, it is only
given to children)
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Dx of Adenomyosis: MRI (most accurate)
(U/S has lower sensitivity and specificity)
Abnormal Vaginal Bleeding:
Periodic, abnormal flow: Anatomic cause
Irregularly Irregular: Endocrine cause
Routine screening of asymptomatic population for dyslipidemia:
Screening of population with CAD/risk factors:
(non fasting random spot cholesterol not indicated)
Patient must have quite smoking 15 years ago
for it to not count as a risk factor for CAD
Digoxin with or without a nodal blocking agent (beta-blocker) is effective in
achieving rate control in Atrial Fibrillation
Chronic A.Fib.:
associated with enlarged Left atrium
Medical emergency in a physician's office:
1st step is to initiate call to “911”
beta-blockers improve outcome in patients at cardiac risk undergoing noncardiaovascular
Mx of HTN in patients with migraine: â-blockers
Renal Failure: is associated with calcium wasting & secondary
hyperparathyroidism (Calcium supplementation is beneficial)
Patient with syphilis & penicillin allergy:
Do a penicillin skin test to confirm & perform desensitization if necessary
uncomplicated UTI:
.perform urinalysis
.Oral TMP-SMX (3 days)
.no need for urine cultures
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The occurrence of PVCs post-MI is associated with increased mortality &
morbidity. Treatment of asymptomatic PVC's with anti-arrhythmics is not
indicated. (Such treatment is itself associated with increased mortality)
No role of prophylactic anti-arrhythmics post-MI
Initiate Calcium supplementation even in cases of prolonged secondary
Exercize-induced amenorrhea
.low adipose tissue
.estrogen biosynthesis shifts to 2-hydroxylation with increased synthesis of catechol
.catechol estrogens compete with catecholamines for COMT
.results in inreased dopamine
.dopamine decreases GnRH release
.results in secondary amenorrhea
.whatever the age, OCPs (for HRT) & calcium supplementation are required to prevent
bone loss
Mx of psychotic depression: ECT
Post-void urinary volume estimation:
Straight Urinary Catheterization
(U/S is inaccurate in estimating bladder volumes)
All GDM patients should be tested @ 6w post-partum with 2-hr (75g Glucose) Oral
GDM is a risk for DM unrelated to pregnancy (regardless of glycemic control in
Klebsiella penumonia
.necrotizing pnemonia
.hospitalized patients / aspiration / post-stroke & alcoholics
.currant-jelly sputum (bloody)
Staph aureus: causes cavitatory pneumonia
(associated with rapidly progressive effusions & empyema)
Colon Cancer screening:
.FOBT annually
.Colonoscopy q10y
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.Sigmoidoscopy q5y
PSA estimation is not recommended for Prostatic cancer screening (if at all one test has
to be done, it should be Digital Rectal Examination)
Chronic Uterine prolapse:
.first fit a pessary
.prescribe estrogen cream
.later proceed to surgery (surgical failure rate is high when performed in the presence
of dry atrophic mucosa)
In any patient with pain of cardiac origin: EKG
(to differentiate between Ischemia & Infarction)
Inhaled corticosteroids:
long-term stabilization of severe asthma
(beta-agonists provide only symptomatic relief)
Hypotensive response to NTG drip in patients with inferior ischemia: Right Ventricular
(Mx: Stop NTG, Start I/V crystalloids)
suspected anemia: 1st Ix – CBC
suspected Fe deficiency anemia: Serum Ferritin levels
Normocytic anemia: 1st Ix – Reticulocyte count
h/o GI bleeds with DVT: not a candidate for anticoagulation
Alcohol induced dilated cardiomyopathy:
#1 step – stop alchol intake to halt progression
Polycythemia vera: increased risk of stroke
Valsalva maneuvre: decreases pre-load
Jedrassik maneuvre: decreases after-load
Valsalva decreases HCM murmur,
Jedrassik increases HCM murmur
Ankle – Brachial Index:
< 0.5 suggests severe ischemia
(surgical revascularization required)
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MVP without MR: no IE prophylaxis required
[absence of MR to be documented by Echo]
Pilonidal Cyst: infection of hair follicles in sacrococcygeal area. Mx: removal of hair /
Elderly with Knee “locking”: Medial Meniscal Tear
“pop” in he knee: ACL tear
pain in lateral knee, athlete: Iliotibial Band Syndrome
COPD @ any stage, smoking cessation in beneficial
Painless Testicular Enlargement
.? Malignancy [Embryonal/Seminoma/Lymphoma]
.Ultrasound, no Biopsy
.spreads to retroperitoneal nodes, if inguinal nodes (+), suspect scrotal invasion
.Sx: Inguinal approach, not Scrotal (Orchiectomy)
Evaluation of lung malignancy: CECT (IV contrast)
Dermatomyositis: search for occult malignancy
Most testicular varicoceles are on the left side
Neomycine allergy: 5% of population (Treat with Steroids). It is a Type IV
hypersensitivity reaction
SCC Lip Risk factor: Smoking > Sunlight exposure
Hydrocele: typically idiopathic (No Rx required).
Persistent hydrocele: Refer to Urology for Sx
Tuberous Sclerosis: Skull X-Ray to look for intracranial calcifications
AFP increase: NSGCT
b-hCG increase: Seminoma & NSGCT
Li-induced hypothyroidism: Mx – levothyroxine
(not discontinuation of Lithium)
Latest recommendation advise Influenza vaccination for >50y instead of >65y
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suspected Pseudotumor cerebri:
LP (inc. CSF pressure)
complex partial seizure:
aura, behavioral arrest, automatisms
Myesthenia gravis: CT Chest to r/o Thymoma
Propranolol is associated with depression
Fluoxetine takes 6-8 weeks to act !
Asplenia: PneumoVax / HiB / Influenza vaccine
Headache excacerbated by position & exertion:
increased ICT (? mass lesion)
Mitral Regurgitation
1.Transthoracic Echocardiography
2.If quantification reqd.: TEE
3.Gold Standard for any valvular disease:
Cardiac Catheterization
Suspected Anemia: next step – CBC
MICROCYTIC ANEMIA, to Dx Fe.-def anemia:
SERUM FERRITIN (Gold. Std.: Bone Marrow Bx)
GI side effects are common with oral FeSO4. They are not an indication for
discontinuing therapy. Always assess response (% Retics) after Iron Therapy.
OCPs can prevent anemia, they do not treat established Iron deficiency anemia. (Rx:
ABI < 0.5: s/o significant PVD (Sx revascularization)
Steroid Rx in suspected GCA: start without waiting for ESR / Temporal Artery Bx results
Excessive Cow's Milk Intake: Fe. Def. Anemia
Pericarditis: Diffuse ST elevation
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Factor V Leyden: Lifelong Warfarin Prophylaxis
beta-blockers in stable CHF: decrease mortality
DVT with h/o UGIH: no prophylaxis (?IVC Filter)
Critical Aortic Stenosis: Mx – Valve Repair (Valvulopalsty only for high risk cases)
Esophageal Varices: BANDING
TIPS is for portal decompression before Transplant. Not used as a primary procedure
only for Eso. Varices
Chronic Malabsorption in Pancreatitis: Mx – non-enteric coated Pancreatic enzyme with
H2 blockers
Child < 2 years with symp. Inguinal Hernia:
Contralateral Exploration indicated
.non-pharmacological measures
.emperical pharmacological measures (H2 / PPI)
.if fail, do Esophageal 24 hr. pH monitoring
probe kept 5 cm proximal to LES
pH<4 for >5 minutes or >9% of total time
.followed by UGIE & Surgical Mx if needed
Irritable Bowel Syndrome is a Dx of exclusion
12 weeks of GI symp. In preceding 12 months
Gilbert's: jaundice may only be noticed in the times of stress / infection or fasting
Anal Fissure: Steroid Cream & Sitz Bath
Stress is a trigger of IBS, not cause
Biliary colic: RUQ pain following meals
Cholecystitis: RUQ Pain / Murphy's / Fever / Leuko.
Cholangitis: RUQ Pain / Fever / Jaundice
False (+) Guaiac stools: meats & vegetables containing peroxidases (Inorganic Iron
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does NOT cause False (+))
F/H Duodenal Ulcers with Hypercalcemia:
HNPCC: Mx – subtotal colectomy with TAHBSO
Child with Constipation: Mx prune / pear juice (sorbitol)
Rectum devoid of stool: Hirschsprung's
Rectum full of hard stool: Fecal Impaction
Graves': Cigarette smoking increases ophthalmic involvement (advise patients to quit
Smoking Cessation:
1.success usually takes 5-6 attempts
2.associated with weight gain
3.counsel patients at each visit
4.pharmacotherapy should be offered to all
5.relapse rates decrease after 6m of abstinence
suspected Phaeo: first step is alpha-blockade with phenoxybenzamine (before Bx /
#1 side effect of radioactive Iodine: hypothyroidism
Glitazones – asociated with liver toxicity (LFT's)
Hypothyroidism with macrocytosis & hyperlipidemia:
1st step is THYROID hormone replacement
(might correct macrocytic anemia & decrease lipid levels)
Infection in suppressed adrenal axis due to chronic use of exogenous steroids
(refractory hypotension) :
administer stress dose of i/v steroids
Cholesteatoma: CT scan of temporal bone (Mx: Sx)
CN III palsy with pupillary involvement: MRI
Child attending day care with viral conjunctivitis:
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remove from daycare till symptoms subside
Fifth Disease: child is infectious before onset of rash
Mx of epistaxis: pressure, no need to tilt head upwards
Alk. Phosphatase is norally increased in pregnancy
Med. Mx of Ectopic: MTX
(b-hCG sample on Day 4 & 7, 15% decrease in level)
LGSIL = CIN I (most lesions resolve spontaneously)
Newborns can lose upto 10% of their weight in 1st wk
Breast – Cystic Mass
clear : discard
bloody : send for cytology
Delayed age at 1st preg: increased risk of Ca. Breast
Polycystic Ovaries: 1st step: OCP's
Churg-Strauss: (+) pANCA
#1 extra-renal manifestation of adult PCKD:
Colonic Diverticular Disease
(not Intracranial Berry Aneurysms: seen in 15%)
Nephrotic Syndrome in adult with recurrent hematuria:
IgA nephropathy
HSP: self limiting. Do urinanalysis (r/o kidney involv.)
Cisplatin: nephrotoxic
Never prescribe prescription drugs over the phone, especially if the patient is “new”
(call for evaluation)
F/H (+) of HTN: ? Adult PCKD
Biopsy has no role for Diagnosis of RCC. If suspected, refer for Sx management (Bx
only if e/o metastasis present)
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Nephrotic Syndrome with HTN: start ACEI's
(no role of high-protein diet in nephrotic syndrome)
T-score: cf. Normal healthy young population
Z-score: cf. Age matched conrols
Osteoporosis is defined by the T-score
Rx (HRT + Bisphosphonates) indicated if:
.T < 2.5 or
.T < 1.5 with presence of risk factors
Smallpox Rx: Cidofovir
Smoking cessation: Mortality reduced to ½ in first year and smoking caeses to be a risk
factor 15 years after quitting
Infants: always rear facing on backseat
< 12y: always on rear seat
Fertility returns as early as 1-2 weeks after cessation of OCP use.
Tinea capitis: KOH prep (Ix)
not Wood's lamp, all species don't show fluorescence
Postherpectic neuralgia: Mx – TCA
(Acyclovir decreases PHN when given prophylactically)
Toxic megacolon in U/C:
.high mortality rate
.Ix: AXR
.Mx: NPO/NG/Rectal Tube/Antibiotics
.Sx if doesn't resolve in 2-5 days
Peptic Ulcer disease with Gout: acute Rx – colchicine
(NSAIDs can not be used)
Necrobiosis Lipoidal Diabeticorum: DM
plaques with depressed atrophy on anterolateral leg
Parkinson's patients hould be referred to neurologist
Anosmia: r/o neoplasm/#/sinusitis (CT/MRI)
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.abdominal pain
.painful defecation
.GI upset with periods
.Ix: Laparoscopy
Influenza vaccine is indicated in healthcare workers @ any age
alpha-1-AT def.: avoid smoking & alcohol
(to prevent emphysema & cirrhosis)
Pruritic Urticarial Papules & Plaques of Pregnancy
.no umbilical involvement
.Mx: conservative
Impetigo herpetiformes:
rare form of pustular psoriasis
.acute onset
.erythematous plaques surrounded by sterile pustules
Herpes Gestationis:
.2nd or 3rd trimester onset
.involves umbilicus
.recurs in subsequent pregnancies
Routine rectal examination does not lead to elevation of PSA (levels can be done on the
same visit as DRE)
Uncomplicated varicella in preg., Conservative Mx
Hematuria without UTI: next step – contrast study
LiCO3 can excacerbate psoriasis
TT in past 5y: No Rx reqd.
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TT in past 5-10y:
prone wound: T toxoid
clean wound: No Rx
TT > 10y ago
prone wound: T toxoid
clean wound: No Rx
Post-PE: maintain INR between 2.0 & 3.0
If > 3.0 (no e/o ICH):
admit / give Vit. K (heparinize if INR falls to 2.0)
If e/o ICH: give FFP to replenish clotting factors
Thioridazine: prolongation of QT interval
PPD(+): obtain CXR to r/o active infection before starting INH prophylaxis
Chronic Steroid Use:
.Avascular Necrosis of Femoral Head (not due to osteopenia) avoid trauma, slow taper
of steroids
Relapsing Polychondritis
.Ear (Painful external ear)
.Larngeal Inflammation (focal narrowing) with airway obstruction
.can be associated with aortic aneurysms
Avascular Necrosis of Scaphoid: Sx Pinning
(X-Ray: sclerosis)
#1 cause of U/L vocal cord paralysis: Lung Ca.
Prostatic Mets.: respond to andrigen deprivation for the first 2-3 years and then
become resistant
>6m with exclusive b.f. : Iron Supple.
Breast Feeding (Hormonal Contra.): Progestin-only
minimal effect on milk quality & quantity
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Uterus & Cx reach normal size:
6 wks post-partum (IUCD & Diaphragm can be used)
If one FBS > 126, send another sample (Dx of DM)
MMR immunization is assoc. with simple febrile reaction. Can be associated with
seizures too.
Gingko biloba used with warfarin:
severe bleeding tendency
Give MMR to children with egg allergy (contains cross-reacting egg protein but in
very small quantity)
Varicella vaccine @ 12 months
suspected Giardiasis: send stool for ova/parasite before starting treatment
Shell fish intake: associated with Hep. A
Rx of Clostridial infection: Penicillin & Clindamycin
Neonatal Sepsis: Ampicillin + Cefotaxime
Meningococcal disease with persistent hypotension: Give I/V hydrocortisone
SBP prophylaxis: Levofloxacin
Acute post-infectious cerebellar ataxia:
.ataxia / nystagmus
.post varicella infection (1m later)
.acute onset, resolves
.Mx: conservative
Pulmonary Coccidiomycosis:
Pap smear of fresh expectorate is diagostic
Meningococcal prophylaxis:
Immunosuppressed: increased risk of fungal sinusitis
(high mortality rate, intracranial compli., Ampho-B)
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After toilet, wipe front to back (decreases UTI inci.)
Candida Diaper Rash: Topical Nystatin
Primary Irritant Dermatitis: Zinc Oxide
Rx of viral pericarditis: NSAIDs
Rotavirus vaccine is no longer FDA approved (due to incidence of intussusception in
Ant-HCV is (+) 18 weeks after infection
Newborn with (+) TB contact should be given
INH prophylaxis for 3 months irrespective of CXR/PPD status.
If at 3 months PPD(+), continue for 6 more months (else stop INH)
Pruritus ani: E.vermicularis (Mebendazole)
Mandatory seat belt laws decrease MVA mortality
Smoking cessation counseling should be provided to all patients regardless of age,
duration, previous attemps. (decreases cardiovascular mortality)
HSV transmission may not be prevented by condoms: skin-to-skin transmission occurs
G(-) diplococci in Otitis: Moraxella
(usually Penicillin resistant, use penicillinase resistant antibiotics)
MMR is not contra-indicated in AIDS
Dog Bite infection
Rx with Amox-clav for puncture wounds or bites on hand (for non-infected wounds: local
Home air humidifiers favor growth of house dust mite
Post GA Sx hoarseness of voice:
evaluate by ENT
Mx aspiration pneumonia:
Clindamycin (anaerobic cover)
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Breastfeeding mother with Trichomoniasis:
Give MNZ one dose stat, discard milk for 24 hours
Air Travel: decreased cabin pressure
.decreased pO2 can cause hypoxemia, CAD patients have increased risk of MI
.decreased pressure leads to expansion of gases. (problematic for patients with
volvulus, GI surgery, recent intestinal obstruction)
Female patients with CF may be infertile (plugging of fallopian tubes)
Inpatient Rx for community acquired pneumonia:
Malignancy, AIDS, cardiopulmonary/renal/liver disease
PSA is not present in ejaculate. Butejaculation can increase PSA levels transiently for
48 hours
Hemoptysis workup:
.Chest X-Ray
Chlamydial/Gono. Epidydimitis can be treated with a 10 day course of Ofloxacin
PSA > 4.0ng/mL: required prostatic biopsy
(esp. with F/H prostatic Ca.; 30% risk of Prostatic Ca. When PSA levels are >
4.0ng/mL). But no evidence that screening with PSA is beneficial
suspected esophageal perf.:
esophagoscopy with water soluble contrast
Anabolic Steroids:
Acne/Testicular Atrophy/Liver Dyfn./Depression
IV contrast is contra-indicated in renal dysfn.
Contrast nephropathy can be prevented by prior administration of N-acetylcysteine
Dx of Sarcoidosis: Skin / Transbronchial Bx
[Kveim is obsolete, Ca/ACE levels unreliable]
Postop Sensory loss: EMG (Ix)
Physiotherapy has role in motor weakness only
Occupational Vitiligo: affects persons who work in rubber clothes, rubber gloves or
handle phenolic or antioxidant chemicals
Aster's USMLE Step3 Notes
Page 100 of 94
May 19, 2003
Seborrheic Keratosis: Stuck-on appearance
100's of Seborrheic keratoses (Leser-Trelat sign)
search for internal malignancy
BZD in OLD patients: Oxazepam (hepatic excretion)
BZD in Liver Disease: Lorazepam (renal excretion)
Severe pain in OA is indication for joint replacement
Hyperpigmented lesions with velvety appearance on nape & axillae: Acanthosis
[associated with DM, obesity, Cushing's]
Nursemaid's elbow: Mx – supination of forearm with elbow flexed (No cast
Blackheads: open comedones
Whiteheads: closed comedones
Supraclavicular node: BIOPSY
Axillary node in female: Mammography -> Bx
3-10% of patients with spina bifida are hypersensitive to latex (also to foods like
banana, chestnut, avocado, kiwi): SPINA BIFIDA – LATEX ALLERGY
Osler Weber Rendu: epistaxis, GI bleed
(lesions on lips/nose/tongue/palatepalm/sole)
(chronic blood loss anemia)
Chronic plaque psoriasis: Scale Bx
Mx of autoimmune vitiligo: Steroids+Phototherapy
Time released oxycodone: can be abused by drug-seekers (snorting or injecting
crushed pill)
prevention of recurrent erythema multiforme minor:
Bullae / Papules on Hand with Naproxen intake:
Aster's USMLE Step3 Notes
Page 101 of 94
May 19, 2003
r/o Porphyria cutanea tarda / pseudo-porphyria
(order urine porphyrin & hepatic panel)
Kyphosis with thoracic vertebrae wedging:
Scheurmann's Kyphosis
Tracheal deviation with impinging neck mass:
consult thoracic surgery for securing airway
Agitation in Delirium: d/o/c low dose Haloperidol
When giving i/v high-dose Haloperidol, add Benzotropine to prevent Parkinson's
Benzotropine is c.i. In Malignant Neurolept Syndrome
(anticholinergic, leads to worsening of hyperthermia)
If a child is to be given long-term salicylates, prior Influenza vaccination is
(to prevent Reye's syndrome)
Post-MI: chest pain (aggravated by supine posture, relieved by sitting and leaning
forward): Dressler's
Emergent Pericardial Drainage: V5 EKG guided
Postpartum psychosis: increased risk of infanticide
Pt. with A.Fib.:
require anticoagulation before cardioversion
(if anticoag. c.i.: TEE to r/o mural thrombus)
AIDS: primary CNS lymphoma
CSF EBV PCR estimation is highll sensitive & specific
If patient with altered sensorium has no DPAHC:
do not use relatives for consent
Post-SAH deterioration: mediated by vasospasm
(prevent by NIMODIPINE)
Aster's USMLE Step3 Notes
Page 102 of 94
May 19, 2003
diffuse osteoporosis despite HRT / inc. infections
??? Myeloma
MVA with Quadriplegia with h/o recent Sx:
DVT prophylaxis required but anticoag. c.i.
(use IVC Filter)
absolute bedrest required only for 12 hours.
Patients can begin graded activity after 12 hours.
Submaximal EST @ discharge
Maximal EST @ 2-4 weeks
Sexual activity after 2-4 weeks
#1 complication of vascular Sx: MI
No Verapamil / Diltiazem in WPW ass. SVT
(sync. Cardioversion)
tPA use in stroke: monitor neuro. Q1h
(high risk of intracranial h'age)
suspected Conn's in 2º HTN: 1st step – CT abdo.
(not Renal Vein Renin Levels), CT yields more info.
Definitive Mx of Hepatorenal Synd.: Liver Transplant
Diverticulitis with Pneumaturia: Mx – Sx
(Colovesical Fistula)
<50y Diverticulitis: Sx after 1st episode
> 50y Diverticulitis: Sx after 3rd episode
UGIH: i/v Octreotide (Splanchnic vaso-constriction)
Malignant Otitis Externa: CT scan of temporal bone
(Mx: i/v antibiotics)
Rapid Rx of DKA: risk of cerebral edema
Radio. Dx of Pleural Effusion: X-Ray in decubitus view
Aster's USMLE Step3 Notes
Page 103 of 94
May 19, 2003
Elderly with Bloody Diarrhea & patchy mucosal depigmentation (with other e/o
Ischemic colitis (Mx - Bowel Rest & Hydration)
Dural Venous Sinus Thrombosis (headache/seizure):
Ix: CT Mx: Anticoag.
Infants of GBS (+) mothers who received <2 doses of ampicillin: Take CBC/Bl.Culture &
observe for 48hrs.
Nephrolithiasis with Hydronephrosis with Urosepsis:
Percutaneous Nephrostomy Tube Insetion
(Antibiotics alone will not help)
Mx of Neonatal UTI:
i/v Ampi + Genta
Neonatal Adrenal H'ages (B/L):
sign of birth trauma (F/U with rpt. U/S in 1-2 weeks)
Urinary retention with Renal Dysfn.: Catheterize (Decompress tract)
Competent pregnant female may refuse diagnostic or surgical procedure that may be
therapeutic, even life-saving, for the fetus (Patient autonomy)
Previous abortion & OCP use are not risk factors for ectopic pregnancy
Breast engorgement: Continue breast feeding
(Use warm compresses) – antibiotics not needed
An intact pulse distal to injury DOES NOT R/O compartment syndrome
Ix – measure compartment pressure
Mx – fasciotomy
Lap Chole in Pregnancy: best results in 2nd trimester
discoloration of synovial fluid indicates infection
Acute onset of renal dysfn. - look at BUN/C
next step: estimate electrolytes
Aster's USMLE Step3 Notes
Page 104 of 94
May 19, 2003
Children, with delayed passage of meconium, born to mothers who recv'd MgSO4
“bubbly” appearance on radiographs
(not synonymous with meconium ileus)
Ix & Mx: Water-soluble contrast
Biliary vomiting in infant: VOLVULUS until proved otherwise (Mx – Sx)
Muddy Brown Casts in urine: ATN
(Contrast nephropathy is a common cause, prevent by prior administration of Nacetylcysteine)
#1 Sensitive test for proper intubation:
End-tidal colume CO2 detection (colorimetric)
1st step after insertion of ETT (>7y):
inflate cuff, auscultate (or check end-tidal CO2)
Any anatomical defect in airway, get thoracic surgery consult before securing airway
Ix for Latent TB: PPD
Ix for Active TB: Sputum AFB Stain
RA+Splenomegaly = Felty's
severe disease, might require immunosuppressive agents like cyclophosphamide /
azathiprine for Rx
Patient on ventilator:
acidosis & hypercarbia: increase Tidal Volume
hypoxic respi.failure (ARDS, cardiogenic pulmonary edema): increase PEEP
Apiration penumonia:
Right Lower Lobe, foul smelling, anaerobic cover reqd.
Selective pulmonary vasodilator: NO (Nitric Oxide)
Aster's USMLE Step3 Notes
Page 105 of 94
May 19, 2003
Evaluation of TMJ: MRI
Heliox: mixture of Helium + Oxygen
(used for oxygen delivery in severe bronchoconstriction, it has better laminar flow)
Cystic Fibrosis with pneumonia:
Aggressive chest physiotherapy to clear secretions
Steroid acne: papules & pustules
.steroid induced
.atypical site
.Mx: Tretinoin (no need to stop steroids)
.also with: anabolic steroids, Iodide, Bromides, Li
If unable to intubate after repeated attempts:
Surgical Airway Access (No Resusci. without airway)
Increased survival with ARDS:
ventilator setting of TV < 6cc/kg bdy weight
Alkali ingestion:
.UGI study with water soluble contrast
.if (-) can be repeated with Barium
.Early endoscopy (endoscopy in acute ingestion might cause perforation)
post-AAA repair, loss of sensation but intact proprioception: Anterior Spinal Artery
(posterior cord spared)
Catheter associated sepsis:
Remove catheter, start broad spectrum antibiotics
if still spiking fever (add fungal cover)
Post-heart transplant chest pain / dysnea / fever
? Mediastinitis (Mx: broad-spectrum antibiotics)
Post-thyroidectomy STRIDOR:
? Arterial bleed (call vascular surgeon, will open neck @ bedside – do ot attempt to
open neck yourself)
Post-thyroidectomy hoarseness of voice:
Recurrent Laryngeal Nerve injury
Aster's USMLE Step3 Notes
Page 106 of 94
May 19, 2003
IJV line: associated with Carotid Bleed (if bleed occurs, and neck is tense, call vascular
Subclavian Line: associated with pneumothorax
Guide wire loss while inserting central line:
#1 complication – arrhythmia (call interventional cardiologist or radiologist for guide wire
post-GI Sx, ileus, LLQ mass, localized tenderness with some air under diaphragm
(Pelvic Abscess)
.some air under diaphragm post-op may be normal, does not necessarily indicate
perforated viscus
TURP syndrome: associated with hyonatremia
(aborption of irrigating fluid)
Alcohol withdrawl: Day 3
Fat Embolism: shortly after Long Bone #
DVT: risk increases with duration of immobilization
Nitroprusside : CN toxicity (Mx-Na thiocyanate)
Mx of MethHb: Methylene Blue
Rib #: shallow rapid respiration (due to chest pain): associated with higher incidence
of atelectasis
Patients receiving epidural narcotics should not receive I/V narcotics till epidural
narcotics have stopped
#1 cause of wound dehiscence: poor surgical closure
DPL may not reveal retroperitoneal processes
LGV: suppurative inuinal adenitis
(1º lesion: herpetiform vesicle or erosion on glans)
Chancroid: Painful punched out lesion
.Syphilitic chancre can appear after appearance of chancroid 'cuz the incubation period
of syphilis is longer than chancroid
.Mx: Ceftriaxone / Azithromycin
Aster's USMLE Step3 Notes
Page 107 of 94
May 19, 2003
Granuloma inguinale:
.seprenginous ulceration of groin/genitalia/anus
.granulomatous tissue
.beefy red / bleeds easily
Acute suppurative parotitis:
.S aureus
.high mortality rate
.seen in post-op patients with poor oral hygiene
.fever with preauricular swelling
Fastest way to achieve androgen deprivation (for prostatic mets.) is B/L orchiectomy
(castrate level testosterone in 3 hours) – Leuprolide can take 30 days to achieve
castrate level testosterone
INR > 3.0, dysnea, no fever/leuko, increased Dlco:
Dx is Pulmonary Hemorrhage
AIDS with PML: start HAART (improves survival)
.no Rx for PML (caused by JC virus)
Post-LP: c/o postural headache
.Post-LP headache
.Mx: remain horizontal
Broca's aphasia: broken speech, comprehension intact
Wernicke's: “word salad”
1st episode of vasovagal syncope: reassure (get EKG)
recurrent vasovagal syncope: TILT TABLE TEST
Neuro. deficits in hypoglycemia: give I/V Dextrose
SAH: Early CT can be normal, if CT does not agree with clinical suspicion – do CSF
TIA: 1st step – auscultate carotid
If bruit (+): do Duplex U/S
If Stenosis > 70% - CEA
TCA overdose: admit to ICU
Aster's USMLE Step3 Notes
Page 108 of 94
May 19, 2003
(high risk of arrhythmia)
Bell's palsy: Mx ?Conserv. / Acyclovir & Prednisone
Li levels > 4.0mEq/L – urgent hemodialysis
Bifrontal headache, OK when supine, worse on getting up : Intracranial Hypotension (?
Dural tear – exertion)
Meningitis with Papilledema: No LP
Pt. with A.Fib
on warfarin with increased INR with stroke:
CT Head : if non-h'agic – tPA
CT Head : h'agic – administer FFP & Vit.K
Acute arterial occlusion:
start i/v heparin + prepare for Sx embolectomy
Pt. in ED with asystole: Transcutaneous pacing
severe CAD & brady alternating with tachy:
Sick Sinus Syndrome
Pt. with uncontrolled HTN with chest pain & unequal blood pressure in R & L arm:
Acute Aortic Dissection (Dx: CT)
Mx - 1st step – lower systolic to < 100-120 mmHg
HbS disease with fever: ADMIT (high risk of sepsis)
CT can detect pericardial effusion, only ECHO can detect cardiac tamponade
Dx of IE: isolation of organism from 2 separate sites
FFP transfusion is also blood group matched
anemia, t'penia, fever, renal dysfn., neuro ab(n):
TTP (Mx: Plasmapheresis)
Sigmoid volvulus: forms an omega loop
can be reduced with sigmoidoscopy
Aster's USMLE Step3 Notes
Page 109 of 94
May 19, 2003
Abdo exam: 1st step is AUSCULTATION
eavluation of any acute abdomen: check hernial sites
DM with hearing loss / pain / granulation in external auditory canal: Malignant
Otitis Externa
(Pseudomonas) Mx – I/V Antibiotics
Frontal sinusitis: can lead to a subperiosteal abscess (Pott's puffy tumor)
Adult PCKD: cysts are found in kidneys, aso in liver
PID with severe pain / guarding / mass:
TOA ? Ruptured
Child < 1 m with fever > 100F
send Blood / Stool / CSF to r/o Sepsis
Epiglottitis: Intubate (in OR by Anesthetist)
Avoid NSAID use in renal insufficiency
Acute Gout with PUD / recent Bleed:
Acute Gout with Renal Failure
(NSAIDs and Colchicine are both unsafe)
Intra-articular steroids
HZ Ophthalmicus: ORAL Acyclovir
Rx human bites with antibiotics
Rx rat bites with Penicillin (rat bite fever)
Pain remover: absorbed by skin, metabolized to CO in liver, can lead to CO poisoning
100% O2 vs Hyperbaric Oxygen therapy
Indications for Hyperbaric O2 therapy in
Carbon Monoxide poisoning
.CarboxyHb > 40%
.CarboxyHb > 25% with neuro. symptoms
Aster's USMLE Step3 Notes
Page 110 of 94
May 19, 2003
CarboxyHb > 15% in pregnancy (HbF has a high affinity for CO and fetal CO levels are
10-15% higher than maternal levels)
to detect small pneumothoarx: end-expiratory CXR
Radial Head #: heals faster with early mobilization
Clearing Cx Spine: X-Rays and Examination
Clearing involves response from patient. Therefore, a patient in altered sensorium with
suspected Cx spine injury can not have hi Cx spine cleared !!!
Antibiotics improve outcome in COPD flare
A Living Will with DNR orders needs to be verified by the hospital's legal / social work
Penile chordee: CONGENITAL, fibrosis of tunica albuginea – increased curvature of
Peyronie's disease: ACQUIRED, fibrosis of tunica albuginea – increased curvature &
palpable plaques
evaluation of rotator cuff injuries:
Diabetic Foot Ulcer: X-Ray to detect air
Mx: Debridement
DVT/PE: start i/v heparin & warfarin. Stop heparin 2 days after attaining therapeutic
Pemphigus: acantholysis, Nikolsky sign (+)
In patients @ high-risk for aspiration, apply cricoid pressure while intubating
Fall from height & landing on feet:
increased incidence of calcaneal & vertebral #'s
Mx of acute prostatitis: Fluoroquinolones / TMP-SMX
.no prostatic massage / no catheterization
Aster's USMLE Step3 Notes
Page 111 of 94
May 19, 2003
e-mail additions / revisions / suggestions to:
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* Re:exam experience
  lucy01 - 02/24/06 12:53
  hi, rbd?
where can i find asner,s notes?
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* Re:exam experience
  daner90007 - 02/24/06 08:57
  Had very similar feeling as you, rdb. Maybe more terribel and depressing. The only difference is that I studied even less than you. 16 days. Now the only thing I can do is to pray.  
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* Re:exam experience
  dik - 02/24/06 08:49
  Hi rdb,
I was trying to get Aster's notes but i could find nowhere.Where do I get this from?

I will appreciate your input on this.Sorry to bother you with this.

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* Re:exam experience
  perk - 02/24/06 08:36
  hey rdb
congrats, keep up the good work. i just wanted to know which nbme exam did u take, the trial one? it says for step 1 only right/ so just wanted to know which did u tkae step 3 or 1..plz let me know, i am also planning ot take a trial one itslef coz dont have time to tkae the entire exam.
thanks and gl
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