Category Archives: MEDICAL ETHICS

OPEN WOUND

As part of a transplant workup, each potential candidate goes through a series of grueling tests, including meeting with a psychiatrist on the team. I wish that one particular psychiatrist were capable of being even mildly sensitive about cultural, gender, and trauma issues. As in, having even a modicum of familiarity with basic psychology and sociology, which should be part of any mental health professional’s development. I was truly dismayed and disturbed in what vicarious trauma experts have now dubbed “moral distress”. Moral distress is the stress that “occurs when one knows the right thing to do, but institutional or other constraints make it difficult [read impossible] to pursue the desired course of action.” That definition hits interpreters very hard, as the limits of what we can do are so incredibly narrow. Yet we are literally first-hand witnesses to every possible manifestation of healthcare, and observe with our hands tied.

This psychiatrist did not give the patient any context for her to understand his role and what was expected of her. He failed to inform the patient that she was not actually under any obligation to answer all his questions or give details that bring up severe trauma as part of the evaluation. He failed to protect her. I believe he had no clue that she would feel absolute compulsion to answer every question he put, even when he delved into what seemed a selfish indulgence of his prurient personal curiosity rather than any part of a transplant workup. I believe he is completely clueless about her culture, her respect for authority figures and men, and how obligated and helpless she would naturally feel under his rapid-fire interrogation. And she had zero context for what he was asking and why.

I would love to have patients receive something like this as an opening: Welcome to my office! Allow me to give you background on why the transplant team has each patient meet with me, a psychiatrist. Studies have shown that something as intense as a transplant can bring up all kinds of feelings besides joy and relief. People who have had depression or anxiety may get those feelings again. People who have had trauma, whether from abuse, growing up in a war zone, car accident, or whatever, which is pretty much all of us, so don’t feel alone, can have our post-traumatic stress come up. That’s okay, as long as we have supports and coping skills in place to help with these things. It’s all a part of normal life. Some people deal with these feelings by self-medicating with drugs or alcohol, but as you can imagine, with a brand new organ, and all the prescribed medications, that would be the worst thing we could do! Luckily, there are so many other ways to deal with sadness, worry, bad memories, and other human feelings.

I am here to help the team, and to help you. For the team, I am evaluating what kind of skills you already have in place to deal with the difficulties you will be facing. I will report on your strengths, your support system, any counseling or meditation, exercise or whatever you already have in place, so the team knows you would be a good caretaker of a donated organ. I may make suggestions as well. I am also here to offer you support and resources. I have lists of support organizations both before and after transplant in your area, and a list of resources for counseling and support in your language. Let me start by asking you some questions. And please understand, although I may ask about specific traumatic events, it is not my job to investigate your past. My focus is on your coping skills. You can always let me know if you would rather not delve into something, as we will not have time to really do healing therapy in this short hour! And I wish to apologize ahead of time, as these sessions can be uncomfortable. I will try to be sensitive. Any questions before we start?

That is what I wish would have happened. Here is what did:

I am a psychiatrist and I need to write a report as part of the transplant workup. Let’s get started. What is your full name? What is your date of birth? Are you married or single? How many children do you have? How old are they? Do they live with you? Do you think they would take care of you? Do they work? How could they take care of you if they work? Can they get time off? Have they asked their bosses? You think so, but can you find out for sure? When can you find out for sure? Who lives with you? Is it really just a roommate, or something more? Do you work? When did you last work? Why did you quit working? But you weren’t on dialysis then, so why did you quit then? Why couldn’t you work then? What did you do? Housecleaning? How long? How many years? How much schooling do you have? Can you read and write? Why did you quit school so young? What did you do then? Was there violence in your home? Did you ever see your Dad hit your Mom? Did he hit you, too? How many siblings did you have? Where do they live? Are you in touch with them? Are you close? Did they quit school, too?

This goes on for half an hour. The patient is clearly distraught, but there is no recognition of that. No acknowledgement. No breather. No time. The psychiatrist is taking calls, texting messages to colleagues about in-patients on his computer screen, between writing into her open chart, and clearly thinking of other things. Time is money. I am sure he considers himself great at multi-tasking, a picture of professional efficiency. The interruptions hardly slow him down. He doesn’t seem to feel it disrespectful, but simply his right. He is important! He is a valuable professional! He has so much to do! So let’s push ahead with this interview so he can wind up his report to the team, which he is typing as we speak. He keeps firing off his questions, rat-a-tat-tat:

So your Mom left your Dad. How old were you? Where did you live? Why did you live with your Grandma? Why didn’t you live with one of your parents? Oh, your mother lived there, too! Okay. Have you ever been sexually abused? By whom? Your stepfather? How old were you? How long did it go on? Pregnant? I am sorry! Did your mother find out? What did she do? She made you marry your stepfather, but stayed with him herself! I am sorry! Oh, I must answer this page, sorry. Where were we? Oh! Your mother made you marry your stepfather and then you had his baby. Is that your older child then? Does she know her father was your stepfather? How is that for you? Do you think about it a lot? When’s the last time you thought about it? That long ago? What brings it up? How do you deal with it? Are you in touch with your stepfather, your husband, or I guess your ex? Oh, he’s dead? What about your other child, was that the same father? A second marriage? What does he know? Oh, the second husband is dead, too? Oh! I see from your chart you used to drink a lot. Why is that? Because your second husband got killed? How old were you then? Did you really only started drinking then, and not before? How did he get killed? I am sorry. How long did you drink? How many years? Did you ever black out? How many drinks could you drink? Did you ever miss work? Did it affect your children? Do you drink now? How did you stop? Did you go to treatment? How long? Why did you quit after two months? It was all men? You mean AA? I see. Okay, well, I think I have enough now.

The patient has been trembling for over half an hour. I am the one who offers her to kleenex because the psychiatrist doesn’t think of it, although she is using her coat sleeves to wipe her face. I place my hand on her arm in support as she stutters out the words of her shameful (to her) life story and the horrible things she had to survive, and faces the excruciating pain of this clinical retelling to an unknown and frankly distracted, possibly dissociating male authority figure. A doctor. A rich man. A white man. A citizen of the country where she lives underground. The kind of person whose house she cleans, when she is well enough. A gatekeeper who potentially will stand between her and the life-saving transplant, if she cannot show that she can deal with her trauma and pain well enough to pass muster. And she cannot, at this moment, after this interview. She gets up still in tears, still trembling, to politely thank him for his time and his business card. He nods with a grimace and dismisses her as he stands up to mark that she is excused and may leave now. I may leave with her.

Well, thanks for coming in. I will send my report to the transplant team., and they will let you know. Here’s my card. You can call me if you need me. Goodbye.

I personally find this as unconscionable as doing surgery on a patient and failing to sew them up properly. A properly trained psychiatrist should surely know something about the psychology of trauma. Can he really not see, does he really not care, that by opening wounds that he cannot close, he is leaving these already very ill, very vulnerable patients to heal themselves as best they can? The gratuitous, completely unnecessary human suffering! It astounds and distresses me to no end. And across these power boundaries, encounters such as this one are carried on in hundreds, thousands, millions of settings, in hospitals, tribunals, war zones, workplaces and in the often dangerous privacy of our family homes. We are created equal, that I do believe, but we are certainly not all in a position to be treated equally. And it is just so damn unfair.

COVERING

We all make mistakes. It is human nature. Yet we are often trained to believe that we can never say, “I don’t know” at the workplace. We may hesitate to ask for assistance from a colleague, because we want to save face. This attitude contributes to making mistakes, big and small. And the temptation exists, because we don’t want to get in trouble, to cover up our mistakes. This human frailty is one of the reasons that most major medical centers have put systems into place, so we can reduce these errors, and have transparency. The smallest mistakes, the most minimal errors, may cause ramifications that we cannot foresee, and not only in the operating room. Not only in human flesh, but in human suffering. And isn’t the main purpose of medical care to reduce human suffering?

Let me give you an example of the simplest kind of preventable error. A non-English speaking couple shows up at the information desk. The new staff person calls Interpreter Services. They interpret for the patient, who is going to a specialized obstetrician because they have just found out that her unborn child is not viable. The patient is scheduled for a procedure today. So the staff sends her straight to the correct clinic, where her certified interpreter awaits. She meets with the specialized doctor, gets all her questions answered, then meets with the nurse re surgery prep, then with a social worker. Then she has the procedure. As smooth as losing a baby can possibly be, without adding any stress or suffering to what is one of life’s most painful situations. Except it doesn’t happen that way.

Instead, the couple shows up at the info desk to ask for help, but no interpreter is provided. The staff cannot understand the couple. So she asks for the patient identification. She because she is not culturally aware of the way last names work in this particular speech community, she cannot find the patient in the system. Because she has chosen not to access an interpreter, she cannot tell the couple what she is doing, and where she is wrong. Instead of seeking help, she guesses, finds a patient with a similar name, and tells this couple that they need to leave the hospital and drive to another satellite clinic. The couple tries to say they are sure their appointment is here. They just need to know where in the building. They want to be on time. But the staff now is adamant that she cannot be wrong. She is new at the job and fears being wrong, and that is now more important than the patient’s healthcare. She insists that they drive to the other place, and she writes down the address and gives a map. “You go there!” she orders them. So they go.

Meanwhile, the interpreter at the clinic is waiting for the patient, as the appointment time is rolling by. The clinic scheduler calls the patient, and finds out, because she has an interpreter on the line, that the patient and her husband are now at another clinic, where they are in the middle of being informed that no, they do not have an appointment there. They have now parked twice and been to two facilities, and their appointment time has officially passed. Over the phone, they are told to come back to where they started, and we will try and fit them in. All in all, it takes around an hour for them to get back to where they started, where the error occurred, which was only a few hundred feet from their appointment location.

While waiting for the patient, the scheduler goes out to the info desk, and approaches the new hire. When she inquires about the mix-up to try and figure out how it happened, and maybe avoid this kind of thing in the future, the new staff member swears she never saw this couple, never saw a non-English speaker this morning, or a pregnant lady, did not direct anyone off-site, and suggests maybe it was someone else. When asked who else is working there this morning, she admits that she is working alone, but then suggests that maybe a volunteer who was there did it while she was on a break. She keeps shaking her head and saying she didn’t do it. She didn’t do anything wrong. It must have been someone else!

Meanwhile, the clock is ticking. Other patients are lining up. This is a high risk clinic, so other patients also have complex and difficult situations. They also need their time with the specialists. Things will have to be shuffled. The interpreter waits by the clinic entry. She finally sees a couple approaching, looking scared and lost, still unsure if this is the right place. She greets them and confirms they are the couple and brings them to the desk. Their first question is, “Did we miss the appointment?” They are in so much anxiety. The staff assures them they will absolutely be seen, but it may take a while. The doctor is now backed up.

Staff apologizes to them on behalf of the medical center for the mistake and the misdirection. She tells them that the staff person at the desk said it was not her, but perhaps a volunteer. To fix this in future, we will make sure our volunteers are better trained on how to get an interpreter and look up appointments, if possible. The husband gets very surprised and says, “We just walked past her, and it was the same one, with her employee badge on, and she recognized us right away and called out in English, ‘I don’t know WHY I sent you there!’ She does work here.”

Staff is surprised in her turn. Once the patient has been roomed, she calls the info desk. She tells the info desk staff person that she wants her name, and this time the person admits that yes, it was her. She is now sorry. Okay, a moment of panic. A new job. The fear of getting in trouble. Shame. Wanting to save face. A simple mistake. Only one problem. Our simplest mistakes can have wide ramifications in healthcare. And that is why we have systems in place. We have protocols. And if we deviate, we have transparency. I understand the fear of judgment. I understand the panic and the shame. But we need systems, and we need transparency. Anything else is simply corruption. How can we fix a problem if we don’t know it is happening? If it is covered up? We need to know. Not to shame anyone, but to fix it so it works.

Imagine how you would feel to be losing a baby. In a foreign country. Where you don’t speak the language. Being sent to a large city you don’t know into the swirl of traffic. Imagine your fear as you rush around from building to building, asking people for help, and not understanding the answers, as your appointment time ticks past. Parking three times, fearing all the while that you may not even be seen, then arriving so late, through no fault of your own, so that you are forced to have the appointments shifted out of order.  Chaos and instability. The interpreter coming in and out of the room to try and arrange that she can stay, because now her scheduled time is up, and another patient is waiting for her, and you are facing maybe having a telephonic interpreter for the most important part of your appointment, if they even have a phone for this in the procedure room.  Then due to the shuffling, you are FIRST asked by social work to make funeral arrangements for your unborn child, and THEN have the chance to ask the doctor one more time to please confirm that the pregnancy is not viable.  That your baby has no chance of survival. Because you really need to hear it one more time, to tell your heart that it is true. This whole morning, this whole thing, seems so unreal. Like a nightmare. Was this necessary? The baby was destined to die in the womb, but did it have to be this way?

Small mistakes are not small mistakes. The actions we take impact others in ways foreseen and unforeseen. Let us be clean in our words and actions. Let us ask for help when we need it, so we can help others. Let us learn to be humble and say we don’t know when we don’t know, rather than try to save face at great expense to the very people we have been hired to serve.

BEYOND AWKWARD

I was recently asked to replace an interpreter whose job was running over the allotted time. When I arrived, the session had already begun and we quickly switched out. As the interpreter shut the door, the patient said, “Too bad that interpreter left so quickly! I was supposed to get her personal phone number! She wants me to paint her house and I told her I can do it for extra cheap!”

I rendered that into English, as required, and the surgeon and I locked eyes for a moment. The surgeon then shook his head and said, “Yeah… probably the less said about that the better.” I rendered that into the patient’s language, and then asked permission to add for the patient’s edification that we are not allowed to give out our personal phone number or hire patients to work, much less for substandard wages. We are only here to serve their medical needs, and happy to do so. Permission granted, this was conveyed. We were then able to get back to the patient’s health issue.

I am sure that if I ask this particular interpreter, I will be told that I have misunderstood. That it was never the interpreter’s intent to take advantage of a vulnerable patient, or get extra privileges or favors. That it was some kind of a misunderstanding. And if I take it to my boss, and they investigate it, and call the patient, he will say that the interpreter never asked for a discount, but rather he himself offered it, because he is so happy to get this medical care and to have an interpreter provided. I don’t doubt this. But it is still wrong. And I would hope this is obvious.

As awkward as it may feel to explain our ethical guidelines when these issues come up, it is imperative that we do so. Because it is the only way that patients can find out about our very strict policies and boundaries. If you are an inexperienced interpreter, and you do not do this, because you think it will be awkward, practice among your colleagues until you find some scripts that work for you. Here are a few ideas:

“Thank you for offering to give me this. But interpreters have very strict rules. We are not allowed to take any presents at all, or we can lose our certificate. We get paid to interpret, and the law says we cannot take anything extra. Believe me, we are paid for our work, and you do not need to compensate me on top of that. It is my pleasure to interpret for you! I love my job.”

“Oh, thank you for offering me your business card. I am sure you are great at what you do. And I appreciate your saying that you could give me a sweet deal. The thing is, I am not allowed to take any extra compensation for my work here, not even a discount, and if I see you outside of work, even to paint my house, I would have to tell my boss and then you would be on a list of patients I cannot interpret for. That makes it tough for our schedulers. So I really cannot hire you. But good luck getting work!”

If the offers persist, and sometimes they do, please explain that these rules have been established for the protection of the patients. We do not want patients to feel that they have to pay us off in order to get their medical appointments. We don’t need or want them to give us tips, discounts, or gifts. It is written into our regulations that interpreters may not “accept additional money, consideration, or favors” or “attempt to use their position to secure privileges or exemptions”. We consider it the anti-corruption section of our code of ethics, and take it seriously.

And for those few of you who may think you are “just” attending a wedding or baby shower, and not “getting anything for it” beyond friendship, remember that our code expressly requires disclosure of any “real or perceived conflicts of interest” that would affect our professional objectivity. And the code intentionally gives the very specific example of providing interpreting for a friend, because it “may violate the […] friend’s right to confidentiality, constitute a conflict of interest, or violate a contract.” So yes, you can make friends with your patients – you can just never interpret for them again.

The friendship offer script goes along the following lines: “I would love to come to your baby shower, but unfortunately, once I meet you outside of work, I am banned from interpreting for you ever again. And I so enjoy providing services for you here. Also, if I get a long list of patients I cannot interpret for, I will have lots of new friends, but I could lose my job! We don’t want that!”

I find patients are quite gracious and understanding. They may say it is too bad, but they are not personally offended, once they understand the framework. We want to avoid corruption and handouts, kickbacks and under the table dealings, special favors and unequal treatment, across the board. We want patients to have open, equal, and unhindered access to quality care, and they shouldn’t have to do us any favors to get it. We are service providers, not gatekeepers. This is vital for patients to understand.

Yes, if you are new to interpreting and just getting used to it, this may feel awkward at first. But believe me, it will be beyond awkward if you lose your certification because you wanted to be polite – and thus end up accused of taking a bribe, or appearing to have a conflict of interest. So we all have to be upfront about what interpreters can and cannot do.

There is nothing rude about letting our clients know that we will not take advantage of them and that they do not owe us anything. And it should be nothing short of the truth to add that it is our honor to serve them. So please, if the situation arises, take the opportunity to educate and empower our patients. They don’t have to come paint our house for cheap. They don’t have to take us out for a meal. They don’t have to give us extra compensation in order for us to do our job. That is what we get paid for.

BEST PRACTICES

Once upon a time, a major regional hospital got a very large donation from someone whose life they had saved. In her donation, she stated that while her physical care was top notch and life-saving, she had not always liked the way she was treated. She dedicated this fund to improve patient relations, and help this very excellent hospital implement best practices for patient care and comfort. Her belief was that when patients feel respected and comfortable, their outcomes are better. I agree with her.

Fast forward and many US hospitals are incorporating best practices into their patient care. Here is a summary of the main points on a checklist that staff have on the back of their badges, for example:

Knock before entering patient room. Be open and friendly, make contact. Acknowledge their family members.

Tell patients who you are by name and title. Tell them your role in their care and what you are going to help them with.

Let patients know how long you expect procedures or tests to take, and when you expect results. Let them know the purpose of your plan.

Communicate clearly using simple terms. Explain things in a way patients can grasp. Ask open-ended questions. Make sure they are clear.

When you say goodbye, show them appreciation. Thank them for being a patient. Show them love.

Some of these guidelines could be modified slightly and used in many of our work and home situations, couldn’t they?

NUT UP

Let’s face it.  Doctors are used to having a lot of power.  So in spite of some very stringent ethical guidelines, some of them overstep their boundaries pretty consistently and thoughtlessly.  They fail to ask the patient what the patient herself wants, and what her values are.  They direct unsolicited advice both to patient and family members.  They use sarcasm, off-hand, and even off-color remarks.  In addition to being unethical, some of it is truly cringe-worthy.

Case in point, and as the saying goes, “You cannot make this shit up,” or at least in my case, I don’t have to, because so much of it actually happens, and yes, this really did.  Word for word.

While counseling her patient on whether to consider a tubal ligation during a cesarean section, out of the blue, the doctor turns to the very shy and traditional husband and says, “Or you could nut up and get a vasectomy!”

Now in my personal value system, a vasectomy is a good idea.  It is a very simple and straightforward office procedure.  Just think about where testicles hang out, compared to how deeply embedded our precious ovaries are.  I don’t think men even get a stitch, just a little steri-strip bandage.  A day or two of ice packs, and they are good to go, with a happy female partner who no longer needs birth control.

My personal belief system is that both genders should share responsibility for birth control, family planning, and all other aspects of family life, including whether or how to have children, and what gender to identify as.  If something such as permanent birth control is needed and comparatively much easier for one partner, the answer is clear.  But here is the thing: I am not the patient, or the patient’s family.  It is none of my business to direct them, and in this case, it is not the doctor’s either.  Informed consent means you give the patient the information, and the patient decides.  This is decidedly NOT the way to inform the patient about her options.  And this is not even a patient.  Let’s go over some of the ethical issues:

Number 1.  The husband is is not a patient of the gynecologist, for obvious reasons, or even of our hospital.  It is every kind of inappropriate to give him unsolicited advice on whether to undergo an elective surgery the purpose of which is to render him permanently sterile. Do we have any health history?  Do we know if he is a hemophiliac, or has a liver disease that prevents blood clotting? For that matter, do we know that he is our patient’s only sex partner, and will be for the rest of her life?  If not, sterilizing him is not going to solve her issue of not having more children.

Number 2.  Understanding patient culture includes understanding what may be uncomfortable for a patient (or a non-patient in this case).  In an ideal world, a man would be perfectly comfortable to talk about his testicles, his fertility, his future sex and reproductive plans, and much more with two random women and his wife, but this is not an ideal world, and doctors should at least make some attempt to meet patients where they are at.  And he is not a patient.

Number 3. Doctors need to talk grown-up talk, unless the patient (or again, non-patient in this case) is developmentally incapacitated or chronologically infantile.  It comes across as condescending at best, and once we turn to very crude terms, it can come across as shocking, insulting and disgusting to populations with a lot of taboos.  Grown-up talk includes not swearing or using street terms like balls, dick, twat, titties, and yes, nuts.

Number 4. I would like this on a t-shirt, bag, or my interpreter badge:  Sarcasm does not translate.  I have written about this before.  Sarcasm in the US is used with the intention of being inclusive, but it is in fact exclusive and very hurtful and even humiliating to the vast majority of patients who do not expect it, share it, or even want to mildly joke with their doctor (or non-doctor in this case) about their health and their illnesses.  Let alone their nuts.

Linguistically speaking, you take the phrases “grow up” and “be a man” (fraught with sexist peril already) and breed it into a child with congenital problems, at least as to socio-linguistic functioning: man up.  This supposedly makes a new and hip phrasal verb meaning to grow up and be “a man” and take responsibility.  Then you take out the man, which is fine, but instead of making it a nice gender-neutral phrase about being an adult, you make it even more forcefully and crudely gendered by bring the testicles into play.  Then to add insult to injury, you use the casual and crude term “nuts” instead of testicles.  And to add to the interpreter’s personal suffering, you make “nut” into a frikking verb.  Testicles can hang or dangle, and tend to do so unless safely cupped, but a verb they are not.  Neither are nuts.

The interpreter has to focus on the message.  There is no such thing as “word for word” interpreting.  We convey meaning, rendering as closely as possible the meaning, and the intent of the speaker.  Now I could argue that this speaker meant to be crude, insulting, and even humiliating.  She meant to put her license on the line by offering medical advice to a non-patient, joking sarcastically about a man’s balls and what he should do with them, and swearing at her vulnerable, high-risk patient’s beloved.

What I believe her linguistic intent was, though, was simply to make a casual, offhand suggestion that yes, Mrs. Patient, we could do additional surgery on you while we are in there anyway, but hey (friendly smile turned to the husband for a split second) “you could always be a gentleman and have the vasectomy surgery yourself!” (Friendly nod and glance, still smiling, giggle, then turn back to patient as if she didn’t just casually and thoughtlessly diddle her ethics the way you might your beloved’s balls).

Am I positing that no doctor should ever mention vasectomies to their patient or families?  Of course not.  But I think we can all imagine a scenario where the doctor – speaking seriously, using her grownup words, and directing her attention to her patient – mentions options for the patient and includes the fact that “if your husband is willing to consider taking on the family planning from here on out, you may want to consider the option of his getting a vasectomy, instead of you having further surgery.  I can certainly get you some written information on that today, you can look it over, and if you like, I can refer him on to a urologist for more information.”

This would be the way to provide professional, ethical, and responsible healthcare, directed and guided by the patient’s goals, needs, and preferences.  Based on the patient’s values, not the doctor’s.