4 Steps to Ace Medical Ethics Stations - Our Framework (Podcast & Article)
We recorded the medical ethics framework as a podcast, you check it out here: https://anchor.fm/frasers-interview/episodes/Episode-1---Medical-Ethics-e2061j The transcript is below if you prefer to read Tom's advice. Today, we're going to be talking about a framework that you can use for medical ethics. In particular, I think medical ethics is an area that most students are most nervous about, they often think that it is something that is difficult to conquer. Or that there's some expectation that you're meant to understand all of the different complexities of the issues both from a legal, ethical and medical perspective, which is actually not the case. Ultimately, medical schools actually have to teach you this themselves, within their own course. In an interview, it would be a little bit unusual if you were to walk in and list off every single possible principle, and ethical consideration in a difficult situation. However, you are meant to show that you are a very interested and well considered candidate, and someone that has given considerable thought to being a doctor, and by proxy, has really considered different situations. Someone that at least at a surface level appreciates the responsibilities of a doctor, in confidentiality and preserving patient autonomy, also, in the actions that one takes, we want to do the best by the patient, that is beneficence and we also want to avoid harm, being maleficence or malfeasance, as some other people would call it. In thinking about a framework to approach medical ethics there are a few steps that I usually take in approaching a medical ethical question. So broadly speaking there are a couple of different types of situations that you'll be faced with. The first type of scenario that you may be faced with is one in which you're expected to act within a scenario. Either as a doctor, a student or as a lay person, and they put you in a difficult situation and you have to make a decision. In that type of scenario I would take the framework approach of stakeholders. I would talk about the stakeholders in the situation and go through a timeline from before the decision, the decision I am making now, and after the decision what are the additional considerations I would like to make. Lets take this station as an example. You're a doctor working in a local rural hospital and two patients come in after a road accident. One patient is a 48 year old named John, he's being very aggressive with staff, but also appears to have significant injuries and was actually the person who had been walking across the road and was hit by the other patient who was on a motorbike. We also have a 76 year old Doris, who had been driving in a car nearby and had stopped to help 48 year old John, and had been hit by the motorbike as well. She's calm, she seems remarkably less injured, and we don't have the motorbike patient themselves. They drove away after hitting both John and Doris. Who do you treat and why? What considerations would you make in your choice?
Okay, so let's imagine we have one to two minutes to answer this first question, and remember now we're in this situation, we are the doctor.
Fraser's Interview Framework - Medical Ethics Step One - Entering the room (executive summary) First in any station in medical ethics you want to identify the core issue or thing that you're being asked to do in that station, and why it makes it difficult. I like to think of it as the main thrust of the issue, that's what you're trying to summarise in that first step. So you may wish to say something like, this station I'm being put in a difficult situation where I have to prioritise care or allocate resources in a situation where I may or may not have help, between Doris and John. We have different characteristics like age, their culpability in the actual accident, and I'm being asked to prioritise these things. The reason that it is useful to start a situation like that, it shows the interviewer that you are very aware of what the station is about, and not only that it shows that you really, really understand what's going on behind this question, and what they're trying to get out of it. It's more risky than just walking in and sort of verbatim summarising what was on the station, but that risk is rewarded with a significantly better mark no matter what happens next. Because even if I don't hit all the points that I maybe want to, or the examiners looking for, from the outset I've taken control in the station and I've said clearly what I think is the main issue here, if you get it right then it's very likely that you're going to do well.
Step Two - Past (before the situation) All right so we've done that, so step two, so talk about the things that happened before the situation. "So before talking about which patient I would like to give care to, I'd like to first acknowledge that what is my situation? So I'm in a local rural hospital, am I actually on my own? Is this truly a situation where I'm the only person available to give care? Is there anyway that I can anticipate this? I would hope that the ambulance would notify me of the patients incoming, hopefully I could mobilise my team, nurses, other doctors in the area to help me in this situation of this type of trauma." So that just it's very brief but it shows that you have some sort of thought, decision making about the whole spectrum of the issue."
Step Three - Present (stakeholders) Identify the stakeholders in the moment of the actual decision. So now we get to our decision you don't want to take too long, you've only got a minute to two minutes. So we talk about each stakeholder: "In this situation we have two patients and for the case of this scenario I'm going to assume that I'm the only doctor. So ultimately the question is, how do I go about allocating resources? Well in any difficult situation like this you want to use an appropriate medical triage's system. I know that most hospitals would have an existing system to do this, but most of them acknowledge acuity, so how dangerous or significant the injuries of the patient are. Also, time in a first come, first serve basis. So sometimes patients maybe triage as Cat One, which means that they have to be treated immediately, urgently. Cat Two maybe in 15 minutes, Cat Three might be in an hour, Cat Four might be within four hours. Given the basic description that I've been given it's hard to say exactly, but I get the sense that John has had more significant injuries, he's aggressive, which is obviously making it difficult for staff but maybe behind that aggression there's some sort of brain injury, or he may be more distressed. But ultimately my decision making its more about the medical issues, they are both medical, chemical and physical restraints that I can use if I need to. So ultimately I would probably treat John first in lieu of Doris, have her carefully monitored by the other staff that I mobilised. Then treat her second, given that at least on face value we think that she has less injuries than John. We also have to consider other patients in the hospital, how would these patients be triaged amongst them? Again it depends slightly about the acuity of the other patients in the hospital. But ultimately using existing triage systems we could solve this problem, and it wouldn't be an emotional or age based, or gender based thing. We just treat the patients that need our care most. To try and optimize the use of our resources for patient outcomes." So that's step three done, and then we go onto step four. Step Four - Hindsight (evaluate your choice) So step four is approaching hindsight or what other things could we do better? You only want to mention this briefly because it's often the follow up questions, if John had, had this, that or the other? If Doris had been this person or that person? If you had another doctor what would you do? You don't want to over talk through the scenario, and kind of try and pre-empt all the questions. But it is worth mentioning that, and I would say something like, it's worth considering in this local rural hospital after the situations been done, and we've provided care to John and Doris, we just want to make sure that in the event of a future trauma or motor vehicle accident we do everything in our power to optimize the hospital, and to improve the outcomes for the patients that arrive. So I would definitely have a debriefing situation with all the staff, and hopefully the senior administrative and medical work force staff at the hospital. In doing so hopefully we can establish new procedures to make sure that there isn't a situation where I am only able to give care to John or Doris, and I'm unable to treat everyone in a timely fashion, which is quite dangerous if it was only two patients and we were unable to treat them. Imagine if there were more patients than that. So there you go, that's a medical ethical framework, you have a four step approach, which you can use in any type of scenario, it doesn't have to be just resource allocation. You talk about one the main thrust or ethical sort of crux of the issue. Step two, you talk about the things that happened before the scenario that you're in. Step three, you talk through the decision within all the stakeholders, tell me what are the different things that you were considering and valuing in your decision making. Step four, you give us a hindsight, and think through what the actual issues were that were dealt with, and how you could better improve patient outcomes in the end. The other type of medical ethical station that we didn't talk about in this podcast was the issue around a scenario where it's a more direct medical ethical issue. IE: giving a blood transfusion to a Jehovah's witness, maybe dealing with a minor, prescribing a pill to a patient under the age of 15 etc. Or another situation where you have to value autonomy and patient, doctor confidentiality, beneficence, maleficence in a more systematic way. You can still apply this same framework to those types of stations, however each of the stakeholders in question you talk about each of those principles in turn. So you talk about autonomy, you talk about confidentiality, you talk about justice. You talk about beneficence and maleficence in any of the decisions that you make. You go through each of the people that are involved in the scenario quickly, but you still do it in the same sort of time line based stakeholders approach. The thing that I would mention here is that it's not important to mention the words, autonomy, confidence, beneficence, maleficence, medical ethics etc. You don't want to show them that you've read a text book, or listened to this audio file, or read the blog post. However, you do want to show that you have a good understanding of the issues and how it may come to play. So talking through it in a natural way, in a way that you'd have a natural conversation it's best. So you can say something like, I want to make sure that I give the patient their autonomy, because that's something that you would normally say. I want to ensure that we keep confidentiality in this situation, I would make it clear that as a doctor I'm not allowed, and would not divulge the discussion that I'm having with this patient, especially given how difficult the situation is. Then beneficence and maleficence, I think are not part of a normal vernacular, even though it's in a medical interview it's not something you would normally talk about. So I would just say something along the lines of doing the best by the patient and avoiding harm. Those kinds of terms just come across more natural, it still shows that you've done the necessary work but it's also subtly showing that you're just talking about it in a natural way. That's our medical ethical framework, a four step process to going about any different medical ethical scenario. We used a resource allocation example, but really you could have used any different example in this situation. Good luck with your medical ethic stations, we will be back soon with another framework by Fraser's Interview Training. Hope your preparation is going well. You can check out our other free resources here