Ethical Obligations
Do professionals have ethical obligations that ordinary citizens dont? In addressing this question you should think about: how do we define a professional, over and above a person who makes money doing what they do? What sorts of ethical obligations do ordinary citizens have? What sorts of ethical obligations do professional have just because they are professionals? And then, finally, do professionals have ethical obligations that ordinary citizens dont? Written assignments are due by 11:59 pm Eastern time on Sunday. They need to be 2 pages double spaced, include citations where appropriate and refer to and incorporate the material in the text book and other sources. Written assignments draw on the topics raised in the forum discussions and you may refer to and use the material in your posts in your written assignments. However, a written assignment may not be a simple recycling of your posts but needs to go further to bring in additional materials and to elaborate on, respond to, or refute points made in discussion posts. Finally, writing is a component part of your grade and I will grade down for grammatical errors or poor writing. I have posted a handout called “The Sinful Seventeen” in the week 1 materials that outlines some of the most common grammatical mistakes and their corrections. Im posting below An article we had to read, PLAYING IN THE MAJORS Herbert J. Keating, M.D. “What does it take to be a professional?” The year was 1980. Dr. Ralph Reinfrank, chief of medicine at Hartford Hospital, was running “morning report,” a time-honored teaching method in medical training programs. Each morning, second- and third-year residents, people two or three years into their postmed-school training, would assemble in a circle in a Spartan conference room, Styrofoam cups of bad coffee close at hand. There the “on call” resident would present cases, essentially telling patients’ clinical stories from the night before. The chief doctor, in this case, Ralph, would help provide instructive feedback, which he did in a Socratic style. Except for the case that prompted this memorable question, most of the feedback concerned nuances of internal medicine diagnosis and therapy — not critical “life and death” stuff. (Ralph is now, himself, dead, which is sad. Although he was diminutive and bespectacled, and wore off-white hush puppies, which were distinctly uncool, we residents were profoundly respectful of Ralph’s brainpower.) “Tell me exactly what you were thinking,” Ralph said to the admitting resident, a petite, self-confident, brown-eyed woman with straight black hair. A three-headed silver stethoscope draped around her neck like a tribal necklace. “Are you telling me, Doctor, that you started heparin last night on a patient who was bleeding from the GI tract?” “Yes, I started the heparin, ” she answered. “I thought he might have pulmonary embolism. And the blood was only on the Hemoccult slide.” (Heparin, a blood thinner, interferes with the generation of clot –a good idea if there is pulmonary embolism, but a bad idea if there is bleeding.) Ralph took a loud, deep breath, and then exhaled as if he were in pain. Some of us near him could smell the tobacco from cigarettes he would sneak and smoke sometimes, a weakness he was not proud of. “Let me recap,” he said, his face deadpan. “How old was this man?” “Forty,” she muttered. “What precisely were his risk factors for a pulmonary embolism?” Silence. Then, she said, “He had chest pain, worse when he took a deep breath, and he was short of breath.” Ralph paused a moment, then asked quietly, “Did I ask you what his symptoms were?” The resident looked confused. Then came the point of Ralph’s blade: “Please pay attention, Doctor. These words have meaning. Medical words mean something. I said risk factors, not symptoms.” The admitting resident flushed red and seemed as if she might cry. Then she regrouped, almost as if she were telling herself, “Buck up, you went to Vassar and UVA, you can handle this.” “He was obese.” Ralph looked around. “He was obese,” Ralph restated, tersely. “Forty and obese. Hmmm.” Ralph looked at each of the rest of us residents, one at a time, as if his eyes could look into the gray matter of our brains. Some of us squirmed a bit. “What are the established risk factors for pulmonary embolism?” he asked. Several voices shouted out responses: Virchow’s triad, post-op state, drugs that promote clotting such as estrogens or birth control pills, etc. Ralph returned to the resident. “Did your patient have any of these, Doctor?” “No.” Her answer came with an edge to it, a bit defiant. “And yet, you started him on heparin knowing that he had blood in his stool?” No answer for a while. Then a reluctant “Yes.” At this Ralph paused. Evenly, without a touch of irony, he said, “Doctor, at the end of our little conference, I should like you to go back to your patient and check and see if he has not yet bled to death.” The admitting resident looked down at her lap, and closed her eyes, as if she were feeling sick. And then Ralph posed the question. “What does it take to be a professional?” It seemed like an odd question; no one spoke. Ralph ended the silence. “I don’t care what kind of professional. Any professional. Let’s take Ted Williams. Or Joe DiMaggio. What made Joe a professional baseball player?” The surprise reference to a ballplayer eased the tension, and several of us nervously laughed. “‘Cause he got paid to play?” one of us offered. “No, that’s not it,” Ralph said. “Plenty of people get paid to do jobs that they cannot do. Even ballplayers.” Silence followed, and then Ralph answered the question. “Joe was a professional for many reasons. He didn’t waste a lot of energy. He showed a special “economy” in his movements; he had `good moves.'” “But most importantly,” Ralph continued, “Joe was a professional because he was selfconscious about his craft, constantly analyzing what it was that he was doing. He didn’t just hack away at it.” The room was totally quiet. No one moved a muscle. “What you, ladies and gentlemen, are doing — taking care of complicated problems in human beings — needs professionals. Like Joe DiMaggio. Don’t just hack away at it.” Ralph allowed a few more seconds of silence and then concluded. “An automatic decision that pleuritic chest pain and shortness of breath equals heparin is the medical equivalent of hacking away.” Suddenly, the admitting resident got white in the face, bolted out of her chair and flew out of the conference room, the tails of her white lab coat trailing after her. We learned later that her patient had pneumonia, not pulmonary embolism. As a result of the heparin, he had, indeed, bled significantly from what turned out to be a colon polyp. But he did OK. And from then on, the rest of us, the residents, did better. Dr. Keating practices internal medicine and geriatrics and is clinical professor of medicine at the University of Connecticut School of Medicine. Patients’ identities are concealed for confidentiality. You can e-mail Dr. Keating at hkeating@prohealthmd.com
