Tag Archive for: patients

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Staring Into The Abyss

I was surprised at the referral in the first place, but baffled after seeing the patient in the flesh. It was someone else’s clinic, and the note read that this 94 year-old man on androgen deprivation for asymptomatic low volume metastatic prostate cancer for many years had a climbing PSA. About 8. Please discuss combined androgen blockade with him. I began the talk about how combined blockade has a pretty weak benefit at the best of times, and that in a 94 year-old it almost certainly would not make him live any longer. He was asymptomatic, so he would not feel any better, and he may have a worsening of his side effects. I wrapped it up by telling him he was old enough to make his own decisions about his treatment, and if he didn’t want another pill to take, he could certainly say no. He said yes. I clarified the points about limited or no benefit, and possible exacerbation of side effects. He said if it would give him a few more years, he’d take it. I told him it wouldn’t. He wanted it anyway. I could not promise the treatment would not make him live any longer, and that was good enough for him. At the end of the consultation he was well counseled, and had made his decision. You might think of an 80 year-old you have seen who seemed more like a 60-year old, and think I was being unfair to the man, but I can confirm he was a 94 year-old who seemed very much to be 94.

I tend to assume that when people get to a certain age, they have come to terms with a few things, including death. This is not always the case, and I think running from death is becoming more popular. While research confirms that doctors have few illusions about treatment leading up to their own demise, and plan to refuse much of it, laypeople are hungry for all the invasive treatment they can get. As doctors, we don’t always help with this. We have pills and procedures that make statistically significant improvements in cancer specific survival, and what cancer sufferer would say no to that? We spend a lot more time studying how to hold failing anatomy together than we do learning to let entropy take its course. We have treatments that hint at immortality, nobody needs to die of Condition X anymore, now that we have Drug Y. What if this patient in front of us is the one in a hundred that has a durable remission? What if we kill them through inaction? What about the guilt-ridden estranged son who wants “Everything Done”?

Popular media have kept up a sustained and determined campaign for cardiovascular resuscitation in particular. Having an intelligent, sensitive, pragmatic talk to a family about not resuscitating the palliative patient due to the invasive, undignified nature of resuscitation for a virtually negligible chance of durable success is not as convincing as James Bond being defibrillated in his Aston Martin.

 

What is the definition of “good survivor” if not continuing to drink, gamble, and assassinate day zero post-resuscitation? Sadly, days or weeks of vegetative decline is much more common.

So what of the 94 year-old, who has already outlasted his cohort’s life expectancy by over 20 years? Who lived through two world wars, the rise and fall of the Soviet Communist state, the invention of Rock ‘n’ Roll, space flight, and electric foot spas? Objectively, he made an informed decision about his health care, prioritizing his values and concluding that the chance of increased quantity, however tiny, trumped quality. I can’t help think that in reality he kidded himself that he was beating death once again. He had evaded those cruel icy fingers, and secretly maybe thought he could live to a hundred and fifty. If he was my Grandpa, maybe I could have talked to him about embracing the end as a part of the natural cycle; not fearing, but accepting. But then, I was just his doctor.

Jim Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Tauranga, New Zealand. @Jamesduthie1

 

Prophylaxis against the Paradox of Choice?

My wife recently dropped and smashed her iPhone screen. She didn’t have insurance, and on consultation with her phone provider was told that her only option was to purchase another phone as she was locked into a lease contract. Our initial annoyance was then amplified when we discovered that we could just have the screen fixed privately for a fraction of the cost and effort, which we duly had done.

I began to think of the old Henry Ford adage (1910) in relation to his legendary Model-T edition car “You can have it in any colour as long as its black”, and wondered how often we as urologists might be criticized of adopting a similar approach with patients in their clinics.

Urology has always been a very progressive surgical specialty. Developed in 1909, TURP was the first successful, minimally invasive surgical procedure of the modern era. The first laparoscopic nephrectomy for a renal mass was carried out in 1991 in Johns Hopkins, surprisingly around the same time as the development in robotic (PROBOT) technology for use in urology (Murphy et al. 2006). As technology advanced, fellows and consultants became more sub-specialized in tandem with this change, leading to the large repertoire of treatment options and modalities available today. However, somewhere along the way with the vast change in the playing field, there appeared a concerning pattern of failure to discuss all treatment options with patients, or to refer them to other institutions which may/may not have provided an alternative treatment path. This trend, which is not oncology-specific, can be seen across a number of sub-specialty areas such as the management of renal masses, PUJ obstruction, radical prostatectomy, reconstruction post cystectomy, and even in paediatric urology with hypospadias repair being a classic example.

The question remains as to the reasons why one would not choose to cross-refer. Allowing for variables such as patient choice or consumerism, non-established or experimental procedures, and for urologists that may be financially or institutionally coerced into only providing certain treatments, the concept of not providing cross-referral brings into question whether this is perhaps down to financial considerations, a belief that referrals will not be reciprocated back, leading to a reduction in patient base and de-skilling, or a strong sense of paternalism where the urologist genuinely feels that they can offer a superior treatment package. This theme has previously been shown by Miller et al. who described how many patients with kidney cancer were offered treatment based on the surgeon’s practice style rather than on the characteristics of their disease.

However, given a choice of a number of options, it has previously been shown many times, that patients are more likely to build a strong rapport with the first specialist clinician they meet, and therefore likely to revert back to the first treatment option. Perhaps a lack of cross-referral is based on a pre-emptive sense of patient autonomy. Often the greatest power of autonomy is relinquishing it, and letting the consultant decide the best course of treatment offers the greatest solace. Despite the optimism and favorability of newer technology and techniques, and a general demand for minimally invasive procedures (Duchene et al. 2011), no-one is simply advocating technology for its own sake, or that a robotic-assisted circumcision could be currently seen as acceptable, however the idea of communication, cross-referral and the confidence in asking for further sensible treatment options should always be embraced.

In many ways, our annoyance with the mobile phone screen could have been avoided had the mobile provider been honest, and provided us with further options. It may not have stopped us from fixing the screen elsewhere due to institutional constraints however; a rapport and confidence would have been maintained.

One would do well to find a specialty in which the addition of a constructive (competitive) second opinion has not driven progress. Cross-referral is not a matter of failure, nor a lack of progress, but a continued determination to ensure the highest level of patient care available, to improve patient perception of the specialty as one committed to open communication, and a means to foster concrete inter-institutional relationships. Should we have to document that a second modality opinion was at least sought by the specialist, or waived by the patient?

“The single biggest problem in communication is the illusion that it has taken place” – G.B. Shaw

Fardod O’Kelly is a Specialist Registrar in Urology at AMNCH, Tallaght, Dublin 24, Ireland. Twitter @FardodOKelly

 

New technology for prostate cancer…beyond robotics!

Urology has led the way introducing new technology for men with prostate cancer. Robotic surgery, focal therapy, nanoknife, cyberknife – the list goes on. But have we fully embraced the everyday technology we all have access to in our care for men with prostate cancer? There are a growing number of Apps designed to support prostate cancer patients and improve quality of life. If you type ‘prostate’ into the iTunes App store about 82 results are found, but many of these are fundraising events, journals and staging tools, many of which are not patient friendly. Whilst there is an increasing appetite for patient-centered tools – focused on supporting and empowering patients in managing their health and wellbeing – we still have some way to go in this regard.

As a clinical psychologist working in urology, I often hear patients and their families describing their feelings of uncertainty and loss of control. Furthermore, Australia is a huge country with vast rural and remote areas and many patients that live in these areas find it very difficult to access the information, advice and support they require to ensure optimal outcomes from their prostate cancer.

The benefits of harnessing technology in the pursuit of improved health and wellbeing via improved patient engagement and access to services are clear; so why not use this technology to improve the care we provide to men with prostate cancer?

We have developed an online prostate cancer portal www.PROSTMATE.org.au

PROSTMATE provides tailored information, access to self-help interventions, a personal record of treatments and other milestones, a PSA graphing function and a regular check-up that records self-reported ratings across 5 quality of life domains and graphs these over time. PROSTMATE also offers telehealth (web-enabled video) consultations with prostate cancer nurses and allied health clinicians.

A complex and dynamic algorithm has been designed to tailor the extensive library of information to match the user type and stage of treatment for each person using PROSTMATE. Recommended library information is delivered to the user via their private dashboard and this information automatically updates when information has been read. This aspect of PROSTMATE was designed to help prostate cancer patients navigate to the information most relevant to them and their circumstances, and to reduce the often overwhelming feeling of information overload.

The timeline provides an opportunity for patients to record all their prostate cancer milestones including their treatments, test results, medical appointments, personal journal entries and more. The timeline’s graphical illustration of PSA results and self-reported quality of life over time also allows users to keep track of things as simply as possible.

The telehealth consultations are one of the most exciting aspects of PROSTMATE as they connect men, and their families with expert prostate cancer nurses and psychologists (and hopefully in the future exercise physiologists and physiotherapists) whom they may not have had access to in their routine care. We know that many men, particularly men from rural and remote areas, find it very difficult to access allied health services and we hope that delivering clinical consultations via telehealth will facilitate improved access to services as well as overall improvements in quality of life in the long-term; not to mention the potential savings made through reduced travel time, time off work and reductions in patient loads in busy outpatient clinics.

PROSTMATE launched to the general public in November 2013 and since then has attracted more than 700 new members. We have received overwhelming feedback supporting the use of technology in the care of everyone affected by prostate cancer. It’s surprising how many men and family members feel isolated by the traditional medical model and we are delighted that we can harness the power of technology to empower and connect people to their health and wellbeing.

PROSTMATE is free to join and has been supported by generous philanthropic funding. Our program is continually evolving as we learn what is most useful to our members, and through this, we intend to expand and develop new components and functionality in the near future. You can become a member yourself by selecting health professional in the sign up pages to see what PROSTMATE might offer your patients.

Visit www.PROSTMATE.org.au and follow us on Twitter @PROSTMATE

Dr. Addie Wootten
Clinical Psychologist

eHealth Research Manager
Australian Prostate Cancer Research
Twitter: @addiewootten @PROSTMATE

 

Brown Sauce and honest reporting

The British are fond of a condiment called Brown Sauce. The product itself leaves me unmoved, but the thing I find interesting about Brown Sauce is that it purports nothing about itself whatsoever, other than a description of its colour. It claims no link to any known product of nature, just a factual statement about its appearance. Consider, for instance, tomato ketchup. If an independent lab discovers that a ketchup is, in fact, only 5% tomato and 95% starch, sugar, salt, and flavor enhancer 621, people will be justifiably irate about the “tomato” claim. If, on the other hand, Brown Sauce is eventually proven to be made from asbestos and drowned kittens, the manufacturers can quite rightly state that they only said it was brown.

The same kind of plain speech is often missing in surgery. The truth has often been a casualty in the patient consent process due to a combination of ignorance, fear, avarice, or ego on the part of the surgeon. Whatever the motivation, when we explain rates of risks and benefits to the patient before us, many of us are not giving an honest report of our own outcomes. In the case of the battle between robotic and open radical prostatectomy, for example, real-world complication rates are often ignored in favour of Walsh’s rates on one side, and Patel’s on the other. Surgeons are certainly not all the same. If you have ever considered who you would allow to perform surgery on yourself the chances are you have written a very short short-list. When we tell a patient that the rate of complication x from procedure y is only 5% and we have not audited our own outcomes, we are likely giving the rates produced by the high-volume specialist centres that had the expertise, numbers, and clout to get their rates published in a reputable journal. Most surgeons do not work in those centres.

There is an on-going debate on whether hospitals should be compelled to publish their procedure-specific outcome data, so that the public can make informed decisions about their surgical care. I think this misses the point. Yes, there are potential hazards to compulsory publishing; centres of excellence may have worse outcomes than others due to operating on the sickest patients with the slimmest hopes of success, one major complication in a lower volume centre can skew the data, and there is the potential to develop a culture of suspicion and dishonesty, but the real point is more personal. We should honestly report to the patient in front of us from our own results as a matter of honesty and ethics, regardless of hospital policies. We can then (hopefully) reassure them that our outcomes are comparable to those published, and they can expect good quality care from us. If we cannot reassure them of this, our audit process will inform us of our shortcomings and we can seek to address them. We might even consider leaving certain procedures to a colleague who is better at it than us. A bitter pill, maybe, but arrogance is the enemy of improvement.

It can be a nuisance to collect and collate operative data. It can be painful to discover that we are not as good at something as we had assumed. Thankfully surgeons are mature adults who can take these challenges on the chin, and use the results to make our patient care better. Can’t we?

Otherwise, the information we give our patients is “pork-pies”, which is Cockney rhyming slang for lies, and no amount of Brown Sauce can make those pies palatable.

James Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Melbourne, Australia @Jamesduthie1

 

Are you ready to go to prison on a manslaughter charge?

Which of us fancies ending their career with a spell in the clink? Being a surgeon in the UK has just become a whole lot riskier. We all know that in our job success can add extra years to our patients lives, by contrast, failure, can result in significant harm, or, in the worst circumstances, death. We all do our best, but sometimes things don’t work out. The sentence of two and a half years in prison for Mr David Sellu, who was referred a patient who developed peritonitis after an orthopaedic operation and subsequently died, smacks of injustice, and sends a shiver down the spine of all of us surgeons, who work hard on behalf of our patients, but who cannot always guarantee success.

The case is reported in detail in the latest bulletin of the Royal College of Surgeons (Ann R Coll Surg Engl (Suppl) 2014; 96: 112-113). It appears that the main problem was a delay in taking the patient to theatre because of the difficulty in finding an anaesthetist; a problem that cannot be reasonably be blamed upon the surgeon himself. If prosecutions for manslaughter become more frequent in circumstances similar to the Sellu case, we may all have to develop new defensive strategies. The prospect of ending an otherwise unblemished career in a prison cell as a result of an unfortunate clinical mishap might deter many from entering the profession in the first place. How should we react to the very sad scenario?

Roger Kirby, The Prostate Centre, London

 

Digital Doctor Conference 2013

Digital consumerism is progressing relentlessly and whilst the advantages of new technology are evident in our personal lives, there is a palpable air of concern amongst the medical profession. “The Digital Doctor” team are positively embracing the benefits of moving healthcare into a new era and hope to direct the use of new technology in a constructive manner that will benefit both healthcare professionals and patients. To achieve these aims the “Digital Doctor Conference 2013”, was held for its second year last November, again kindly sponsored by the British Computer Society and held at their excellent headquarters in Covent Garden, London. The conference was attended by IT professionals, doctors, medical students and patients; thus group sessions contained some perspective on every aspect of healthcare technology. The organisers are also an eclectic mix of doctors and IT professionals, united by their interest in improving Health IT.

The conference included plenary talks, interactive group sessions and workshops. Eminent plenary speakers included Martin Murphy, Clinical Director at NHS Wales Information Service.

Martin challenged us to redefine our relationship with our patients in a new era where clinical information will be in control of patients and access to healthcare professionals can be as easy as a click away. How can we do all this safely in the light of the Snowden revelations? References to Stevan Wing’s (one of the organisers) two favourite books George Orwell’s 1984 and Aldous Huxley’s A Brave New World remind us of the superstition that underlie the beliefs, fears and challenges of society.

Software mediated care – implications for our patients and ourselves from Digital Doctor on Vimeo.

Popular teaching sessions at the conference were daily life IT tools, including the “Inbox Zero” philosophy, how to collaborate online, keeping up to date with RSS readers and Stevan Wing gave an introduction to the open-source “R project” for statistics. Other sessions focused on how to develop IT systems. This insight is useful both to allow healthcare professionals to construct their own IT solutions but also to help translate ideas to IT professionals. One such example being Sarah Amani, who used her experience as a mental health nurse to develop a mental health app for young people, called “My Journey”. In her inspiring plenary, co-presented with Annabelle Davis who developed the Mind of my Own app, she makes the point that the vast majority of young people rely on email, social media and online services therefore this is the best place to reach them. A session giving the methods and practicalities of developing IT systems was given by Rob Dyke, Product Development Manager of Tactix4. To help delegates get their ideas to reality Ed Wallitt, one of the organisers and the founder of Podmedics, built on earlier sessions about how to code, how a website works and information design, explaining how to use wireframes and prototypes, to achieve professional design of websites and apps.

Existing NHS IT systems were explained using the example of an emergency patient admission. Tracking the patient journey from home to hospital, via A+E, then transfer to ward, rehab back home, with GP clinic the final destination. At each stage a different IT system is employed such as the emergency 999 network and the N3 private network. Concepts such as the NHS spine were introduced and explained. A complex web of systems were shown to be in use, with numerous safety mechanisms; providing some explanation as to the difficulties faced by employees in the NHS.

Delegates were able to implement this teaching in the “App factory”, to solve problems they face in daily life or work. Three app ideas were created and presented by separate teams. These were a teaching log for doctors to record teaching sessions and simultaneously get feedback from students, a productivity app to provide useful information for new doctors to know about any hospital, however the winning idea was a patient facing app for use in hospital, to track updates in ongoing care.

In another session Matthew Bultitude, an Associate Editor of BJUI, was invited by Nishant Bedi (another organiser) for his vision of the future of medical journals. Journals are key in shaping the way medical practice is conducted and the dissemination of information is as important as ever in the digital age. Paperless journals may be the future however traditional business models rely on paper journals for revenue and many journals have yet to feel confident in moving all of their content exclusively online. Yet there are signs of change with European Urology adopting a paperless format for members from Jan 2014, now surely others will follow?

Under new leadership, the BJUI has recently focused on revolutionising its online presence, starting with a complete website overhaul. Amongst many changes to its design, the website now hosts an article of week, user poll, blogs and picture quiz. Numerous metrics for the website now show significant improvement in website visitors, duration of visit (1 to 3 min) and “bounce” rate. The increasing importance of social media for health professionals is demonstrated by the fact that more than ¼ of website traffic now arrives from Twitter and Facebook, having previously been dominated by search engines. Matthew finished by discussing alternatives to impact factor, such as the journal’s “Klout” score or “individual article” metrics, which are likely to be increasingly important as medical journals develop more web and social media presence. Extremely accurate individual “article level metrics” are calculated by checking number of views, tweets and re-tweets, and mentions in review sites (such as F1000 Prime). It is clear to see how powerful this could be, for example when discussing viewing numbers and duration of reading, Matthew can inform us that currently BJUI Blog articles are each read for a total of 5 min, with even the 15th most popular article receiving almost 500 views.

This talk was paired with one from the futuristic journal “F1000 Prime”. This journal provides an extra layer of expert peer review, using scientific articles that are already published in other journals. Thus articles selected by F1000 Prime direct users to the most significant developments in their chosen field, the expert reviews of the articles include an article rating, relevance to practice and whether there are any new findings. Research has shown that selection of an article by F1000 Prime, is an accurate indicator of future impact factor. Users may also receive email alerts of recommended relevant papers and they are able to nominate articles, follow the recommendations of an expert reviewer. Also refreshingly, any submissions to the journal, receive a completely transparent peer review process, openly available to any user.

Conference attendees were given the patients’ perspective of Health IT, by a panel chaired by Anne-Marie Cunningham (another organiser). These real life stories, gave insight into the mindset of people suffering from demanding chronic disease, both at home and in the hospital. Importance is given to people taking ownership of their health; both rare and common diseases were mentioned including Addison’s disease, asthma and mental health issues, where 24 hour support is an unfulfilled requirement and there is a need for a more integrated approach. Positive examples were given with one patient gaining reassurance by regular home peak-flow monitoring that can be reviewed remotely by her respiratory consultant. This helps to determine optimal timing for clinic review, with other similar examples seen in home blood pressure or blood sugar monitoring. Importantly social media and support groups can provide 24 hour advice and connect patients with expert doctors or similar sufferers all over the world. It was clear that the lack of hospital WiFi disconnects some patients from their online support networks, when they are actually most vulnerable. Other complaints centred around the underuse of email appointments and text alerts, which could empower patients to chase their own appointments or scans. 

Delegate feedback suggests this conference is unique and covers a rapidly expanding area of Medicine. We look forward to the next conference in 2014. The Digital Doctor 2013 conference program and highlights are available from the website or directly on our vimeo chanel. For updates and upcoming events follow us on Twitter @thedigidoc and the podcast is available from iTunes or our website. 

Mr. Nishant Bedi
Core Surgical Trainee (Urology), West Midlands Deanery

Dr Stevan Wing
Academic Neurology Registrar, East of England and The University of Cambridge 

 

Annabelle Davis

Should we beware of the patient bearing gifts?

Whilst I was observing a doctor in an oncology clinic, the doctor mentioned to me a gift she had received the previous week from a patient after giving her the wonderful news that she was cured of her lung cancer. This gift was a pair of concert tickets, which clearly cost a lot of money, and made me think about the ethical issues of, and the regulations behind, receiving a gift from a patient. However, thieves and con-artists don’t give up easy, so here are the tactics you can expect them to use. You can expect them to represent themselves using domain names that sound like government agencies. Names such as Obama Modification, or Obama Housing Plan, and similar names. They will buy.org domains to present themselves as non-profit agencies. For instance, there are bankruptcy Long Island Personal Injury Law Firm, family law and divorce lawyers, tax lawyers, etc. There is no area of practice known as loan modification. Many attorneys can provide help with a loan modification. But, it’s important to understand, that the only party that can modify your mortgage is the lender. The attorney can only help facilitate it. It’s fine, even a good idea to retain an experienced attorney to help you when you are faced with a financial hardship and the possibility of losing your home.  A law firm is a law firm and has no need to qualify itself as back, based, or driven. If you are facing these issues, most law firms offer free consultations to discuss your case. Take that opportunity to meet with an attorney and find out how they can help you. It will cost you nothing and may save you not just thousands of dollars, but very likely will save your home as well. David Miller is a freelance writer and marketing consultant. He has written extensively about bankruptcy, debt settlement, debt consolidation, credit and credit cards, collection agency abuse, consumer law, credit card defense, FDCPA guidelines and complaints, loan modification scams, and foreclosure.

Injury cases can be very complex for an average person to deal with, especially if that person is injured and under a lot of stress. If you are injured, then the last thing you should be focusing on is paperwork and legal semantics. This is just one reason why hiring a personal injury attorney may be best for you. These attorneys will automate the entire legal process for you, so you won’t have to worry about filing any paperwork. Another reason why hiring a personal injury attorney would be a good idea is to receive reparations for any property damage that may have occurred during the incident in which you were injured. Often times property damage and injuries go hand and hand. Aside from receiving financial health aid, it would be best to ensure the safety and well being of your property as well, and a personal injury attorney can help you with that. You can read this article for more information about the Chicago Personal Injury Lawyer.

 It is human nature to show gratitude for a deed done. This is why after a doctor has treated a patient they are sometimes presented with a gift from the patient or a relative. This becomes particularly apparent at Christmas time with long-term patients whom doctors see on a regular basis. This gift is usually simply a token of their gratitude towards the doctor and is meant in good will. Of course, the gift may not be given in gratitude, but meant as a bribe or used as a way of manipulating the physician into a particular treatment decision. Thus, receiving and accepting this gift raises a few ethical dilemmas. The acceptance of the gift can be suggestive of bribery and favouritism when it comes to treating the patient on a subsequent occasion or even influencing the doctor’s treatment decision if received part way through treatment. The GMC guidance in ‘Good Medical Practice’ (GMC, 2013) states in their ‘Honesty in Financial Dealings section’:

“You must not ask for or accept – from patients, colleagues or others – any inducement, gift or hospitality that may affect or be seen to affect the way you prescribe for, treat or refer patients or commission services for patients. You must not offer such inducements.”

Under the Bribery Act (2010), bribery is defined as “inducement for an action which is illegal, unethical or a breach of trust” with inducements being in the form of “gifts, loans, fees, rewards or other privileges”. Thus clearly this is a relevant piece of legislation to the ethics of receiving a gift from a patient.

Gifts can often range from tickets to a concert or show, money, high street shop vouchers, wine, or just a box of chocolates. The value of the gift, in terms of monetary value, is more important than what the gift actually is. Where these gifts are easy to share, for example a box of chocolates, then most healthcare professionals would place these in the staffroom or nurses’ office for everybody to share. The current General Medical Services (GMS) contract states that any gift worth over £100 must be declared and the details must be kept in a register at the hospital or surgery (MPS, 2013). Of note, individual hospital trusts will have their own rules, so it is worth finding out what your local policy is. For example, one hospital trust clearly states that while small gifts e.g. chocolates are ok up to a value of £25, larger gifts e.g. wine or food hampers are not and should be refused and entered onto the hospitals gift register.

If local rules are not followed, not only would it constitute a breach of employment with the ultimate sanction being dismissal, the doctor who received the gift may even be accountable on the Bribery Act charge, which has the maximum penalty of 10 years in prison and an unlimited fine. The advice given is that if you do accept a gift, you must declare it, be able to prove that it did not influence your treatment decisions regarding that patient and to make sure that the patient is aware of the implications.

The size of the gift is also important when considering how substantial it is and whether the patient can afford this gift within their means. If you believe this gift is too extravagant for the patient to afford then the best thing to do would be to politely refuse it. The refusing of the gift is one of the main ethical issues, where the act of refusal may offend the person giving the gift and even disrupt the doctor-patient relationship which has clearly reached a certain level of respect and kindness. An excellent and important example of this can be learnt from the high profile case of psychiatrist Dr Peter Rowan who accepted monetary gifts of £50,000, £100,000 and a £1.2 million beneficiary from a woman under his care in London (MDDUS, 2010). When he tried to refuse these gifts she became angry and he felt obligated to take them. Due to the large amount of money, he made sure this was within her financial means by consulting her solicitor. Dr Peter Rowan has since been struck off due to the unclear reason why his patient left him £1.2 million in her will.

The concert tickets gift received by the doctor in the oncology clinic mentioned above clearly cost more than £100 and thus had to be declared. The doctor, not wanting to offend the patient, accepted the tickets and feeling it was not right to accept the tickets for her own use, organised a raffle for everybody in the oncology department to win the tickets. This, to me, seems like an appropriate and perfectly acceptable decision, which solves the ethical dilemmas of accepting the gift and not offending the patient, but not being accountable for using the gift as a bribe or to influence patient treatment by raffling the tickets for the whole department.

Kathryn Miller
3rd year Medical Student, KCL, London, UK
@Kathryn4365058

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