Professionalism/Ethics Exam 2

What does HIPAA stand for?

Health Insurance Portability and Accountability Act

How does Carilion find out about patient privacy concerns?

Individuals may raise specific concerns
Carilion may proactively monitor a high-profile patient's
medical record
An employee can be fired if they break one of these rules!

Percentage of US Medical Schools that reported incidents of students
posting unprofessional content online?
Of that percentage, what percentage involved breach in patient confidentiality?

60%
13% of the incidents involved violations of patient confidentiality

Who introduced the HIPAA Policy?

Senators Kennedy and Kassebaum

Why was HIPAA created?


Congress determined that there was a
need to develop standards to
protect the privacy of patient records and to
reduce cost through the streamlining of billing and
reimbursement processes.

Timeline of HIPAA

Enacted on August 21, 1996 and required Congress to
pass comprehensive health privacy regulation by August 21, 1999.
If Congress did not act, the Department of Health and Human Services
would have had to.
Congress did not act.
After receiving over 52,000 communications from the public, HHS
published the final rules in December 2000.
The effective date was April 14, 2001 with
implementation expected by April 14, 2003

TITLE I

Title I prohibits any group health plan from
creating eligibility rules or assessing
premiums based on health status and limits
restrictions that a group health plan can place on benefits for
pre-existing conditions.

TITLE II

Preventing Healthcare Fraud and Abuse, Administrative Simplification,
and Medical Liability Reform

Administrative Simplification

Electronic Transactions
Privacy
Security

What does PHI stand for?

Protected Health Information

Security Rule

Confidentiality � PHI is not available or disclosed to unauthorized
persons or processes
Integrity � PHI is not altered or destroyed in an unauthorized manner
Availability � PHI is accessible and usable upon demand by an
authorized person

Privacy Rule

Assure that individuals� health information is
properly protected while allowing
the flow of health information needed to provide and
promote high quality health care and to protect the public�s health
and well being

Who is affected by HIPAA?


Covered entities - Healthcare
providers including physicians, dentists, hospitals,
pharmacies, laboratories and health plans
are directly impacted.

Business Associates � Businesses that provide
services to healthcare providers such as collection agencies,
answering services and lawyers are
indirectly impacted.

What is considered individually identifiable health information?

information (including demographic data) that relates to:
The individuals past, present or future physical or mental condition
The provision of care to the individual
The past, present or future payment for the provision of health
care to the individual
Identifying individual or for which there is reasonable basis to
believe can be used to identify the individual

Covered Entities may disclose PHI under what 2 circumstances

As the Privacy Rule permits or requires
As the individual who is the subject of the information (or the
individual�s personal representative) authorizes in writing

According to privacy rule, who can you disclose PHI to?

The individual who is the subject of the information.
Other health care providers involved in the treatment and/or
referral of a patient
To obtain reimbursement for services provided to an individual.
For health care operations, such as quality assurance, case
management, credentialing, and accreditation and the training of
students and residents.
Obtaining informal permission by asking the individual outright
as long as the individual has the opportunity to agree, acquiesce, or
object. Examples include facility directories and permission to
disclose information to family members.

According to the privacy rule, when MUST you disclose PHI?

As required by law (statute, regulation, court order)
Public health activities
Victims of abuse, neglect or domestic violence
Health oversight activities
Judicial and administrative hearings
Law enforcement purposes
Decedents (funeral directors, coroners)
Organ, eye, tissue donation
Research
Serious threat to health or safety
Essential government functions
Workers� Compensation (as required by law)

HIPAA is federal or state run?

Federal, BUT states can make more restrictions
Floor NOT ceiling

When disclosing PHI, it is the responsibility of the covered entity
to do what?

must make reasonable efforts to use, disclose, and request only the
minimum amount of PHI needed to accomplish the intended purpose of the
use, disclosure, or request.

What do covered entities do to protect PHI?

Written policies and procedures
Designated privacy officers
Employees and independent providers are educated at the time of
initial employment, and annually thereafter, �not to disclose or
discuss PHI with others unless it is necessary to serve the patient or
required by law.�
Business Associate Agreements are executed with entities that
utilize PHI to provide services to covered entities
Reasonable efforts to protect PHI:
�Limiting access to electronic records
�Auditing those who access electronic records
�Shredding of documents
�Conducting audits and surveys to improve the physical security
of PHI.
�Screensavers
�Fax cover sheets
Patients are provided a �Notice of Privacy Practices� which
includes patient rights.

Patients Rights

To inspect and obtain copies of medical records.
To amend information the patient believes is incorrect subject
to organizational approval.
To request an accounting of disclosures for those disclosures
other than for treatment, payment or healthcare operations.
�Reports made subject to State and Federal laws such as
disclosures to funeral homes, communicable diseases, vital statistics.
To request restrictions on what information is provided to
others - exception if patient pays cash then information cannot be
released to the insurance company.
To request that confidential communications are provided by a
particular means or location - exception for emergencies.

Exceptions to the rights

Copies may be denied if the access requested is reasonably likely to
endanger the life or physical safety of the individual or another person.
Amendments may be denied

Denials must...

Be in writing
include the reason for the denial
include directions for filing a complaint

What do covered entities do if you violate HIPAA

Oral warning with retraining
Written warning with retraining
Termination
Referral to law enforcement

Civil Penalties

$100 per incident not to exceed $25,000 for identical violations per year

Criminal Penalties

Up to $50,000 and 1 year for knowingly and improperly obtaining or
disclosing PHI
Up to $100,000 and 5 years if the offence is committed under
false pretenses
Up to $250,000 and 10 years for obtaining or disclosing PHI with
the intention to sell it or use it for malicious purposes.

Things we are advised NOT to do (be aware of these, dont memorize)

You should not access PHI for which you have no legitimate reason to access.
You should not discuss PHI in public places such as elevators,
bathrooms, lobbies, etc.
You should not share your computer password or use someone
else�s password.
You will not store PHI on your PDA unless approved by the
covered entity.
You should not throw PHI in regular trash cans.
You should not leave PHI in a place that can be accessed or seen
by the public.
You will never use social media to discuss
patient information.
Do not try to access your records or those of your family
members or friends.

What we can/will do

You can access records for which you have a legitimate need to access.
You can share PHI with those who need to know.
You can discuss PHI in appropriate places.
You will verify that you can share information with someone,
such as a family member, by asking the patient or by reviewing their
written authorization, or asking for the password/code assigned by
the covered entity if there is one.
You will follow all the covered entities IT policies and procedures.

What is more important privacy and confidentiality or patient safety

Patient Safety

Reasons for maintaining confidentiality

1.Shows respect for patients.
2.Patients want to control access to
sensitive information and expect physicians to
maintain confidentiality.
3.Confidentiality encourages people to seek medical
care and discuss issues candidly.
4.Complete information allows the physician to provide
the best treatment for the patient and public health.
5.Maintaining confidentiality prevents
discrimination and stigmatization.
6.The legal system may hold health care providers liable for
unwarranted disclosure of patient information.

The Duty to maintain confidentiality is outlined where

The Hippocratic Oath
The Osteopathic Oath
AMA Code of Ethics

What if a patient signs a waiver of confidentiality?

Waivers of Confidentiality DO NOT grant blanket permission to share
patient information!

When can confidentiality be breached to protect others?

Protect third-parties from violence
To protect others from the spread of disease

5 Criteria for Breaching Confidentiality

ALL MUST BE MET
1.�The potential harm to identifiable third
parties is serious.
2.The likelihood of harm is high.
3.There is no less invasive alternative means for warning
or protecting those at risk.
4.Breaching confidentiality allows the person at risk to
take steps to prevent harm.
5.Harm to the patient resulting from the breach
of confidentiality are minimized and acceptable.
Disclosure should be limited to information essential
to the intended purpose, and only those persons who need to know
should receive information.�

Tarasoff vs Regents of the University of California

Case where boyfriend disclosed that he was going to kill is
girlfriend to his therapist. Therapist was told that he could not
disclose information to girlfriend. Girlfriend was murdered and family
sued the University.

What state courts have ruled in regards to potential violence

�the duty of a psychotherapist to protect people who are not
patients applies under two primary conditions: (1) when the violence
is foreseeable; and (2) when the therapist has enough control over the
patient to prevent the violence (that is the patient is in an
institutional setting).�

3 Factors for Forseeability

1. a history of violence
2. a threat to a named or clearly identifiable victim
3. a plausible motive
If two of the three factors are present the provider has a duty to warn

Besides acts of violence, when can confidentiality be breached


Infectious diseases � healthcare providers are often
required to report certain diseases such as Lyme disease,
tuberculosis, MRSA, HIV and gonorrhea to the health department.
Many states require that healthcare providers report conditions
such as epilepsy to the department of motor vehicles.
All states require that injuries caused by weapons or
crime be reported to law enforcement.

When do you have to breach confidentiality to protect the patient?

All states require healthcare providers to report suspected
child abuse or neglect to the
appropriate agency.
Most states require healthcare providers to report suspected
elder neglect to the appropriate agency.
Many states require healthcare providers to report suspected
domestic violence to the appropriate agency.
Some states, Virginia included, require
healthcare providers to report impaired health care providers.

Problems with Omitting information from medical records

1.May compromise care.
2.Important clinical information will not be available in an emergency.
3.Appropriate documentation is required for reimbursement.
4.In many organizations testing/results can only be
ordered/received by computer so omitting potentially sensitive
information is not possible.

What if the patient specifically asks for something to not be
included in the medical record?

A physician may not include certain historical
information if it is recorded that this was at the
patient�s request. The physician may then keep a
file on patients with secure information
requested not to be shared with anyone, (including providers
or insurance companies).
With rare exception, diagnosis and treatments
including medications do require documentation so to
protect the patient in times of emergency or the physician
if a liability case should evolve. If information is
pertinent to the current treatment of the patient it should be
included in the record.
The information to not include should be a joint
decision between the patient and doctor, and should
be signed by the patient �to not share with any
outside party� if it is in a separate record.

5 Requirements for Consent for Release of Information

1.Written, signed and dated by the requestor
2.Valid
3.Specific
4.Time-limited
5.Right to revoke

Healthcare Disparities

Disparities occur in healthcare because of �differences that
occur by gender, race or ethnicity, education or income, disability,
geographic location, or sexual orientation.�
Inequality in�

Access, utilization and quality of care
Specific health outcomes

Medically Underserved Areas and Populations

Calculated based on need relative to access.
Index of Medical Underservice 0 (worst) to 100 (best)

4 Parts to Medically Underserved Areas and Populations

Primary care physicians per 1,000 population Infant
mortality rate Percentage of population below poverty
level Percentage of population 65 or older

Papua New Guinea Stats


0.05 physicians per 1000 people,
1 per 20,000

1/80th the resources of the US

Infant mortality rate 41 per
1000, 7 times that of the US

Uganda Stats

Approximately 1 physician for every 1000
people (0.12 per 1000) ???

Infant mortality rate 62 per 1000

United States Stats


2.7 physicians per 1000 people

Infant mortality rate 6 per 1000

What skills do we need to develop to be culturally competent as
medical students

Develop knowledge of diversity as it relates to
disease processes
Be able to obtain a culturally competent history and physical
Learn sources of information regarding cultural diversity
Develop understanding of personal biases
through introspection
Be able to conduct culturally competent patient education
Be able to develop culturally competent treatment plans
Understand epidemiological data relevant to
practicing culturally sensitive medicine

What is Cultural Incompetence and How Does It Lead to
Healthcare Disparities?

Providers may unintentionally provide lower
expectations for patients who are in disadvantaged
positions and therefore influence patient health outcomes
Providers may employ stereotypes when
under time constraints resulting in poor
patient communication
Patient may mistrust medical profession ?
leading to poor adherence ? resulting in
provider cynicism toward the patient ? thereby
provider offers patient fewer services (repeat)

% of physicians that believe that race or ethnicity adversely affects
health care delivery

Black physicians 77%
Latino physicians 52%
Asian physicians 33%
White physicians 25%
All physicians 29%

55% of physicians agreed that �minority patients
generally receive a lower quality of care than white patients�

Does the healthcare workforce reflect nation's diversity?

Healthcare Workforce Does Not Reflect Nation�s Diversity!
See slide 14 of lecture 11

Growth of Unwed Childbearing by Race in the US

White 28.6
Black 72.3
Hispanic 52.5

Causes of Healthcare Disparities


Patient factors
Socioeconomic status, insurance status, ability to pay for
health care, patient preference and adherence

Institutional factors
Cultural and linguistic barriers, provider shortages in
underserved areas

Provider factors
Racial or ethnic bias, poor communication, clinical
uncertainty when interacting with patients of another racial or
ethnic group

Geographic Issues
Physicians are less likely to locate in areas where greater
poverty exists

Key themes of the 2009 National Health Disparities Report

1.Disparities are common and
un-insurance is an important contributor.
2.Many disparities are not decreasing.
3.Some disparities merit particular attention,
especially care for cancer, heart failure, and pneumonia.

Efforts made by AHRQ and HHS to accelerate the pace of improvement by

1.Training providers.
2.Raising awareness.
3.Forming partnerships to identify and test solutions.

The Greatest Disparities Access to Care and Quality of Care for:

Cancer
Diabetes
End stage renal disease
Heart disease
Mental Health & Substance Abuse

See tables on slides and know general themes/trends

25-31

Appalachian Region

Population that spans the Virginia, West Virginia, Ohio, Tennessee,
Kentucky, Appalachian boundaries.

Appalachian Health trends

Higher rates of Cancer, in particular
cervical cancer
Higher rates of Heart Disease
Higher rates of premature infant mortality
Higher rates of lung disease
Higher rates of people living at or below poverty level
Higher rates of poor access to medical services
Higher rates of high school drop � out or non-completion

Global Perspective


Life-saving advances in science and medicine have
not reached 4+ billion of the 7.3+ billion people on Earth

Millions in developing countries die
unnecessarily each year from diseases that are
currently preventable
Just 3 diseases � AIDS, TB and Malaria � kill 6 million
people annually

Vaccine-preventable diseases kill 1.7 million
children annually

120 million women who want and need access to
family planning do not have it

98 percent of newborn deaths are in
developing countries (4 million annually)

Approaches that benefit disadvantaged populations


Enacting Pro-Growth and Pro-Poor Policies
�policies that promote economic growth should be accompanied
by social policies in areas such as education, labor, and primary
health care

Investing in Education - helps
reduce health inequalities because it enables people to obtain safer,
better jobs, have better health literacy, take preventive health care measures

Directing More Health Benefits Toward the
Poor - the poor tend to use health services less
than the rich, public health programs may use �targeting� strategies
to direct more benefits toward the poor

Promoting Primary and Essential Health Care -
�essential services� approach means providing a basic package
of cost-effective health services to everyone

Developing Public-Private Partnerships -
Nongovernmental organizations(NGOs) working with governments
to deliver health services

Mobilizing Community Resources - Intensive training
of community based health workers and traditional leaders

Establishing Health Financing Approaches - pro-poor
financing system emphasizes prepayment for health care through taxes
or insurance with contributions tied to a person�s ability to pay

Gender

The socially constructed characteristics of
women and men � such as norms, roles and
relationships of and between groups of women and men. It
varies from society to society and can be changed. While most people
are born either male or female, they are taught appropriate norms and
behaviors � including how they should interact with others of the same
or opposite sex within households, communities and work places. When
individuals or groups do not �fit� established gender
norms they often face stigma, discriminatory practices or
social exclusion � all of which adversely affect
health. It is important to be sensitive to different
identities that do not necessarily fit into binary male or female sex categories.

Sexual Orientation

A person�s EMOTIONAL &/or PHYSICAL ATTRACTION to
people of the same gender &/or a different gender
Most people identify themselves as lesbian, gay,
bisexual, or heterosexual, but there are many other
terms that people use to describe their sexual orientation

Gender Identity

An individual�s INTERNAL SENSE OF GENDER, which may
or may not be the same as one�s
gender assigned at birth

Gender Expression

Way in which an individual OUTWARDLY
presents their gender, through how they choose to
speak, dress, or generally conduct themselves socially.
The way one expresses their gender is NOT always
indicative of their gender identity

L in LGBTQ+


Lesbian: a woman who is attracted to other women

G in LGBTQ+


Gay: a man who is attracted to other men

B in LGBTQ+


Bisexual: someone attracted to people of
either gender

T in LGBTQ+


Transgender: when one�s biological sex and
gender-identity do not match

Q in LGBTQ+


Queer: individuals who don�t identify as
straight or who have non-binary gender identity

+ in LGBTQ+

inclusive of all identities

Cisgender

Having a gender identity that matches one�s
assigned sex

Intersex

A general term used for a variety of conditions in
which a person is born with reproductive or
sexual anatomy that doesn�t seem to fit
the typical definitions of female or male.

Gender Non-Conforming

Anyone who does not fit neatly into a gender role.
Sometimes this is used to suggest that there is something wrong with
people who do not fit gender roles. There is not.

Trans*

An umbrella term derived from a contraction of
�transgender� or �transsexual�. The asterisk is a
�wildcard� that stands for the multitude of
ways that trans* people identify. The prefix �trans� can
mean beyond, across, between, through, transcending, or changing. Many
trans* people have a gender identity that is different from the one
they were assigned at birth. Some people identify as trans* if their
gender expression is different than what is expected for their gender.

MTF

1. �Male to female�; a person who was assigned
male at birth and identifies as a woman.
2. Some trans* people use �MTF� to describe their medical
transition goals; they want their body to lose some �male-typical�
sex characteristics and gain some �female-typical� sex characteristics.

FTM

1. �Female to male�; a person who was assigned
female at birth and identifies as a man.
2. Some trans* people use �FTM� to describe their medical
transition goals; they want their body to lose some �female-typical�
sex characteristics and gain some �male-typical� sex characteristics.

Binary

Having two parts. Some societies such as ours tend
to recognize just 2 genders, male and female

Non-Binary

A person whose gender identity does not fit the strict
man/woman dichotomy.
Some non-binary people feel that their gender identity is
between a man and woman, is simultaneously fully man and
fully woman, changes from man to woman and back, is a separate
entity without connection to man or woman, is similar to either
man or woman but is not quite either, is entirely neutral, or does
not exist at all.

Two-Spirit

A term for LGBTQ members of the Native American
community, first coined in 1990 by a Native
American group in Winnipeg. The term references a
tradition common to several tribes, where some individuals possessed
and manifested a balance of both feminine and masculine
energies, making them inherently sacred people.

Accumulated Stigma


Barriers may be reinforced for LGBTQ+ people
who belong to more than one marginalized and stigmatized
group (race, ethnicity, or SES), or who simply express
themselves in ways that differ from accepted norms.
leads to both medical and behavioral health disparities.

How can stigma and discrimination affect individuals?


Directly: Bias by health care professionals, violence fueled by
hatred of LGBTQ+ people, and policies that deny health insurance
coverage to same-sex partners

Indirectly: Discriminatory actions toward LGBTQ+ people around
the world creating a negative environment for LGBTQ+ individuals
wherever they may reside.

Health Disparities facing LGBTQ+

Increase risk for depression, anxiety, suicide attempts, and
substance use disorders (LGBTQ+ youth are
4x as likely to attempt suicide)

Delayed or refusal of healthcare

19% of transgender individuals reported being refused
care because of their gender identity

Fears or concerns over disclosing sexual identity and
lack of culturally competent providers

Some Barriers Examples

Insurance: Wording excludes coverage outside of standard care
(hormones, surgery, definition of family)

Lack of providers knowledge of social issues
surrounding the LGBT community, or lack of desire in
treating this particular population.
LGBTQ+ in the elderly: Limited social support systems

Discrimination in assisted living facilities in
dealing with homophobia/transphobia

SS and pension plans often exclude a partner from
being on a significant others plan if marriage is not legally recognized.

Social Determinates of LGBTQ+ Health

Refer to economic & social conditions that
influence individual and group differences in health
status (e.g. social & economic resources such as housing
education, employment, and health care; government & institutional policies)

Social determinates of health are often linked to
stigma & discrimination. Examples
include: Schools that do not include sexual orientation &
gender identity/expression protections in their anti-bullying
programs can leave LGBT youth vulnerable to verbal & physical
harassment, which is associated with depression, suicidality, &
risk for HIV & other STIs. Employment discrimination
against transgender people can cause many to go without health care
& can lead some to engage in the sex trade as a means of
survival, putting them at risk for multiple health issues.
Unequal access to health care is of critical importance to all
LGBTQ+ people, particularly those who are poor &/or living with
HIV/AIDS Beyond insurance issues, many LGBTQ+ people continue
to lack access to providers who are knowledgeable about their unique
health needs or who understand how to address them with cultural
sensitivity.

4 Conceptual Frameworks

1.Life Course
2.Social Ecology
3.Minority Stress
4.Intersectionality

Life Course

People have different health care needs at different life stages.
e.g. LBGTQ+ youth may have concerns related to coming out to
their families, while older LGBTQ+ adults may have concerns about
loneliness & living without extended families.

Social Ecology

Characteristics of the social environment, including family, other
relationships, the community, culture, and general society, can affect
an individual�s behavior and well-being. How does the social context
of people�s lives influence their health?

Minority Stress

Sexual and gender minorities (like other minority groups) experience
chronic stress arising from social stigmatization and manifested in
both external and internal processes. Lack of social tolerance of
homosexual behavior may result in stress-related disorders, such as
depression, for LGBTQ+ people, especially in those who feel the need
to be covert about their sexual orientation or gender identity.

Intersectionality/Intersectional Lens

Social, racial/ethnic, religious, economic, cultural and other
factors-in addition to sexual orientation and gender minority
status-influence the identities, health, and lived experiences of
LGBTQ+ people. Clinicians may need to explore and understand the role
and intersection of different identities and other factors in their
patient�s lives.
so intersectionality is the intersecting of our diverse social
constructs. And these social constructs are what help us formulate our identities

Diversity

It is a broad concept that refers to the variety of group experiences
that result from the social structure of society. It is influenced by
social constructs such as but not limited to race, gender, age, class,
nationality, sexual orientation, religion, region of origin, and so on�

Social Media

Any electronic communication through which users create communities
to share information, ideas, personal messages, videos, etc.
User-generated content
Network, support, and educate

Digital Footprint

Trail of our online activity
-Information we access
-Details we share
-Games we play
-Groups we interact with
Remember that communication online can be
PERMANENT! You leave a trail of posts, searches, and
interactions (digital footprints) every time you log on!

Ethical and Professionalism Issues with Social Media

Limits of confidentiality
Can privacy settings really protect you and your patients?
Challenges in establishing and maintaining appropriate
boundaries in social networking
Need to define personal vs professional

The Social Contract

The American Medical Association Journal of Ethics:

SOCIETY GRANTED PHYSICIANS status, respect, autonomy
in practice, the privilege of self-regulation, and financial rewards
ON THE EXPECTATION THAT PHYSICIANS WOULD BE
competent , altruistic, moral, & would
address the health care needs of individual patients and society.
Professionalism online should demonstrate these attributes of a
good physician

Personal Conversations

Those you have with family, friends, significant others, and some
colleagues; power is
often shared

Professional Conversations

Include information that is relevant primarily to the nature of the
business relationship; power
is ultimately held
by the doctor

Exploitation


when personal interests take precedence over the primary
obligation to the patient in a way that harms (or appears to harm)
the patient or the patient-physician relationship

Increased chance of exploitation with social media
Often due to the disinhibition, belief of anonymity, and
asynchrony of interactions online (AMA)

Stats regarding medical students and unprofessional behavior on
social media

Out of 78 U.S. medical schools, 60% reported
incidents of students posting unprofessional content online. Material
classified as: Profane , discriminatory,
depicted intoxication, sexually suggestive, violated
patient confidentiality

92% of state medical boards in the United States
received reports of violations including:

improper contact with
patients

inappropriately giving
diagnoses

misrepresentation of
credentials

VCOM Social Media Guidelines

Be transparent
Maintain confidentiality
Do no harm
Consider your audience
Respect copyright and fair use
Be aware of liability
Define your role
Do not advertise on behalf of external vendors on VCOM websites
& social media presences.
Do not have interactions with patients on your social networking
sites; to do so may damage the doctor-patient relationship and may
have legal consequences.
Online discussions of or about specific patients should be
strictly avoided, even if all identifying information is excluded;
someone may still recognize the patient.
Avoid giving medical advice�this may result in a violation of
HIPAA and may cause danger to others.
Under no circumstances should photos of patients, cadavers or
other photos depicting body parts of patients or cadavers be
displayed online.
Under no circumstances should photos from OMM or physical
diagnosis labs be displayed online unless VCOM Administration has
given approval for the posting.
VCOM�s logo or other VCOM image cannot be used on personal media sites.
VCOM�s name cannot be used to promote a product, cause, political
party, or candidate.

Do not promote or condone unprofessional or
high risk behaviors such as,
excessive use of alcohol, high risk sexual behaviors, and other such
behaviors that would be embarrassing to the person or to VCOM.

Do not make disparaging comments about VCOM employees
(faculty and staff), other students or VCOM in general.
Do not make any comment that could be viewed as
discriminatory or harassment of any kind.

Potential Consequences for Misuse of Social Media

Disciplinary action by VCOM administration (ex. verbal reprimand,
suspension, expulsion)
Revocation of a residency selection or denial of residency
State medical boards have the authority to discipline physicians
for unprofessional conduct ranging from a letter of reprimand to
revocation of a license
Risk of legal ramifications, including claims such as libel,
slander, defamation of character, negligence, etc.
Rejection from potential employers or job termination
Tarnished professional reputation that will take years to
reverse, if ever

% of Recruiters who have rejected candidates based on data found online

0.7

Postive Uses of Social Media and Social Networking

Educational for doctors and patients (Student Doctor Network
(studentdoctor.net)-remember, this is a public forum!
TwitterDoctors.net- doctors can share articles, health tips, and other
practice updates)
Inexpensive way to spread word about your practice (ex. clinic
Facebook account)
Promotes community connectedness
Connecting with other doctors (Doximity.com: HIPAA compliant,
physicians only, Sermo.com: profiles are anonymous, verify users as physicians)

Fiduciary

A relationship in which one party (the patient) places special trust,
confidence, and reliance in and is influenced by another (the
physician) who has a duty to act for the benefit of that party.

Physician-Patient Relationship

As a general rule, physicians are under no obligation to treat a
patient unless they choose to. (Exceptions are made when emergency
care is needed and when refusal to treat is based on discrimination).
However, a patient-physician relationship is generally formed when a
physician affirmatively acts in a patient�s case by examining,
diagnosing, treating, or agreeing to do so [5]. Once the physician
consensually enters into a relationship with a patient in any of these
ways, a legal contract is formed in which the physician owes a duty to
that patient to continue to treat or properly terminate the relationship

Physician Sexual Misconduct

Behavior that exploits the physician-patient relationship in a sexual
way. Whether it is perceived as sexual by either party or only one party
This behavior is not for diagnostic or therapeutic
purposes, may be verbal or physical, and may include expressions
of thoughts and feelings or gestures that are sexual or that
reasonably may be construed by a patient as sexual.

Two levels of sexual misconduct

Sexual Impropriety
Sexual Violation
Both levels may be the basis for disciplinary action (e.g., from
state licensing boards) if the behavior exploited the
physician-patient relationship.

Sexual Impropriety

May comprise behavior, gestures, or expressions that are seductive,
sexually suggestive or sexually demeaning to a patient, including but
not limited to:
disrobing or draping practices that reflect a lack of respect for
privacy, deliberately watching a patient dress or undress instead of
providing privacy for disrobing
subjecting a patient to an intimate examination in the presence
of medical students or other parties without the explicit consent of
the patient or when consent has been withdrawn.
examination or touching of genitals without the use of gloves
inappropriate comments about or to the patient, including but not
limited to:
making sexual comments about a patient�s body or underclothing,
making sexualized or sexually demeaning comments to a patient,
making comments about potential sexual performance during an
examination or consultation except when the
examination or consultation is pertinent to the issue of sexual
function or dysfunction,
requesting details of sexual history or sexual likes or dislikes
when not clinically indicated for the type of consultation
using the physician-patient relationship to solicit a date
initiation by the physician of conversation regarding the sexual
problems, preferences, or fantasies of the physician
examining the patient intimately without consent.
Scope of sexual misconduct behavior would also include advances
towards employees, staff, former patients or immediate family of
patients of any origin (called a �third party� relationship) whether
office, clinic, or hospital.
Patient consent should not be viewed as a legal defense
because it is felt the patient cannot provide truly informed consent
due to the power differential in the Patient-Physician relationship

Sexual Violation

May include physician-patient sex, whether or not
initiated by the patient, and engaging in any conduct with a
patient that is sexual, or may be reasonably interpreted as sexual,
including but not limited to:
sexual intercourse, genital to genital contact
oral to genital contact
oral to anal contact, genital to anal contact
kissing in a romantic or sexual manner
touching breasts, genitals, or any sexualized body part for any
purpose other than appropriate examination or treatment, or where the
patient has refused or has withdrawn consent �ask the
patient�s permission �In order to check your prostate I need to
insert my finger into your rectum, may I?� instead of �I
am going to do a rectal exam now��
encouraging the patient to masturbate in the presence of the
physician or masturbation by the physician while the patient is present
offering to provide practice-related services, such as drugs, in
exchange for sexual favors.

Slippery Slope

Whenever a physician uses a patient for his or her own end, an
unethical relationship arises
The exploitation may be subtle or blatant May
result from strong feelings by either party (DO or Patient)
First infraction may be small
clinic appointment at end of the day and spending more time;
meeting outside of the office for coffee, or social situations;
or calling on the patient�s expertise in a particular field
These initial boundary violations can initiate a
�slippery slope� leading the physician and patient to serious
compromise and harm to the patient.

Examples of Boundary Violations

Sexual coercion
Relationships that disrupt the required objectivity in the
physician-patient relationship include:
?Prior or current social or emotional attachment to patients
(e.g., when treating a family member or special friend)
?Favoring a �VIP� patient
?Forming additional dual or reciprocal relationships with
patients (e.g., establishing a business partnership with an existing
patient, this would be a dual relationship)
?Purchasing a car from a patient

Ethical Issues Associated with Boundary Violations

Trust Betrayed
Unequal Relationship (Inherent Power Differential)

Can you enter relationships with former patients?

Medical Boards handle this question on a case-by-case basis.
The psychiatric professions view it as �once a patient, always a
patient��the power differential continues

North Carolina Medical Board

It is the position of the NC Board that proper care and sensitivity
are needed during the physical examination to avoid misunderstanding
that could lead to charges of sexual misconduct against licensees.

Guidelines for the prevention of misunderstanding


Sensitivity to patient dignity should be considered by the
licensee when undertaking a physical examination
Patient should be assured of adequate auditory and
visual privacy and should never be asked to disrobe in
the presence of the licensee Exam rooms should be safe,
clean and well maintained, and should be equipped with appropriate
furniture for examination and treatment�the exam table should be
positioned thoughtfully relative to the door and the
workstation Gowns, sheets and or other appropriate apparel
should be made available to protect patient dignity and decrease
embarrassment to the patient while a thorough and professional
examination is conducted. The licensee should individualize
the approach to physical examinations so that each patient�s
apprehension, fear, and embarrassment are diminished as much as
possible. An explanation of the necessity of a complete physical
examination, the components of that examination, and the purpose of
disrobing may be necessary in order to minimize the patient�s
possible misunderstanding.


GUIDELINES CONCERNING THE USE OF CHAPERONES
DURING PHYSICAL
EXAMINATIONS

For an examination of the breast and/or genitalia of a patient of the
opposite sex, a physician
must have a chaperone
present. (Chaperone also called a
stand-by )
The physician should have a policy that patients are free to make a
request for a chaperone; & the request by a patient to have a
chaperone should be honored �this is
regardless of the type of physical examination needed and the
genders of patient and physician.
This policy should be communicated to patients, either by means of
a well-displayed notice or preferably through a conversation
initiated by the intake nurse or the physician.
It is recommended that an authorized health professional
should serve as a chaperone whenever possible.
Physicians should establish clear expectations about
respecting patient privacy and
confidentiality to which chaperones must adhere.

If a chaperone is to be provided, a
separate opportunity for private conversation between the
patient and the physician should be allowed.

Boundary Violation Stats

Surveyed undergraduate medical college deans; - 60% reported
incidents of students posting unprofessional content
13% Violations of patient confidentiality 52% Use of
profanity 48% Discriminatory language 39% Depiction
of intoxication
38% Suggestive material

Prescribing to family

In certain instances a physician may need to prescribe medications
for family members, HOWEVER, such treatment may provide less than
optimal care.
Prescribing must be based on a �bona fide� practitioner-patient
relationship 1. Medical or drug history is obtained 2.
Provide information to the patient about benefits and risks 3.
Perform an appropriate physical exam 4. Initiate additional
interventions and follow-up care as needed
�A practitioner may prescribe Schedule VI controlled substances
(as defined in as defined in �54.1-3455 of the Code of Virginia) for
him/her self or a family member.�
�A practitioner cannot prescribe a controlled substance to himself
or a family member, other than Schedule VI, unless the prescribing
occurs in an emergency situation or in isolated settings where there
is no other qualified practitioner available to the patient, or it is
for a single episode of an acute illness through one prescribed course
of medication. �

Dual Relationships

Dual relationships can occur anytime that a physician relates to
patients in more than one relationship, whether professional, social,
or business in addition to being in the treatment relationship.
Presents both ethical and possible legal challenges.
Common types of dual relationships:Social Dual relationship (friend)
Professional dual relationship (work colleague)
Business dual relationship (executor of their will!)
Student and professor

Bartering

unless both parties to the barter arrangement report the value of the
services received as income, the barter may be illegal.

Sale of Non-Prescription Health Related Products

1.Limit sales to products that serve the immediate and pressing needs
of patients.
2.Distribute health-related products to their patients free of
charge or at low cost to make useful products readily available
3.Fully disclose the nature of the financial arrangement with a
manufacturer or supplier to sell health-related products.
4.Do not participate in exclusive distributorships of
health-related products that are available only through physicians� offices.
A licensee shall be deemed to engage in dishonorable conduct if :
Licensee recruits or solicits a patient to participate in a
business opportunity involving the sale or promotion of a product or
service, or
Licensee requires the patient to recruit or solicit others to
participate in a business opportunity, and the sale or promotion of
the product or service directly or indirectly results in financial
gain to the licensee.

Termination of the physician-patient relationship

Give sufficient, advance notice to the patient in order to ensure
continuity of care and to permit another medical attendant to be secured.
The patient or the patient�s legal representative should be
notified in writing, sent by certified mail Offer to refer
the patient to another qualified physician or appropriate
medical professional. Provide emergency care to the patient
for up to thirty days.

Reasons to terminate a relationship

1.Treatment non-adherence�The
patient does not or will not follow the treatment plan.
2.Follow-up non-adherence �The
patient repeatedly cancels follow-up visits or is a no-show.
3.Office policy
non-adherence �The patient uses weekend on-call
physicians or multiple healthcare practitioners to obtain refill
prescriptions when office policy specifies a certain number of refills
between visits.
4.Verbal abuse �The patient or a
family member is rude and uses improper language with office
personnel, exhibits violent behavior, makes threats of physical harm,
or uses anger to jeopardize the safety and well-being of office
personnel with threats of violent actions.
5.Nonpayment�The patient owes a backlog of bills
and has declined to work with the office to establish a payment plan.

Origins of Mindfulness

Ancient Eastern meditation practices
Modern day mindfulness is considered a secular practice inspired by
2,600 year old Buddhist teachings.
Jon Kabat-Zinn founded the 1st mindfulness-based treatment approach
-- Mindfulness-Based Stress Reduction (MBSR)

Mindfulness


paying attention in a particular way; on purpose, in the
present moment, and nonjudgmentally
It is also defined as an awareness
that arises through
intentionally attending in an open, caring, and nonjudgmental
way

Important to distinguish mindfulness as
both a process (mindful practice) AND outcome (mindful awareness)

Mindful Awareness

The art of knowing what you are experiencing, as you are experiencing it

Seeing clearly and accepting what is here and now

Feelings

Thoughts

Perceptions
Involves simply observing your internal self without trying to get
more of what one wants (pleasure, security), or pushing away what one
doesn�t want (e.g., fear, anger, shame)
We develop patterns of behavior that are conditioned & result
in living on autopilot

Awareness involves distinguishing between beneficial
and unbeneficial tendencies
People can develop insight from being aware of their internal
experiences and ultimately make more deliberate choices
Ability to sustain attention and switch focus of attention
crucial for effective rapport building with patients

Mindful Practice


Formal practice: systematic meditation
practices that cultivate mindfulness skills (brief or intensive)

Informal practice: application of
mindfulness skills in everyday life; generalize what
is learned in formal practice

Mindfulness has effects on


Brain: emotion regulation, working memory, cognitive
control, attention, activation in specific somatic maps of the body,
cortical thickening in specific regions

Body: symptom reduction, greater physical well-being,
immune function enhancement, epigenetic up and down regulation of gene activity*

Mindfulness and Medicine

Studies show benefits for patients with acute and chronic diseases
such as:
Chronic pain, cancer, cardiovascular disorders, epilepsy, HIV/AIDS
Meditation used successfully in treatment and prevention of high
blood pressure, heart disease, migraine headaches, & autoimmune
diseases (e.g. diabetes and arthritis)
Proven helpful to curtail obsessive thinking, anxiety, depression,
and hostility

Burnout Rates amongst physicians

Up to 60% of physicians and nearly 50% of 3rd year medical students
report symptoms of burnout
Burnout associated with poorer quality of care and lower quality of life
Mindfulness may help with stress management, emotion regulation,
energy level, empathy, and ability to be fully present for both good
and bad daily life experiences

How physicians benefits from mindfulness

70 primary care physicians who took a year-long mindfulness course
reported lower stress and burnout symptoms

Mindfulness Techniques Formal Practice

1.Sitting Meditation
Breath-Counting Meditation & Deep Breathing
2.Mantra Meditation
3.Body Scan
4.Walking Meditation
5.Eating Meditation
6.Mindful Yoga

Sitting Meditation

Focus is on the breath
Tune into sensations of breath entering nose or mouth, or rise and
fall of abdomen
Note sensory experiences as they arise--hearing, reactions (e.g.
enjoying a thought, urge to scratch an itch), then bring attention
back to breathing

Breath-counting
: count each exhale; note when mind wanders then
simply start over & return to counting exhales

Deep breathing :
use of 4 senses

Mantra Meditation

Focus is on a word, syllable, or phrase of choice repeated over and over
Make a list and read aloud to see what feels right or inspirational
Common mantras: �one�, �OM� (pronounced aum
-traditional mantra)
Say mantra silently or aloud
Be aware of each repetition and bring attention back if mind wanders

Body Scan

Helps develop mind-body connection
Increases bodily sensations related to stress, pain, and other
forms discomfort
Usually practiced lying down with arms by sides, palms up, and legs
hip-width apart
Focus attention SLOWLY and deliberately on each part of the body
from head-to-toe or vice versa
Notice sensations, emotions, thoughts, then let them go and return
to exercise

Walking Meditation

?ocus is on the act of walking
Mentally note �lifting�, �stepping�, �placing� as they happen naturally
Pay attention to sensations in feet and lower legs
Alternative way is to count steps with breathing (�in�2�3, out�2�3)
Remember goal is not to get somewhere or exercise; it is to develop mindfulness

Eating Meditation

Pay attention to each aspect of the eating experience
Notice colors, shapes, smells as well as intentions and desire to
begin eating
Observe process of chewing and swallowing; silently label to help
maintain focus or use non-dominant hand
Works best when eating alone

Mindful Yoga

Practicing mindfulness skills while practicing yoga
Notice feelings, areas of tension, judgments, comparisons with
others, etc. and gently let them go
Practice on own requires intention to be mindful while going
through poses
Helps calm the mind, cultivate kindness for the body and awareness
of the body�s capabilities

531 Daily Practice to reduce burnout

Mediate for 5 minutes
Identify 3 good things that happened
Do 1 act of kindness

Mindfulness Based Clinical Applications

Acceptance and commitment therapy (ACT)
Conducted individually; helps reduce avoidant coping styles
Dialectical behavior therapy (DBT)
Helps improve emotion regulation, distress tolerance, and ability
to be mindful of others and their environment
Mindfulness-based stress reduction (MBSR)
1st and most popular; intensive 8-week program includes both formal
and informal mindfulness practices & didactics
Mindfulness-based cognitive therapy (MBCT)
8-week program aimed at treating depression, particularly relapse prevention
Similar to MBSR; varies in terms of mindfulness techniques

MSPE

Medical Student Performance Evaluation
Document that describes in a sequential manner a student�s
performance, as compared to that of his/her peers
The Dean�s Letter was redesigned
across medical schools in 2002 as the Medical
Student Performance Evaluation to ensure
consistency across medical schools
In 2016, the Association of American Medical Colleges introduced new
recommendations for MSPE letter writers for the first time since 2002.
NOT A LETTER OF RECOMMENDATION

When is the MSPE completed by

The MSPE is completed upon the successful completion of all
third year
core clinical clerkships and requirements
All MSPEs are loaded October 1 of 4th year for
residency site access

Honor Code Infractions

All infractions of the honor code are confidential to the student and
the College.
Serious honor code violations are a reason for dismissal or they are
required to be resolved prior to graduation.
The student will provide an explanation of any honor code violation
at the time of their interview.
Students must sign a release of information for information on an
honor code violation to be provided to the residency program.

Clinical Rotations Evaluations are based on...

Competency
VCOM Faculty utilize a competence based form which identifies
specific competencies:
Communication
Problem Solving
Professionalism and ethics
Medical knowledge
Osteopathic principles and practice

The Registrar completes what part of the MSPE?

Section 1: Academic Hx

The Associate Dean for Medical Education and Associate Dean for
Biomedical Affairs and Research completes what part of the MSPE?

Academic Performance-Preclinical years

The Clinical Associate Dean completes what part of the MSPE?

Academic Hx for clinical year 3
Preceptor comments may be modified to decrease length or on some
occasions for grammar; however, the content is not altered. Grades for
Post-Rotation Exams may be found on the transcript.
Comments by the Associate Dean for Clinical Affairs:
As you can see this student performed satisfactorily on clinical
rotations. The comments by preceptors speak to areas of this student's strengths.

Vice President or Assistant Vice President for Student Services
completes what part of the MSPE?

Campus Engagement

Appendix A includes

Honor Code Violations

What do residency programs look at first when evaluation and choosing candidates

1. Step 1 score
2. Letters of rec in field
3. MSPE
4. Step 2 score
5. Personal statement
6. Grades
7. Any failed attempts at step
8. Class rank/quartile

Veracity

Honesty and Integrity
The duty to tell the truth.
Truth telling and obligation to honesty
Always put the patient�s best interest first

Duty

...

Which documents can we refer to to provide guidance for ethical and
professional behavior?

AMA Declaration of Professional Responsibility
AOA Code of Ethics
Specialty organizations� codes of ethics

Morality

What people believe to be right and good (ex. Honesty), while
ethics is a critical reflection about morality

Ethics

Set of moral principles and a code for behavior (ex. Integrity) that
govern an individual�s actions with other individuals and within society.

Fidelity

The ideal of �faithfulness� - steadfast role of the healer where one
does not abandon or exploit patients
the interest of self/third parties is never placed above the
patient�s needs.

Cultural Intelligence

Using cultural intelligence in communications not just sensitivity
�May vary with culture In this country, it will depend on how
traditional the patient and family are
Individuals may use their autonomy as they see fit
Example: an elderly patient asks for the results of a biopsy to be
delivered to his son
If an interpreter is also family member as they often are, be
aware they are providing more than one role and may not be a totally
objective party.

Paternalism

When there were few treatment options and interventions for care, the
physician exercised his judgment of course of action

Autonomy

Progressive availability of more aggressive treatments, especially in
the care of incurable disease has resulted in increased difficulty in
weighing risk/benefit/cost for the individual � resulted in more
patient decision making � Autonomy.
Communication is a two way street with input from both the
physician and the patient � concept of doctor/patient relationship
being the matrix upon which the therapeutic relationship
exists.

Shift in medicine

Importance of disclosing medical errors
Shifting from a culture of blame and silence to a
culture of reporting, documentation and discussion

Disclosure is essential to error-reporting
In addition to role in patient safety,
�candor about errors between physicians is vital to professional
learning and
�informing patients and their families about errors is an integral
part of patient care.

Why do errors occur?

The courts recognize that in performing a medical service, the doctor
is obligated to use his or her best judgment and to use reasonable care.
Concept of negligence
By undertaking to perform a medical service, a physician
does not guarantee a good result
In fact, mistakes are an inevitable part of being human
We are required to act with duty of professionalism

How does clinical duty apply to medical students?

Professionalism

Stats of Practicing physicians


1/3rd did not completely agree with disclosing
serious medical errors to patients
Almost 1/5th did not completely agree that physicians should never
tell a patient something untrue
Nearly 2/5ths did not completely agree that they should disclose
their financial relationships with drug and device companies to patients
Just over 1/10th said they had told patients something untrue in the
previous year
General surgeons and cardiologists were most likely to report never
having described patients� prognosis in more positive terms than warranted
Pediatricians and psychiatrists were least likely to report never
having told untruths