UIDE

In

Professional Practice Module

S10 - 2024
 TOPIC PAGE
Evidence Based Medicine 1
Reference Citation and Management 4
Plagiarism 10
Reference Management Programs 12
Scientific Paper Publication 14
Presentation Skills 20
Breaking Bad News 23
The Angry Patient 27
Ethical and Legal Dilemmas 30
 Evidence-Based Medicine (EBM)

 Evidence-based medicine (EBM) is the ability to access, assess and apply the best
evidence from systematic research information to daily clinical problems after integrating
them with the individual physician's experience and patient's values.

 EBM is not merely a research; it is a lifelong, self-directed, problem-based learning

process.

Steps of EBM (5A's Cycle):

 Start with the patient:

1- Asking the right question:

- To find the answer to a problem, you need to start with a question.

- Getting the question right can be as important as getting the answer right.

- If you ask an inappropriate question, you could end up with an answer that is
notrelevant to your patient (one that is not applicable to them).

- Or you could waste time reviewing too much information because the question is too
broad and unfocused.

❖ There are 4 elements of a good EBM question (PICO):

 The patient and the problem are being addressed. (Patient - Problem)
 The intervention or exposure being considered. (Intervention)
 The comparison intervention or exposure when relevant. (Comparison)
 The clinical outcomes of interest. (Outcome)

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 ❖ Here is an example of a clearly focused question:

 Does aspirin reduce the risk of death after a heart attack among adults?

1. Adults who have suffered a heart attack. (Patient - Problem)

2. Aspirin. (Intervention)
3. No treatment/placebo. (Comparison)
4. Reduce Death. (Outcome)

2- Access; Searching for evidence

- Use the keywords to search on the internet.

- Visit several large databases that include citations of published studies, e.g.;
www.pubmedcenteral.nih.gov
www.cochrane.org
www.askmedline.com
- Search for your clinical question.

3- Appraising the evidence:

- We need critical appraisal because; not all published articles are properly done, and not
any article is suitable for your situation.

- Even if the contents of a paper are reliable, it is sometimes difficult to find the information
you are looking for and to interpret it.

4- Applying the results of appraised evidence to the patient (integrate evidence

intoclinical decision-making).
-You should be able to explain to your patient the overall balance of evidence considering
both the benefits and harms of treatment and assist the patient in making a choice in what is
called the shared decision-making process.

5- Assesss: Evaluate your performance with this patient.

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 Practical

Assignment (1):

You are a GP with a special interest in smoking cessation, and you want to encourage
teenagers to stop smoking and practice sports for better health. The health education program
about smoking cessation should be evidence based. How could you proceed?
Answer:

Assignment (2):

Despite the belief by some that providing oxygen to patients with COPD can create serious
issues such as hypercarbia, acidosis, or even death, Others belief that providing oxygen with
correct treatment to those patients can enhance COPD patients' quality of life and help them
live longer. Apply the steps of evidence-based medicine to implement the correct practice.

Answer:

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 Reference Citation & Management

 Every scientific paper builds on previous research – even if it is in a new field, related
studies will have preceded and informed it.

 In peer-reviewed articles, authors must give credit to this previous research, through
citations and references.

 Not only does this clearly show where the current research came from, but it also helps
readers understand the paper's content better.

 There is no optimum number of references for an academic article.

 However, depending on the subject, you could be dealing with more than 100 different
papers, conference reports, video articles, medical guidelines, or any number of other
resources.

 That is much content to manage.

 Before submitting your manuscript, this needs to be checked, cross-references in the text
and the list, organized and formatted.

 The exact content and format of the citations and references in your paper will depend on
the journal you aim to publish in, so the first step is to check the journal’s Guide for
Authors before you submit.

❖ What is a Citation?

 A citation identifies for the reader, the original source for an idea, information, or
image that is referred to in the work.
 In the body of a paper, the in-text citation acknowledges the source of information
used.
 At the end of a paper, thecitations are compiled on a References or Works Cited list.

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❖What is the difference between reference and citation?

 Purpose:

- The purpose of a citation is to point to additional information, whereas the purpose

of a reference is to supply that additional information.

 Location:

- Citations appear within the main text, whereas references are added towards the end
of the main text as a list.

❖ Can you have references without citations?

 In general, if it is your words, your opinion, your photo, or your graph, of course,
you do not need to cite it.

 HOWEVER, if you are using information from one of your own previously published
works (journal article, book chapter, etc.), you MUST cite it just as you would cite
another author's work.

❖ What is the purpose of reference citations?

 Citations are a way of giving credit when certain material in your work comes from
another source.

 It also gives your readers the information necessary to find that source again—

 it provides an important roadmap to your research process.

❖ What is an example of a reference source?

 Some examples of reference sources are:

▪ dictionaries, encyclopedias, bibliographies,almanacs, directories, atlases, and

handbooks.

 These can be online or in print.

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 TYPES of Referencing

 Referencing styles:

- There are four widely-used referencing styles or conventions.

- They are called:
1- MLA (Modern Languages Association) system.
2- Harvard system.
3- APA system (American Psychological Association system).
4- MLA system (Modern Language Association) Humanities.

❖ How do you write a reference in a research paper example?

- Basic Citation Elements
1. Author (s)
2. Title (s)
3. Source or venue name (e.g. name of the journal it was published or conference
where it was presented)
4. Editor (s)
5. Volume and edition.
6. Date or year of publication.
7. Page numbers.
8. City and country.

Webpages (with author)

- Author A. Document title [format].

- Place of publication (Webpage name): publisher;Date of internet publication [cited
year month day].

- Available from:

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Part of a webpage

- Title of home page [format].

- Place of publication (Webpage name): publisher; Date ofinternet publication [cited

year month day].

- Available from:

Journals

- Author A.
- Title of article.
- Title of the journal [format].
- Date of publication [cited yearmonth day]; vol. (no): page numbers.
- Available from:

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 Practical

A. Assignment (4): Cite this article:

Answer:

B. Assignment (5): Cite this webpage:

Answer:

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C. Assignment (6): Cite this article:

Answer:

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 Plagiarism

- Plagiarism is presenting someone else's work or ideas as your own, with or without their
consent, by incorporating it into your work without full acknowledgment.

- All published and unpublished material, whether in manuscript, printed, or electronic form,
is covered under this definition.

❖Why plagiarism is a crime?

- Plagiarism is essentially theft and fraud committed simultaneously.

- It is considered theft because the writer takes ideas from a source without giving
proper credit to the author.

- It is considered fraud because the writer represents the ideas as her or his own.

❖Five most common types of plagiarism:

1- Global plagiarism: passing off an entire text by someone else as your own work.

2- Verbatim plagiarism: directly copying someone else’s words.

3- Paraphrasing plagiarism: rephrasing someone else’s ideas to present them as

your own.
4- Patchwork plagiarism: stitching together parts of different sources to create yourtext.
5- Self-plagiarism: recycling your own past work.

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 Practical
A. Assignment (7):
You have finished writing your scientific research, and you would like to check the
plagiarism percentage before sending it to the journal for publication.
How could you do that?

Answer:

B. Assignment (8):

After examining the plagiarism percentage in your research, it was found to be high, and
your research will be rejected for publication in the journal.

What should you do to reduce the plagiarism percentage?

Answer:

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 Reference Management Programs

❖ What is citation management software?

- Citation management software also called "bibliographic software", allows you to

organize, store, and retrieve information, such as citations for books, articles, and
Web sites.

- You can simultaneously import records and PDFs from databases.

- You can add abstracts, keywords, and other functions that enhance and improve
the efficiency ofyour project.

- The citation manager then works with word-processing software to insert properly
formatted footnotes or citations into a paper and create a bibliography.

- There are varieties of citation software tools available, and each has its own strengths.
The AU Library provides EndNote as a free download to the AU community.

- The Library also offers support for Zotero and Mendeley, two other citation
software tools.

- Please see the comparison table of citation software below.

1- EndNote:

 Website: http://endnote.com/
 Operating System: Windows or MAC
 Number of citation styles: Top 100 downloaded, over 4000 more available

2- Mendeley:

 Website:http://www.mendeley.com
 Operating System: Windows, Mac, Linux
 Number of citation styles: Over 1180

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3- Zotero:
 Website: http://www.zotero.org/
 Operating System: Windows, Mac, Linux
 Number of citation styles: About 16 pre-loaded, "thousands" available for
downloadfrom Zotero.
 Other Citation management programs RefWorks, Cite This For Me (formerly
RefME),Sciwheel, RefWorks, ReadCube Papers and EasyBib.com

Practical

Assignment (9):

Create a Mendeley account and download the Mendeley reference management

program on your computer and use it for citing a paragraph.

Answer:

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 Scientific Paper Publication

Types of scientific articles:

1. Litter to editor 3. Review article

2. Case study/report 4. Short communication
5. Regular research paper (article)

Selection of suitable journal:

1. Select journal indexed by ISI or Scopus.

2. Select journal with a high impact factor or that with a high rank in your field.
3. Select journals belong to international publishing houses or internationalacademic
associations
4. Has ISSN.ISI:
a. Institute for Scientific Information (ISI) was founded by Eugene Garfield in 1960.

b. It was acquired by Thomson Scientific in 1992 (Canada) and became known as

Thomson Reuters ISI.

c. It was a part of the Intellectual Property & Science business of Thomson Reuters
until 2016, when the IP & Science business was sold, becoming Clarivate Analysis
(headquarters: Philadelphia, United States).

d. In February 2018, Clarivate announced it would re-establish ISI as part of its

Scientific and Academic Research group.

 In Clarivate and Web of Science

Journal may be covered as follows:
✓ ESCI (emerging sources citation index)
✓ Meet fundamental criteria of WOS
Under eligibility evaluation
✓ Not in JCR

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 Or
✓ SCI (science citation index)=CD/DVD
✓ SCIE (science citation index expand)=online
✓ SSCI(social science citation index)
✓ AHCI (art & humanities citation index)

Scopus

➢ Is abstract and citation database belongs to Elsevier's (Amsterdam, Netherlands),

launched in 2004 and covers nearly 36,377 titles from approximately 11,678
publishers.

➢ All journals covered in the Scopus database are reviewed annually to ensure high
quality standards are maintained.

➢ The complete list is on the SCImago Journal Rank website.

 Journal Citation Report (JCR)

 Impact Factor:
➢ An index that reflects the yearly average number of citations to recent articles published
in that journal.

✓ Calculated yearly starting from 1975 for journals listed inthe Journal Citations Report.

✓ Calculated according to the ISI database.

➢ Within the field, journals with higher impact factors are favorable.

 Scientific journal rank (SJR)

➢ It is a measure of the scientific influence of scholarly journals that accounts forboth
the number of citations received by a journal and the importance or prestige of the
journals where such citations come from.

➢ Higher SJR values are meant to indicate greater journal prestige.

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 Most important academic publishers

Publication progress steps:

 Registration (to log in to author center) + Submission

 Then you may receive the following:
1. Resubmission 5. Under Review
2. Submitted to Journal 6. Required Reviews Complete
3. Editor Invited (Conditional - this step 7. Decision in Process
may not occurs)
8. Completed – Accept
4. With Editor
i. Return without review:

➢ Does not match the journal's scope or the journal's basic standards or
expectations.

➢ Too many grammar and syntax errors

ii. Recommend transfer to another journal: transferred to another journal within

the same publication banner (but only after the author has given his/her approval).
Submission to a journal that is not within the same publication banner (the
author totake forward the submission process).

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 iii. Send the manuscript for peer review:
In most cases, two reviewers are invited or three if there is a conflict The comments
of the reviewer help the editor in making the decision

iv. Editor decision: An editor makes one of the following decisions for a peer-
reviewed manuscript:
➢ Accept in its present form (rarely occurs)
➢ Revise and resubmit:
a) Minor revision (no more revision by the reviewers)
b) Major revision (more revision is required by the reviewers).
➢ Rejected in most cases, the journal will not publish the paper or reconsider
it even if the author makes major revisions.

Peer-review process

Before submission:

 Check English editing (grammar and sentence structure)

 Check the consistency of the article and its sections
 Make sure that all tables and figures have titles and are self-explanatory
 Design a cover page
 Reformat the article according to the style of the selected journal (follow author
guidelines strictly)
 Try to highlight your findings to match with the journal's scope

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 Advices to increase paper publication

1. Ensure and focus on novelty in your work

2. Clear the hypothesis and how MM, results, and discussion strength it
3. Ensure good English editing
4. Minimize plagiarism
5. Ensure the fluent paper is presented to the reader
6. Select proper journal
7. Follow the author's guidelines of the journal

Important websites:

❖ https://journalfinder.elsevier.com/ (help in journal choice according to your field)

❖ https://www.scimagojr.com/ (to check journal indexed by Scopus)
❖ http://mjl.clarivate.com// (to check journal indexed by ISI)
❖ iThenticate (plagiarism detection)

Why to publish in an international journal:

1. Expand our results worldwide

2. Allows author contribution in the global scientific committee
3. Communicate with other researchers
4. Get opportunities to be an editor/ a reviewer
5. Get promotion
6. Improve the rank of our universities
7. Get funds/projects
❖ Once you publish in international journals, your metrics as an author will be
calculatedH-Index, No. of citations.
❖ H-index was suggested in 2005 by Jorge E. Hirsch, a physicist, as a tool for determining
the relative quality and is sometimes called the Hirsch index or Hirsch number.

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 Useful For:
Comparing researchers of similar fields or who publish in the same journal categories.
Providing a focused snapshot of an individual’s research.

 Not Useful For:

- Comparing researchers from different fields.

- Assessing fields, departments, and subjectswhere research output is typically books or

conference proceedings, as they are not well represented by databases providing h-
indices.

Practical
Assignment (10):

Apply the steps to publish your scientific paper in a journal.

Answer:

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 Presentation skills

Assignment (11):

The ability to deliver an effective and engaging presentation is an essential skill for
researchers from all disciplines, providing them with the means to communicate crucial
aspects of their work to key audiences.
How can you present your scientific research effectively at an Academic Conference?

Answer:

❖ What are the 5 P's of presentation skills?

 Purpose. Identify the Purpose of your presentation.

 Plan. Firstly, remember that famous quote, "Failing to plan is planning to fail"!
 Prepare. Split your presentation into a Beginning, Middle, and End.
 Present. You're ready to Present!
 Progress.

❖ Planning your presentation - prepare with care:

1. Thinking about your audience and what aspect of the topic they are most likely tobe
interested in

2. You should be able to state the purpose of the presentation in an easy sentence.

3. List your key points and write down the general structure of the presentation
ahead.

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 4. If you need to, write down every point that you want to cover and practice untilyou
are totally comfortable with the material.

5. Rehearse the presentation thoroughly, particularly if you have been allocated a

speaking time.

6. Consider the 10/20/30 Rule of PowerPoint:

 A PowerPoint presentation should have 10 slides

 lasts no more than 20 minutes
 Contains no font smaller than 30 points.

7. Remember the 6:6 rule:

 Too much information on a single slide is unreadable, especiallywhen
projected on a big screen.

 Use bullet points:

1. Using bullets not only makes your slide readable.

2. They also add to the impact of your presentation.

 Maximum of six bullet points in a slide.

 Maximum of six words in one line. - Contrast the text with the background.

❖These five tips are proven to work:

1. Tell a Story. There's a reason storytelling is the buzzword du jour: It works! ...
2. Use Visual Aids.
3. Use Images Instead of Text.
4. Make Your Presentation Interactive.
5. Use Some Humor.

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❖Delivering your presentation:

 On the day:
1. Get a good night’s sleep beforehand. Eat a healthy breakfast.
2. Check out the venue.
3. Before you present, spend 15 minutes going over your presentation. Don't make last-
minute changes.

4. Delivering the presentation: Remember, the opening and close of your presentationare the
most important parts. So put extra effort into the opening to make it memorable.

5. A good breathing technique used to help meditation (and great for calming nerves).
6. Facts tell, and stories sell – have the key data point on your PowerPoint slide or in the
handout. Use a story to sell the message.

7. Adhere to the time limit.

8. Close effectively. Ensure that your conclusion is strong.

Body Language

- Eighty percent of a successful presentation is about body language, and only 20% is
about content.

- So use these tips to communicate the right message through your body:
1. Make eye contact with people at all times.
2. Appear confident.
3. Relaxed body language.
Voic: -
e
- Learn how to speak effectively! Your tone, pitch, pace, clarity, projection, and use of
pauses can help build credibility and connection.

- Speak slowly and carefully, but passionately.

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 Breaking Bad News

Definition

- Breaking bad news is a process of delivering news, which adversely and seriously affects
an individual's view of his or her future.

- Breaking bad news well is veryimportant essential communication skill for doctors, and
will improve the disease journey for the patient.

Bad news situations

- Informing the patient of having a cancer or terminal disease

- Informing the patient of having a chronic disease such as diabetes mellitus

- Telling a pregnant woman that her fetus suffers from congenital anomalies

- Any significant life changing conditions including mental health illnesses,chronic

infections or neurological disorders.

Strategy for breaking bad new by using Six Steps of S P I K E S:

1- S – Setting
- Arrange for some privacy
- Involve significant others (if the patient wants that like to have family membersor friends)
- Sit down and avoid sitting behind physical barriers, such as a desk.
- If patient is ina hospital bed, pull up a chair, or if there isn’t a chair, ask permission to sit on
the edge of the bed.
- Make connection and establish rapport with the patient
- Manage time constraints and interruptions.
- Look attentive and calm: by adopting the “psychotherapy neutral position.” Thisis a simple
matter of placing feet flat on the floor and ankles together, and putting hands, palms
downward, on your lap.

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 - Maintaining eye contact will also assure patient of doctor attentiveness; if he or she
becomes tearful, it is a good idea to break eye contact momentarily (No one likes to be seen
crying, because he or she feels particularly vulnerable.)

- The doctor can also rest his hand on patient’s armor hand if he or she is comfortable with
this gesture.

- Listening mode:

 Silence and repetition are two communication skills that will send the message to
patient that the doctor is listening.

 The silence (that is, not interrupting or overlapping the patient when he or she is
talking) displays respect for what he or she is saying.

 Repetition involves using the most important word from the patient’s last sentence in
your first sentence.

 For example, a patient might say, “I’m bored with the treatment.” You might reply,
“What aspect of it makes you most bored?” Other basic techniques that show you are
listening include nodding, smiling, or saying “hmmm,” as appropriate.

2- P – Perception of condition/seriousness

- Before beginning of an explanation, ask the patient open-ended questions to find out
how he or she perceives the medical situation.

- Determine what the patient knows about the medical condition or what he suspects,
for example “What did you think was going on with you when you felt the lump?”
“What have you been told about all this so far?” “Are you worried that this
might be somethingserious?”
- Listen to the patient’s level of comprehension to correct any misunderstanding of the
patient
- Tailor the news to the patient's understanding and expectations
- Accept denial but do not confront at this stage

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3- I – Invitation from the patient to give information

- Ask patient if s/he wishes to know the details of the medical condition and/or treatment,
for example “Are you the kind of person who prefers to know all the details about what
is going on?” “How much information would you like me to give you about your
diagnosis and treatment?”

- Accept patient’s right not to know

- Offer to answer questions later if s/he wishes.

4- K – Knowledge: giving medical facts

- Before the doctor breaks bad news, give patient a warning that bad news is coming.
Examples of warning statements include: “I'm sorry to tell you that …” or
“Unfortunately I have some bad news to tell you.”

- Avoid technical, scientific language (” Use plain language and avoid medical jargon:
use the word “spread” instead of “metastasized,” for instance)

- Give information in small chunks(short sentences)

- Check whether the patient understood what doctor said
- Respond to the patient’s reactions as they occur
- Give any positive aspects first e.g.: Cancer has not spread to lymph nodes, highly
responsive to therapy, treatment available locally etc.

- Give facts accurately about treatment options, prognosis, costs etc.

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5- E – Explore patient emotions with Empathic responses

- Prepare to give an empathetic response:

 Step 1:

➢ Identify the emotion (or mixture of emotions) expressed by the patient (sadness,
silence, shock etc.).

➢ If doctor are not sure what emotion the patient is experiencing, you can use an
exploratory response, such as “How does that make you feel?”

 Step 2:

➢ Identify cause/source of emotion, which is most likely to be the bad news that
the patient has just heard

 Step 3:

➢ Show the patient that you have made the connection between the above two
steps—that is, that you have identified the emotion and its origin.

➢ Examples might include: “Hearing the result of the bone scan is clearly a major
shock to you.” “I can imagine how scary this must be for you.”

6- S – Strategy and summary

- Close the interview

- summarize the information in the discussion
- Ask whether the patient want to clarify something else
- Present treatment or palliative care options, being sure to align information with what
ascertained (during the assessment of the patient's perceptions) to be the patient's
knowledge, expectations, and hopes.

- Check frequently to make sure you and your patient are both on the same page

- Offer clear plan for the next meeting ,for example “I will speak to you again
when we have the opinion of cancer specialist”.

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 The Angry Patient

Definition

- Anger is a person’s emotional response to provocation or to a threat to his or her

equilibrium.

- It is the manifestation of a deeper fear, of hidden insecurity, of frustration or self-

rejection.

The circumstances in medicine that provoke feeling of anger include:

1. Crisis situations, including grief.

2. Any illness, especially unexpected, fatal, Iatrogenic and Chronic illness, such as
asthma.

3. Financial transactions, such as high cost for services.

4. Referral to colleagues, which is often perceived as failure.

5. Problems with medical certificates.

6. Poor response to treatment.

7. Inappropriate doctor behavior.

8. Disappointment at unmet expectations.

9. Poor service, such as long waits for an appointment.

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Consulting Strategies

1. The initial response should be to remain calm.

2. “Step back” from the emotionally charged situation and try to analyze what is
happening.

3. Ask the patient to sit down and try to adopt a similar position.
4. Address the patient (or relative) by the appropriate name.
5. Appear comfortable and controlled.
6. Be interested and concerned about the patient.
7. Use clear, firm, non-emotive language.
8. Listen intently.
9. Allow time (at least 20 minutes).
10. Allow patients to ventilate their feelings and help to relieve their burdens.
11. Allow patients to “be themselves”.
12. Give appropriate reassurance.

Steps of dealing with angry

patients
1. Notice they're upset: “You look really upset".
2. Listen to their story: “Tell me all about it”.
3. Show empathy: "I am so sorry that is happening to you".
4. Get their input for a solution: "How would you like me to help"?
5. Offer next steps: "Here's what I am willing to do".
6. Thank them for sharing their story: "Thanks for telling me what happened

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Guidelines for handling the angry patient

Do Don’t
1. Listen 1. Touch the patient
2. Be calm 2. Meet anger with anger
3. Be comfortable 3. Reject the patient
4. Show interest and concern 4. Be a ‘wimp’
5. Be conciliatory 5. Evade the situation
6. Be genuine 6. Be over familiar
7. Allay any guilt 7. Talk too much
8. Be sincere 8. Be judgmental
9. Give time 9. Be patronizing
10.Arrange follow-up
11.Act as a catalyst and guide

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 Ethical and Legal Dilemmas
❖ Dilemma refers to a situation in which a difficult choice has to be made between two
courses of action, either of which entails transgressing a moral principle.

❖ Ethical dilemmas may arise for patients, family members, medical staff members and
physicians alike.

❖ Some of the issues surrounding problems for which ethical and legal consultation may
be requested include:

1. Defensive Medicine

2. Reporting Unprofessional and Unethical behaviors.

3. Resource allocation in the health-care system.

4. Do Not Resuscitate (DNR) orders.

Medicolegal Aspects of Defensive Medicine

Definition:

 Defensive medicine has been practiced for decades in one form or another.

 It has only become the subject of professional, malpractice liability and community
inspectionover the past three decades as it has become more widespread.

 Several definitions have been proposed to the term “Defensive Medicine”.

 It has been defined as “a clinical decision or action motivated in whole or in part by the
desire to protect oneself from a malpractice suit or to serve as a reliable defense if such
a suit occurs”, or that it “is a deviation from sound medical practice that is induced
primarily by a threat of liability”.

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 Defensive medicine happens when a doctor acts not to help the patient, but to prevent a
malpractice lawsuit if something goes wrong.

 This includes performing procedures the patient wants even if they aren’t clinically
necessary.

 In addition, the doctors in this situation may order extraneous diagnostic tests or refer
patients to specialists to rule out possible but very unlikely conditions to cover all bases.

 This is how defensive medicine leads to over-testing and possibly, overtreatment.

Types of Defensive Medicine

- Defensive practices may be carried out by healthcare professionals without realizing the
consequences.

- These could include blood test or scan results that may be harmless and unrelated to the
patient’s presentation.
➢ There are two forms of defensive medicine:

1) Assurance behaviors or “positive” defensive medicine, involve providing

additional services to ensure that legal standards of care were met to avoid malpractice
claims.

- Some Common assurance practices:

▪ Order more tests than medically indicated.

▪ Prescribe more medications (eg, antibiotics) than medically indicated.

▪ Refer patients to other specialists in unnecessary circumstances.

▪ Suggest invasive procedures (e.g., biopsies) to confirm diagnoses.

2) Avoidance behavior, or “negative” defensive medicine, refers to physicians’

efforts to avoid high-risk patients and procedures.

▪ Avoid certain procedures or interventions.

▪ Avoid caring for high-risk patients.

▪ Obtains more consultations or refers more patients to another physician.

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 N.B.
There are types of defensive practices that should be taken out of the medical
malpractice equation:
1. Tests and evaluations that are good for the patients.
2. An additional treatment that is motivated, not by fear of lawsuits, but by fear of
harm to the patient.
3. Patient-directed defensive medicine (when the patient seeks tests the doctor
would not necessarily recommend).

Ethical Classification of Defensive Medicine Practices

➢ According to the 4-principles of medical ethics, the healthcare provider has to act with
beneficence (i.e., that a physician must act in the best interest of the patient) to promote their
patient’s health and well-being, and non-maleficence (i.e.do no harm) that anyrisks of a
treatment or procedure to a patient must be outweighed by benefit.

➢ However, due to the risk of medical liability suits allegations, physicians may beencouraged
to order risky tests or procedures that both raise health care costs and on balance do more
harm than good for patients.

➢ Defensive medical practices may be roughly grouped into three categories according
to their relative impact on patient interests and well-being:

1. No violation for beneficence or non-maleficence principles

Practices that subject the patient to no additional physical or emotional risk and whose
financial cost is either simple or offset by ancillary benefits of the practice.

2. No violation for non-maleficence but violating beneficence:

Practices that subject the patient to virtually no physical risk or pain, but imposeadditional
financial costs, increase the anxiety level of the patient, or subject the patient to other
harms.

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3. Violation for both non-maleficence and beneficence principles:

Practices that subject the patient to significantly increased physical, psychological, and
financial risks, or infringe on important personal rights.

Risks of Defensive Medicine Practices:

1. Increase the cost of health care, and, therefore, deprivation of another area. This practically
means that an increased spending on one patient will ultimately deprive another patient.

2.Exposure of the patient to the potential harm, side effects or complications of the unneeded
test, drug, or procedure.

3. A false positive result of an extra unnecessary test may derail the correct line of
management.

4. Violation of the doctor/patient relationship. Just imagine if the patient sitting in frontof
you doctor is not sure which of your recommendations is for him and which is for you. At
the same time, you as his doctor are not sure whether next time you will see him will be in
your office or in the courtroom.

5. When patients know, and they already know, that some of the recommendations of their
doctor are not for the sake of their own health, their compliance with the management advice
will be reduced, not being able to tell which is which.

6. A common practice of defensive medicine is excessive antibiotic prescribing, which iswell

known to lead to antibiotic resistance, an important public health priority worldwide, not
only for its clinical implications (increased morbidity, mortality, duration of illness, frequent
development of complications and outbreaks).

7. The economic impact of antibiotic-resistant infections which lead to additional costs

related to the use of more expensive drugs and procedures and to longer length of illness
and hospital stays. Also, the emergence of pathogens resistant to multiple antibiotics
reduces the possibility of an effective treatment.

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 Evaluating Defensive Medicine Practices

→ To avoid medical errors and the suspected medical liability allegations, medical
practices should be decided according to the following steps:

(1) Make a clinically sound treatment decision.

(2) Accurately identify the legal risk in the case.

(3) Evaluate that risk by estimating potential costs of the claim in time, anxiety, and money.

(4) Identify the possibility of the risk occurrence and explain its causes.

(5) Evaluate the cost to the patient and society of potential defensive measures.

→ Defensive medicine practices can be accepted to occur more frequently occur

in thefollowing situations:

▪ When the disease or condition to be detected or prevented is life-threatening or

disabling.

▪ When timely detection of the disease or condition changes therapy.

▪ When the change in therapy can be expected to make a real difference to the
patient’s ultimate state of health.

▪ When the diagnostic test or treatment is readily available and low risk.

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 Ten commandments are required from physicians to provide evidence of
effectiveclinical practice. These are as follows:

1. Keep good records

2. Document all discussions with your patient.

3. Do not alter records.

4. Follow up referrals and test results.

5. Check the history before writing a prescription.

6. Do not diagnose and treat over the telephone.

7. Show patients you care.

8. Give patients “enough” time.

9. Manage adverse events proactively.

10. Talk to your medical defense organization.

‫ ﻟﺴنﺔ‬238 ‫تنص ﺑﻌﺾ اﻟﻤﻮاد اﻟﻘﺎﻧﻮﻧﯿﺔ ﺑﻼﺋﺤﺔ آداب اﻟﻤﮭنﺔ اﻟﺼﺎدرة ﺑﻘﺮار وزﯾﺮ اﻟﺼﺤﺔ واﻟﺴﻜﺎن رﻗﻢ‬
:‫ ﻋﻠﻲ اﻵتﻲ‬،2003
20 ‫ ﻣﺎدة‬-
‫ﻋﻠﻲ اﻟﻄﺒﯿﺐ أن ﯾﺒﺬل ﻛﻞ ﻣﺎ ﻓﻲ وﺳﻌﮫ ﻟﻌﻼج ﻣﺮﺿﺎه وأن ﯾﻌﻤﻞ ﻋﻠﻲ ﺗﺨﻔﯿﻒ آﻻﻣﮭﻢ وأن ﯾﺤﺴﻦ ﻣﻌﺎﻣﻠﺘﮭﻢ وأن ﯾﺴﺎوي‬
.‫ﺑﯿﻨﮭﻢ ﻓﻲ اﻟﺮﻋﺎﯾﺔ دون ﺗﻤﯿﯿﺰ‬
23 ‫ ﻣﺎدة‬-
:‫ﻋﻠﻲ اﻟﻄﺒﯿﺐ أن ﯾﺮاﻋﻲ ﻣﺎ ﯾﻠﻲ‬

.‫) أ( ﻋﺪم اﻟﻤﻐﺎﻻة ﻓﻲ ﺗﻘﺪﯾﺮ أﺗﻌﺎﺑﮫ وأن ﯾﻘﺪر ﺣﺎﻟﺔ اﻟﻤﺮﯾﺾ اﻟﻤﺎﻟﯿﺔ واﻻﺟﺘﻤﺎﻋﯿﺔ‬
‫)ب( أن ﯾﻠﺘﺰم ﺑﺎﻷدوﯾﺔ اﻟﻀﺮورﯾﺔ ﻣﻊ ﻣﺮاﻋﺎة أن ﺗﻜﻮن اﻷوﻟﻮﯾﺔ ﻟﻠﺪواء اﻟﻮطﻨﻲ واﻷﻗﻞ ﺳﻌﺮا ً ﺑشﺮط اﻟﻔﺎﻋﻠﯿﮫ واﻻﻣﺎن‬

35
 Medicolegal Obligations to Report Unprofessional and
Unethical behaviors

- Physicians who become aware of or strongly suspect that conduct threatens

patient welfare or otherwise appears to violate ethical or legal standards should:

1. Report the suspected violation to appropriate authorities.

2. Report to a higher authority if the conduct continues unchanged despite initial

reporting.

3. Protect the privacy of any patients who may be involved to the greatest extent
possible, consistent with due process.

- Physicians who receive reports of alleged incompetent or unethical conduct

should:

1. Evaluate the reported information critically and objectively.

2. Hold the matter in confidence until it is resolved.

3. Ensure that identified deficiencies are remedied or reported to otherappropriate

authorities for action.

4. Notify the reporting physician when appropriate action has been taken, exceptin
cases of anonymous reporting.

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 Medicolegal Obligations for Resource Allocation in
Healthcare System.

❖ In every country in the world, including the richest ones, there is an already wide and steadily
increasing gap between the needs and desires for healthcare services and the availability of
resources to provide these services. This gap requires that the existing resources be rationed
in some manner.

❖ Resource allocation is the process of identifying and managing resources. These resources
are distributed among populations, programs, and individuals. This process happens at macro-
and micro- levels in society. Healthcare rationing, or 'resource allocation' as it is more
commonly referred to, takes place at three levels:

1. At the highest ('macro') level, governments decide how much of the overallbudget
should be allocated to health; which healthcare expenses will be provided at no charge
and which will require payment either directly from patients or from their medical
insurance plans; within the health budget, how much will go to remuneration for
physicians, nurses and other health care workers, to capital and operating expenses for
hospitals and other institutions, to research, to educationof health professionals, to
treatment of specific conditions such as tuberculosis or AIDS, and so on.

2. At the institutional ('meso') level, which includes hospitals, clinics, healthcare

agencies, etc., authorities decide which services to provide; how much to spendon staff,
equipment, security, other operating expenses, renovations, expansion, etc.

3. At the individual patient ('micro') level, healthcare providers, especially physicians,

decide what tests should be ordered, whether a referral to another physician is needed,
whether the patient should be hospitalized, whether a brand- name drug is required rather
than a generic one, etc. It has been estimated that physicians are responsible for initiating
80 % of healthcare expenditures, and despite the growing encroachment of managed care,
they still have considerable discretion as to which resources their patients will have
access.

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❖ Justice

In dealing with these allocation issues, physicians must not only balance the principles of
compassion and justice but, in doing so, must decide which approach to justice is
preferable.

→ There are several such approaches,including the following:

1. Libertarian → resources should be distributed according to market principles

(individual choice conditioned by ability and willingness to pay, with limited charity
care for the destitute).

2. Utilitarian ‫ → اﻟنﻔﻌﯿﺔ‬resources should be distributed according to the principle of

maximum benefit for all.

3. Egalitarian ‫ → اﻟﻤﺴﺎواة‬resources should be distributed strictly according to need.

4. Restorative ‫ →اﻟتﺼﺎﻟﺤﯿه‬resources should be distributed to favor the historically
disadvantaged . ‫ﯾجﺐ ﺗﻮزﯾﻊ اﻟﻤﻮارد ﻟصﺎﻟح اﻟﻤﺤﺮوﻣﯿﻦ ﺗﺎرﯾﺨﯿﺎ‬

38
 Do Not Resuscitate (DNR) orders
➢ A do-not-resuscitate order, or DNR order, is a medical order written by a doctor.

➢ It instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's

breathing stops or if the patient's heart stops beating.

➢ The doctor puts or causes to be put the instruction in the hospital notes or on the clinical record:
Do not resuscitate (DNR) or do not attempt to resuscitate (DNAR) or do not attempt
cardiopulmonaryresuscitation (DNACPR).

❖ The basic test to be applied by the judge is the best interests of the patient,
and the patient’s mental capacity.
1- Mental Capacity

▪ If the patient retains his mental capacity, then he must be consulted and his autonomy,
integrity, dignity and decision must be respected.

▪ Patient autonomy should be cornerstone in deciding about patient’s resuscitation status.

▪ Accurate information about the condition, prognosis, and nature of the proposed
intervention, alternatives, risks and benefits may enable the patients to make better
decisions about resuscitation and end of life.
2- Best interests

• For legal purposes, best interests are not to be determined only on the basis of age or
appearance or condition or behavior.

• The patient must be permitted and encouraged to participate in the treatment as long as it is
reasonably practicable.

• The decision-maker must, so far as reasonably ascertainable, take the patient’s past and
present wishes and feelings and beliefs and values and other personally relevant factors
into account.

• Any nominated person, the family, carers, any holder of a power of attorney and anyone
appointed by the court must be consulted.

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