Illustrative Cases

It is a "quiet" mid-morning in the ENT clinics. The staff-person decides to take the team (including the keen elective medical student) to the hospital Starbucks for coffee.
While standing in the usual 20-person deep line, the medical student tells your team about the drunk, unconscious sexually assaulted teenager that was found at the carnival, last night. He was involved in her difficult airway management while on call.

Guiding Questions:

• How is the confidentiality of the patient threatened?
• What sort of support can peers provide in this situation?
• How do time and place affect the appropriateness of this student's storytelling?
• What is the role of storytelling in gaining social support in the workplace?
• How could the student cope with this terrible story in a more professional manner?

A young female physician is overwhelmed by the demands of clinical work, research, home and family. During a routine clinic visit, her patient's mother (who she knows well) tells her that she is looking for work as a housekeeper. The young doctor thanks her lucky stars, and makes arrangements to hire the parent.

Guiding Questions:

• Discuss any conflicts of interest in this scenario.
• How might this arrangement affect the dentist's relationship with his patient?
• Does the size of the community they live in affect your perspective? How?

It is Saturday night, and you finally have the weekend off from the emergency medicine rotation that you are currently assigned to. After a night of partying, you, as the designated driver, are taking people home. One of your friends, a fellow medical student, is very drunk, and has been vomiting. He needs fluids and rest. He can't keep anything down, and you suggest a trip to the emergency. He begs you not to take him, because he is worried that the clinical staff will judge him when he returns to work on Monday. Your friend asks if you would start an IV on him, and give him some fluids, at home.

Guiding Questions:

• Describe any conflicts/issues that might arise from treating a colleague/friend?
• Describe any conflicts/issues that might arise from treating someone outside of your professional setting/hospital?
• Is it 'okay' to take medical supplies from the hospital, IF it spares 'the system' the cost of a medical visit?

You are a radiologist. Your good friend, an orthopedic surgeon, has had progressive, increasing weakness and limited range of motion in her dominant arm, and extreme neck stiffness. She is struggling to move comfortably, and it is slowing down her clinical pace. She has seen her family doctor, and an MRI has been booked, with a date in 2.5 months. Over dinner, your friend mentions her struggles and progressing symptoms, in passing. You think "Maybe I can get her MRI bumped up…after all, she IS getting worse".

Guiding Questions:

• Is it 'alright' to bump up someone's appointment, like this? What circumstances might make it okay? Is it never okay?
• What might be the impact on others (eg patients, other office staff, yourself) of such an action?
• Do you have any strategies for managing/addressing the expectations of family and friends?

It is the end of yet another LONG teaching session! As is often the case, medical student Jaime has left 30 minutes early…leaving you feeling a little envious! As the remaining attendees exit, you, the preceptor, and the divisional administrative assistant are left in the room.
Your preceptor launches into a 5 minute rant, directed at you, about how inappropriate medical student Jaime' behaviour is, and how unprofessionals it is that he routinely arrives late and leaves early. He then turns to the admin assistant and says "Isn't that BS? I mean, seriously, we all have to show up."

Guiding Questions:

• What questions might you want to ask Jaime?
• How might you express your discomfort to the preceptor? Would you express it, at all?

An extremely busy staff surgeon asks a medical student to obtain consent for a patient's tonsillectomy. The student has never seen or performed this procedure before.
The surgeon explains the 'gist of it', and then tells the student to quickly go and get the papers signed so that they can 'get it off their list of things to do', and then heads down to the ED for the pending seven consultations.

Guiding Questions:

• Have you been in a situation like this before? How did you respond then?
• What are the risks to you, the patient, the clinical instructor, the hospital? What are the benefits for the same people?

You are working in the NICU, covering labour and delivery. You have closely followed a lovely pregnant lady who has been admitted for weeks with threatened premature labour. This is a very precious baby for her, having lost two previous infants in childbirth. For a number of personal and professional reasons, you have developed a real sense of caring and concern for this lady.

She was induced early in the morning, and it is now 5pm. She is getting closer to active labour, but not there, as yet. She begs you to stay for the delivery, she is in tears, and says she trusts only you to care for her newborn.

You have promised your boyfriend that you will attend his soccer game tonight, as he feels he 'never' gets to see since you since you started clinical clerkship.

Guiding Questions:

• How would you want to respond in this situation?
• What do you consider healthy professional boundaries?
• What might the impact be to the patient if you choose not stay late?
• What is your opinion on the value of work-life harmony? How do you achieve it?

You are a newly minted staff-person, and have recently moved to Edmonton. At the end of a long OR day, followed by 2 emergency cases, you are finally ready to leave. Your senior resident has worked admirably alongside you, and is equally exhausted.
You want to acknowledge this individual's work and you are hungry! You text them and invite them to dinner…your treat.

Guiding Questions:

• What considerations are there for determining if this is an appropriate social encounter?
• How important do you perceive professional reputation to be?
• How could this situation be perceived from an outside view?

Laila has been working in the same lab for 1 year. During this time, her preceptor has provided feedback, on a number of occasions, regarding her performance. Her preceptor has voiced concerns regarding accuracy of experiments, and timeliness of submitting grants & papers. Laila is very unhappy with this, and feels negatively targeted and singled out.

Guiding Questions:

• Are you ok with this feedback?
• What would you do, in Laila's position?
• Does the purpose of the feedback matter?
• What might be better ways to provide such feedback (ie setting, tone, etc)?
  

You are a graduate student who has worked closely with your supervisor for 3 years. You have worked very hard on a recent paper, and it is ready for submission. Your preceptor submits it, on behalf of the team. When you receive electronic notification of the submission, you note that the results section has been changed from what you submitted to your preceptor, and the conclusion is now more 'dramatic'/ higher impact. Further, another colleague of your preceptor has been added as a 'middle author'.

Guiding Questions:

• Would you approach your preceptor?
• What might the preceptor have done differently?
• Are you familiar with the ICJME Authorship guidelines?

An extremely busy scientist is in the middle of dreaded grant-writing season. She also has a number of complex experiments on-going, and a relatively new graduate student in her lab. While working furiously to meet the grant submission deadlines, she asks her grad student to perform a Western blot. The student has never seen or performed this procedure before. The supervisor explains the 'gist of it', and then tells the student to quickly go and get the experiment done, so that they can 'get it off their list of things to do', and move on to everything else that needs to be done, today.

Guiding Questions:

• If you were the grad student, what might you say to your supervisor?
• Do you think it is alright for the supervisor to ask this of her student?

You are a newly minted Assistant Professor at the University of Alberta, and have recently moved to Edmonton. At the end of a long day, and you are finally ready to leave. Your post-doc fellow has worked admirably alongside you, and is equally exhausted.
You want to acknowledge this individual's work and you are hungry! You text them and invite them to dinner…your treat.

Guiding Questions:

• Does it matter if you take them to the hospital cafeteria vs a fancy restaurant?
• Does it matter if you are attracted to them?
• What problems might this create, and in what contexts?

Lisa, a student in your research group, is working on a highly competitive project and she is not ready to share the results. Another postdoctoral fellow, Tina, from the same lab, has submitted an abstract on a different, but related project, to a major international meeting in your field. Tina is invited to give a talk at a symposium. You are attending the meeting and decide to go to your colleague's talk. You are sitting in the audience when, in response to a question, she talks all about your fellow graduate student's results that have not yet been submitted for publication.

Guiding Questions:

• How should privileged information be treated?
• Should you discuss this with the postdoctoral fellow or your supervisor?

You are a maxillofacial surgeon. Your good friend, a practitioner, who refers you a large number of patients who require orthognathic surgery, calls you about his daughter who needs a bone graft prior to placement of an implant. This is not an urgent procedure but, because of a concern that she would miss school, he asks that she be booked during the summer holidays. You already have a long list of patients waiting for surgery and your first opening is not until October. Booking his daughter will mean cancelling a patient who has waited more than 8 months for surgery. You recognize that the dentist is a very good referral source and you would like to help him. The economy is down in the province and you start to think about how important this practitioner's referrals are to your practice. Over lunch the practitioner mentions that his daughter has an excellent chance of winning a scholarship in her final year of school and the impact that missing school in October will have on this opportunity. You start to think, "Maybe I can move her up on the operating list…after all success in education is very important and I want to help out this practitioner.

Guiding Questions:

• Is it 'alright' to bump up someone's appointment, like this? What circumstances might make it okay? Is it never okay?
• What might be the impact on others (eg patients, other office staff, yourself) of such an action?
• Do you have any strategies for managing/addressing the expectations of family and friends?

During an extremely busy clinic, a clinical instructor asks a second year dental student (who is just starting in clinic) to obtain consent for a patient's procedure. The student has never seen or performed this procedure before.

The instructor explains the 'gist of it', and then tells the student to quickly go and get the consent signed so that he can attend to the other patients.

Guiding Questions:

• Have you been in a situation like this before? How did you respond then?
• What are the risks to you, the patient, the clinical instructor, the hospital? What are the benefits for the same people?

You are working in the U of A hospital dental clinic, helping the general practice resident with a patient who has developed a serious abscess. The patient is a young and challenged man that you have been following in the Kaye Edmonton Clinic over the past few months. He is quite terrified about having dental treatment and easily becomes agitated. During the time in clinic you have developed a good rapport with the patient to the point that he depends on you being there to help him get through his treatment. For a number of personal and professional reasons you have developed a deep sense of concern and responsibility for this young man. The patient needs a tooth extracted and the abscess drained and he begs you to stay with him during the procedure. However, you have promised your boyfriend that you will attend his hockey game tonight, as he feels he 'never' gets to see since you since you started third year dentistry.

Guiding Questions:

• How would you want to respond in this situation?
• What do you consider healthy professional boundaries?
• What might the impact be to the patient if you choose not stay late?
• What is your opinion on the value of work-life harmony? How do you achieve it?

Yousef is enjoying his clinical placement and enjoys having coffee with a particular group of technologists. At coffee, in the crowded main cafeteria, they start talking hockey, when one technologist starts talking about the toxicology result of a "certain" Edmonton Oiler, without divulging his name.

Guiding Questions:

• How is the confidentiality of the patient threatened?
• What sort of support can peers provide in this situation?
• How do time and place affect the appropriateness of this technologist's storytelling?
• What is the role of storytelling in gaining social support in the workplace?

John, an MLS student, is in a relationship with Julie. Recently, Julie has disclosed to John that she thinks she might be pregnant, but she isn't sure. Julie is panicking, because she is still in school, and doesn't know how she would tell her parents. John offers bring her a pregnancy test kit from the lab, so that she can discretely check if she is pregnant.

Guiding Questions:

• Should health professionals be allowed to use medical supplies for personal use? Does the cost of the equipment matter when deciding this?
• Can you think of past experiences where you have seen this happen?

You are on a busy day shift in the lab. A colleague is worried about his daughter's HbA1C, which was collected yesterday. He is trying to decide if he should take a day off work to see his daughter's physician, to get the result. You are so exhausted from being short-staffed, already. Your colleague asks, "Hey Tom, can you check the lab result for me? If it's normal, then I don't have to leave tomorrow".

Guiding Questions:

• What is your understanding of NetCare privacy regarding checking this lab result?
• What is the 'circle of care', and how does it apply, here? Are you in the circle of care for your colleague's daughter?
• How would you discuss your willingness/ unwillingness to check this lab result with your colleague?

Dominic, a Year 3 student, is with his preceptor when a call is received from an angry physician looking for results. The department hasn't received the specimen. Dominic and his preceptor go to specimen receiving to look for the sample. The specimen receiving staff are chatting amongst themselves and ignore Dominic and his preceptor. Dominic's preceptor finds the specimen in a bin and the requisition time stamped 2 hours ago but it has not been processed. Dominic's preceptor starts yelling at the specimen receiving staff, "What the heck, guys? This arrived two hours ago, and thanks to your incompetence, I get to deal with an angry doctor".

Guiding Questions:

• What questions might you want to ask the specimen receiving staff?
• How might you express your discomfort to the preceptor? Would you express it, at all?

Nora is an MLS student who has completed one week of day shifts in core lab. She has just started her evening shifts in the same lab. Marcy, her preceptor, tells her to run the evening QC and start to enter results while she goes for dinner. Nora only observed QC during the past week, and has never entered results for that particular test. She feels uncomfortable running the evening QC, alone.

Guiding Questions:

• Have you been in a situation like this before? How did you respond then?
• Should Nora tell her preceptor she can't do it? Should she report her preceptor for inadequate supervision?
• Is Marcy being irresponsible? What if this is her only break today?

Ann is in Year 3, and she is also working part-time to pay tuition and living expenses. She is scheduled 8-4 at her clinical placement and 6-10 at her part-time job. Her preceptor has some exceptional circumstances this month and won't be in until 9 each morning. She has asked Ann to come in 9-5, instead of the scheduled 8-4. Ann really like her clinical placement and would really like to get a position there when she is done, but finishing at 5 will mean she won't have time to go home and eat/see her daughter before going to work.

Guiding Questions:

• How would you respond in this situation?
• What do you consider healthy professional boundaries?
• What is your opinion on the value of work-life harmony? How do you achieve it?

It has been a long week on the treatment floor. You and your fellow radiation therapy students head out after work to decompress. While there, one of your peers tells the story of a 30-year old patient who is on treatment for glioblastoma multiforme, which was discovered while she was pregnant. The patient has a very poor prognosis, and her baby is in NICU having been purposefully delivered early so the patient could begin treatment.

Guiding questions:

• How is the confidentiality of the patients threatened?
• What sort of support can peers provide in this situation?
• How do time and place affect the appropriateness of this student's storytelling?
• What is the role of storytelling in gaining social support in the workplace?
• How could the student cope with this sad situation in a more professional manner?

You are in the midst of midterm performance evaluations, organizing a conference with your professional association, and finishing a paper with a colleague. Your car doesn't start that morning, and you arrive to the clinic late, feeling guilty that you've missed a meeting with one of your students and unsure when you will be able to reschedule. While walking to the treatment floor to find her, you run into a former patient who is in clinic for follow-up. You remember that this patient owns a garage, and you stop to ask him for advice on what you should do with your vehicle. He tells you that he's "cancer-free" and offers to fix your vehicle as a thank-you for the care you gave him while he was on treatment.

Guiding questions:

• Does it make a difference if the car repair is free, or if the patient charges for it?
• Why does that make it different?
• How could you respond to this situation in the most professional manner?
  

You are a radiation therapy student. A good family friend, a busy family doctor, has recently been diagnosed with an early lung cancer which has been deemed inoperable and she requires a course of radiation therapy. She has been given an initial CT simulation date of 4 weeks from now. Over dinner with your parents, this close family friend mentions her anxiety at having to wait for 4 weeks. Your mother says "Maybe you can get her CT simulation appointment bumped up . . . could you do that, dear?".

Guiding questions:

• Is it 'alright' to bump up someone's appointment, like this? What circumstances might make it okay? Is it never okay?
• What might be the impact on others (eg patients, other radiation therapists, yourself) of such an action?
• Do you have any strategies for managing/addressing the expectations of family and friends?
  

It's your last week of clinical practicum before graduation. You have been working on the same treatment unit for four weeks and know the patients very well. The workload is demanding and the radiation therapists are short-staffed on the unit today. You have sat down to operate the console, an activity you still require direct supervision for by both therapists. However, one of the two therapists on the unit is distracted by an irate patient at the counter who is demanding to be seen by an oncologist. The other therapist verifies the treatment parameters with you, and says, "Go ahead and treat, it's fine. You're going to be one of us next week anyway."

Guiding questions:

• Have you been in a situation like this before? How did you respond then?
• What is the Health Professions Act, and how does it regulate scope of practice?

You are on a treatment unit responsible for delivering treatment and care to a 14 year old patient. She began treatment on Monday, and is now scheduled to have treatment over the weekend in an effort to slow the growth of her aggressive sarcoma. The patient does not speak much, and you are concerned that she may be fearful and untrusting of the treatment team because of past negative experiences.

On Friday afternoon you are explaining to her and her parents that there is treatment scheduled Saturday and Sunday mornings. You have an on-call therapist come to the treatment unit to meet them, to try to ease the transition for the patient to the weekend treatment team. The patient begins to cry openly in the waiting room, saying, "I don't want different people, only you." The parents look at you pleadingly, waiting for you to say something first.

Your weekend plans included a hike in the Rockies with a friend you haven't seen in six weeks due to conflicting schedules. You have arranged to leave at 7am Saturday morning.

Guiding questions:

• How would you want to respond in this situation?
• What do you consider healthy professional boundaries?
• What might the impact be to the patient if you choose not to treat her on the weekend?
• What is your opinion on the value of work-life harmony? How do you achieve it?