1. Teaching Medical Ethics for Practice in the Primary Care Medical Home Debra Gould, MD, MPH Central Washington Family Medicine Residency Program Yakima, WA Patricia Robinson, PhD Central Washington Family Medicine Residency Program, Yakima, WA Mountainview Consulting Group, Inc.

2. Disclosures Dr. Gould & Dr. Robinson: - New Harbinger Publications, Inc. Dr. Robinson: - Mountainview Consulting Group, Inc. - Springer Science+Business Media, LLC - Behavioral Consultation and Primary Care: A Guide to Integrating Services

3. FM Medical Ethics Milestones & Sub-Competencies Develop and present a medical ethics didactic using 4-Topic method for analyzing a clinical situation from their practice.  Didactic Participant –MK2 level 2b –PROF1 level 1b & c  Didactic Presenter PROF2 level 2a; PROF3 Level 3a; C1 level 3b, MK-2- Level 3a & 4a

4. Case #1 You have been seeing a patient in collaboration with a physician colleague for depression and smoking cessation. She was prescribed Wellbutrin and has been taking 300 mg a day but is still symptomatic and smoking - she is smoking less but still smoking. Her PCP sent you a note asking if you thought she should increase the medication dosage or any other recommendations about how to treat this patient. After seeing the patient a few times, she reveals current symptoms of bulimia including food restriction, binge eating, and self-induced vomiting. Her eating and weight issues seem to be a driving force in her depression. As you do with all patients when you first see them, you had explained the collaborative care model and shared record keeping. You also reply to the PCP after this visit with the patient suggesting she reconsider the medication plan in light of this new information. At her next visit with the patient, she brings up her concern about the patient being on Wellbutrin due to her eating disorder and wants to change her medication. When you see the patient again in a few weeks, she is very angry with you for revealing this “private information” to her PCP.

5. Objectives Participants will be able to: Correlate clinical/teaching dilemmas with principles of medical ethics Describe and apply the “Four Topics” method as a model for considering ethical dilemmas using case studies Become aware & respect diverse clinicians’ perspectives and codes of practice Map “The Four Topic” Activity to multiple FM Milestones.

6. Why Medical Ethics? Ethics Education in Family Medicine Training in the US: a National Survey – Manson HM, Satin D, Nelson V, and Vadiveloo T. Family Medicine, 2014;46(1):28-35. “Considerable variation in…curricular content and delivery….” PCMH – inter-professional teams and differing contexts of care require flexibility Need a practical approach – Four Topics

7. Ethical Principles BB Beneficence Nonmaleficence Autonomy Justice HIPPA Confidentiality Informed Consent Patient Capacity Impaired Clinician Boundary Conflicts

8. Ethical Guidance? Family Systems and Health Special Issue, March 2013 Jonsen, Siegler, & Winslade (2002). Clinical Ethics, Fifth Edition

9. Common Ethical Dilemmas in the PCMH The Context makes a difference: Specialty vs PC The Model makes a difference: Specialty Psychotherapy vs PCBH See Handout: Table 1

10. The Four Topics Method: Case Analysis I. Medical IndicationsIII. Patient Preference II. Quality of Life IV. Contextual Features See Handout: Table 2

11. Skill Practice Review Case – Case #1 - Group Use Four Boxes / Topics to assess for ethical issues and identify a course of action Report to large group in 10 minutes: 1.Case description 2.Key Box / Topic 3.Ethical Issue(s) 4.Recommended Course of Action

12. Case #2 In your clinic, some of the staff and even some of the PCPs are patients of the clinic and receive their medical care from a physician colleague. You are also aware that PCPs will extend professional courtesy and offer opinions or even prescribe medications for each other. One of your PCP colleagues comes into your office frequently to chat about life. You have not been friendly outside of work other than work-related functions but have been supportive of each other at work. She has been out for a couple of weeks and you assumed she was on vacation but when she comes into your office today she is clearly not herself. She is down and lethargic and tearful and says she just can’t take it anymore. She starts talking about her marriage, which seems to be ending, and the stress with her kids. She tells you that she has suffered from depression in the past and took medication and wonders if she should go back on medication now. She has been drinking 2-3 glasses of wine a night to help sleep and ‘check out.’ She doesn’t want to go see a counselor but feels that you can help her. She has talked with her PCP who is also in the clinic and she says is willing to formally make an appointment with you.

13. How would you use this model in your home program? Quarterly Ethics Rounds/didactics Monthly PCMH team de-brief Family Medicine In-patient service

14. 14 Stay in touch... robinsonpatricia@me.com deb.gould@chcw.org