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IQMH Holds Successful Conversation Day on Ethics in Diagnostic Medicine

By Julie Coffey, Director of Education

On February 9, 2018, IQMH hosted an engaging conversation day on ethics. Those in attendance were treated to six presentations that covered some selected topics related to ethics as it applies to medical laboratories, specimen collection centres and diagnostic imaging services. These interwove to create an unforgettable day, often laced with emotion and deep thinking about the topics presented. 

We proudly present a summary of the presentations along with selected slides. 

Ethics in Diagnostic Medicine — What does it Encompass Exactly
Ruby Shanker, Bioethicist University Health Network and Women's College Hospital 

Ruby set the stage for the day with an exploration of what ethics is and why it matters. She explained that ethics is the systematic exploration of questions about what is and isn't morally permissible, summing it up with "it's could vs. should." The participants came to understand the relationships between: 

  • Ethics and morality
  • Ethics and religion
  • Ethics and culture 
  • Equality and equity

Ruby presented the IDEA framework for bioethics issues, which is an acronym for:

  • Identify the facts
  • Determine ethical principles in conflict
  • Explore options
  • Act and re-evaluate 
Also explored was the Accountability for Reasonableness Framework for Priority Setting or A4R. This framework forces one to think about fairness, equity, and transparency while embarking on a project and priority setting.

Hitting the Mark with Your Ethics Training Program
Michael Angers, Laboratory Manager, Lakeridge Health

Michael walked us through the steps to creating an effective ethics training program, drawing from his experience in working on the Canadian Society for Medical Laboratory Science (CSMLS) Code of Ethics guidance document (https://www.csmls.org/About-Us/Our-Members/Code-of-Ethics.aspx). He first clarified the purpose of an ethics training program, and then expanded on the following three steps to create a program that hits the mark:

  1. Assess your needs and the resources on ethics available to you. What challenges do you face? Are there areas where your service might be predisposed to the risk of ethical misconduct? What are your values? What should your values be? Are there social professional or organizational expectations? What resources are already available on ethics within your facility or from external sources?
  2. Establish a strong foundation for an ethics program by outlining expectations, gathering those resources, conducting the training, integrating evaluations of ethical conduct into your performance evaluation program, and outline a path to report violations. 
  3. Build a culture of integrity. Ensure the leaders talk often about the importance of ethics, keep employees informed, uphold promises, acknowledge ethical conduct, and model ethical conduct.

Ethical Considerations when Dealing with Adverse Events and Disclosure of Harm
Nancy Lawrence, Compassion Fatigue Educator, Certified Patient Experience Professional

This emotional presentation provided overview of the disclosure of harm process using two powerful case studies where disclosure of harm was needed. Staying with these examples, we discussed the healthcare team's perspective, the patient's perspective, how to respect diversity and how to communicate effectively. The power of apology was emphasized, and considerable attention was paid to the impacts on staff when an adverse event occurs such as compassion fatigue, vicarious trauma and moral distress.

Nancy concluded with compassionate information on how to incorporate both self-care and support of others in the disclosure process, including tips such as low impact disclosure and fair warning. 

Inclusion of Gender Identity within Diagnostic Medicine — Approaching Patients
Ruby Shanker, Bioethicist University Heath Network and Women's College Hospital

Beginning with a case study involving a patient who was treated with a gender-binary approach in a healthcare waiting room, Ruby shared the importance LGBTQ+ inclusive approaches in our medical laboratories, specimen collection centers and diagnostic imaging services.

The following terms were clarified: 

  • Privilege: a particular benefit, advantage, or immunity enjoyed by a person or class of people that is not shared with others. 
  • Oppression: form of injustice that occurs when one social group is subordinated while another is privileged. 
  • Intersectionality: a term coined by legal scholar Kimberley Crenshaw to account for overlapping and interrelated aspects of individual's identity.
  • Implicit biases: the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. All readers are encouraged to follow this link to discover their implicit biases: https://implicit.harvard.edu/implicit/.

Ruby covered in-depth the special considerations needed for LGBTQ+ patients due to their increased vulnerability, the discrimination they frequently encounter, the unfair pathologization of their gender identity, dual alienation, and the barriers to healthcare access largely due to lack of education of healthcare providers.

The participants heard tips on how to practice ally ship with the LGBTQ+ community:

  • Establish trust by taking time to build trust with oppressed populations
  • Ensuring privacy and confidentiality 
  • Using inclusive language
  • Normalizing questions around sex and gender
  • Clarifying pronouns
  • Apologizing for slips with pronouns 
  • Building inclusive spaces with welcoming posters/pamphlets

The following further resources were provided: 

Transgender Healthcare. Right or Privilege? 

Carys Massarella, MD FRCPC

In this powerful presentation, Carys, who is transfemale and heads a clinic that serves about 800 transgendered patients, explored more concepts related to the challenges faced by transgendered individuals when engaging in our healthcare system. She reviewed Canadian Bill C-16, and Ontario Bill 13 which guarantee that gender identity and expression as a protected human right.

Carys stressed that patients who are transgendered will actively avoid seeking healthcare and this may cause unnecessary harm.

She explained the typical laboratory protocol for patients undergoing gender transgender related treatment and surgeries. Also covered were cancer screenings and special considerations for diagnostic imaging. Reference ranges in laboratory medicine were discussed in the ensuing conversation, with agreement that much work is needed in this area, but in caring for her patients, Carys does not make decisions only in comparison to a reference interval. 

The Medical Laboratory and Transgender Healthcare
Miranda Wozniak Hematology Discipline Head Lifelabs, ON

Miranda used a powerful case study to illustrate the main healthcare obstacles of the transgender population as it relates to pathology and laboratory medicine. She began by emphasizing that the transgender population is one of the most marginalized and underserved in our society, and it is a large population, whose true numbers are unknown. In addition, societal intolerance and discrimination deters this population from seeking adequate medical care.

Obstacle #1: unfamiliarity of medical and laboratory professionals with the terminology, epidemiology, and medical needs related to the transgender population.

Obstacle #2: Inflexibility or inability of the laboratory information system to document affirmed gender and other important information.

Obstacle #3: Lack of transgender specific reference intervals.

Obstacle #4: Limited experience handling and interpreting surgical and cytological specimens from transgender individuals.

Obstacle #5: Ministry of Health Ontario billing which requires designation of sex/gender for the purposes of billing, otherwise it is rejected

The following further resources were provided: 

  1. Goldstein Z, Corneil TA, Greene, DN. When Gender Identity Doesn’t Equal Sex Recorded at Birth: The Role of the Laboratory in Providing Effective Healthcare to the Transgender Community. Clinical Chemistry. 2017;63(8): 1342-1352.
  2. Gupta S, Imborek KL, Krasowski MD. Challenges in Transgender Healthcare: The Pathology Perspective. Lab Medicine. 2016;47(3): 180-188.
  3. Deutsch MB, Green J, Keatley J, Mayer G, Hastings J, Hall AM. Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group. J Am Med Inform Assoc. 2013;20:700-703.
  4. Whitley CT, Green DN. Transgender Man Being Evaluated for a Kidney Transplant, Clinical Chemistry. 2017;63(11) 1680-1684.
  5. Deutsch MB, Buchholz D. Electronic Health Records and Transgender Patients – Practical Recommendations for the Collection of Gender Identity Data. J Gen Intern Med. 2014;30(6): 843-84.
  6. Callahan EJ, Sitkin N, Ton H, Eidson-Ton S, Weckstein J, Latimore D. Introducing Sexual Orientation and Gender Identity Into the Electronic Health Record: One Academic Health Center’s Experience. Acad Med. 2015;90: 154-160.
  7. Winter S, Diamond M, Green J, Karasic D, Reed T, Whittle S, Wylie K. Transgender People: health at the margins of society. Lancet. 2016;388: 390-400.
  8. Trans Care BC. [Internet: http://transhealth.phsa.ca/] [Cited 2018 Feb 23].. Gender-affirming Care for Trans, Two-Spirit, and Gender Diverse Patients in BC: A Primary Care Toolkit. October 2017. Available from: http://www.phsa.ca/transgender/Documents/Primary%20Care%20Toolkit.pdf.
  9. The World Professional Association for Transgender Health [Internet: http://www.wpath.org] [cited 2018 Feb 23]. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People (7th Version). Available from: http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk_association_webpage=3926.

IQMH offers gratitude to these five speakers who took the time and put remarkable passion into each of these presentations. 

With regard to better serving the LGBTQ+ community, IQMH has established a working group to continue the conversation on gender-inclusive affirmative care. The working group will determine the content of published guidelines, which could include, but is not limited to the following:

  • Education and awareness around gender expression and gender identity both at patient presentation and with result reporting
  • The identification of need for further work to be done, such as establishment of appropriate reference interval studies
  • Strategies for laboratory reporting in the absence of reference intervals applicable to transgender patients; how to ensure a clinically useful test result is provided 
  • Guidelines for asking patients questions around sex and gender
  • Guidelines for laboratory requisitions that ensure gender-inclusive care
  • Guidelines for record-keeping and accurate, inclusive data files

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