CASPER Prep Program Ethics Guidebook

Edition 1
2022

Written by
Dourra Assani
Claudine Henoud

Edited by
Julianah Oguntala
Claudine Henoud
Asli Fuad
Libny Pierre-Louis
 Table of Contents

Section 1: What is the CASPER Exam? 2

Section 2: Types of Questions on the CASPER Exam 7

Section 3: The Four Ethical Pillars of Medicine 10

Section 4: CANMED Roles 14

Section 5: The Do’s and Don’ts 19

Section 6: Ethics in Medicine 21

The role of physicians in medical ethics 21
Managing ethical dilemmas 22
Section 7: Key Ethical Components 23
Breaking bad news: 23
Medical error: 25
Confidentiality: 27
Conflict of interest: 29
Children and competency: 32
Paternalism and Patient Centered Approach: 33
Language barriers: 34
Cultural and religious barriers: 35

Section 8: Additional Resources 37

Bioethics: Ethics in Medicine | UW Department of Bioethics & Humanities (washington.edu)
37
PrepMatch→ platform to practice Scenario examples 37

References 38
Section 1: What is the CASPER Exam?
How does CASPER work?

To take their CASPER Test, students must register on the official CASPER website at
https://account.takealtus.com/signup. There are different types of CASPER exams depending on
the program the student is applying to. Therefore, it is important to select the right CASPER
exam and to take the exam in the right language (if the school specifies a language). It is also
important for student to ensure that they have the right deadline to take their CASPER test. The
deadlines are provided by the school to which the student is applying.

What are the Key components of the CASPER Exam?

The CASPER Test is an exam (duration: 100 to 120 minutes including an optional 5 minutes
break halfway through part 1 and a break between parts 1 and 2) composed of 15 sections. The
scenarios of the CASPER test can be presented in two possible formats: a video-based or a
texted-based scenario. Candidates must answer three questions in 5 minutes in part 1, the
typed-response section and record a 1 minute video to each of the three questions of part 2,
the video response section (1). Here is a breakdown of the key components of the exam.
- Beginning the exam: Candidates should log in their CASPER account a few minutes
before the exam to make sure that everything is working. They must take the exam in a
quiet room, alone, always have their camera on and remain in the camera field of view.
The exam will begin with a quick security verification that requires a piece of I.D.
Candidates will also be provided with some instructions on what to do in case there is a
technical problem. After the verification and instructions, the exam will begin. Videos
and text-based scenarios do not come in a specific order. They are mixed in the exam
therefore it is not possible to know if the next question is a video or a text-based
scenario. To become familiar with the CASPER test, it is strongly advised to do the
practice exam offered on the official CASPER website

- Video-based scenario: a video is played on the screen. Once the video is over it is not
possible to replay it. Therefore, it is important to focus, observe and listen attentively.

- Text-based scenario: the text is put on the screen for 30s approximately.

- Part 1 – Typed-Response Section: you are given 3 word-scenarios and 6 video-scenarios

and you are given 5 minutes to type a response to the 3 questions

- Part 2 – Video-Response Section: you are given 2 word-scenarios and 4 video-scenarios

and are given 1 minute to respond to each of the 3 questions for a total of 3 minutes.
 - Reflection period: After watching the video or reading the scenario the candidate gets
approximately 30 seconds to think about the scenario before the questions appear. For
Part 2,where you will be recording your responses, you are given 10 seconds after the 30
seconds reflection time to read the question. During this time, we encourage candidates
to think about the video or text and to reflect on the possible questions they could be
asked. If it is a conflict, they can start thinking about how they would approach the
situation. This is not necessary but can be useful because the questions on the test
varies and even if some questions might seem obvious after a scenario, it is very possible
to get unexpected questions. That is why focusing when watching the video or reading
the text is key.

- Questions: after the reflection period is over, the questions will appear on the screen. All
3 questions are displayed at the same time with a textbox following each. Candidates
will have 5 minutes to answer all 3 questions. At the end of the 5 minutes, they will be
redirected to the next scenario. The answers will be automatically saved.

- Next scenario: once candidates are directed to the new scenario, the video will start (or
the text will appear). It is essential to not think about the previous question. Even if it
happens that candidates are cut in the middle of a sentence or have a blank on one
question, focusing on the new scenario must be the priority. It happens often to all exam
takers. It is not possible to go back to the previous answers, therefore, the best thing
one can do is to remain focused and try to do their best on the new scenario.

How is the test evaluated?

Each scenario of the CASPER is scored by a different exam rater. The score is distributed directly
to the school that students add to their distribution list while creating their CASPER account.
Students will receive their score on a quartile scale (2).

What to expect when taking the test?

Even though one rater will grade each scenario, whether the candidate receives a general score
for all 3 questions of the scenario or a score for each question is unknown. Therefore, we advise
students to try their best to answer all three questions. However, having 2 solid responses is
better than having 3 not-well thought out responses

The scenarios on the CASPER test can be of different types. These types can include but are not
limited to:
 - Personal experience: these scenarios will require the candidate to reflect on their own
experiences. These questions can be presented in the format: ‘’Think about a time
when…’’

- Beliefs: these scenarios often ask candidates to opine on a policy, law or rule in place in
our society. An example of a question about one’s beliefs is ‘’Do you think vaccination
should be mandatory?’’. In these questions, the candidate must discuss and justify their
opinion.

- Conflict: in these scenarios, the candidate is presented with any type of conflict
(dilemma, conflict of interest, argument etc.) and must answer questions related to the
conflict. A conflictual situation can take the form of an argument between two
colleagues that they witnessed, and candidates are asked to describe how they would
navigate the situation.

- Problem solving: these scenarios are similar to the conflicts scenarios because the
candidate is presented with a situation and must describe how they would solve it.
However, instead of a conflict, the scenario is about a problem that must be solved. To
better understand the difference, an example can be used: a problem-solving scenario
could present a situation where they must find ways to encourage, improve or change
something such as students’ attendance in classes.

It is important to note that the content of the CASPER exam can vary and therefore, there is no
guarantee that any or all the types of questions listed above will be included. This resource does
not contain any question directly obtained from the exam because the information contained in
the exam is strictly confidential.

TLDR: The CASPER exam is a 100 to 120 min exam that contains text-based and video-based
scenarios with typed and video response sections. In part 1, the candidate must answer a series
of 3 questions in 5 mins after reading the text or watching the videos. In part 2, candidates must
record their response to a series of 3 questions in 3 mins after reading the text or watching the
videos. The answers are automatically saved, and the exam will directly move to the next
question when the time runs out. Questions on the CASPER exam can take the form of personal
experience questions (tell us about a time when…?), beliefs (what are your views on…?),
conflict or problem solving. Even though the exam questions vary and the exam is a personality
assessment, it is important to prepare for the CASPER exam.
How to prepare for the CASPER exam?

Even though the CASPER test is a personality test, being prepared will help answer the
questions within the timeframe given. Before everything, being able to express one’s thoughts
in a concise manner and to type answers within the 5 minutes limit is important to succeed on
your CASPER.

Typing
If possible, candidates should get comfortable with the device they are going to use during their
exam. Getting used to using the keyboard and knowing where some keys such as accents (for
French writers), apostrophes, brackets, comas etc. are located. Before the exam, we advise
candidates to do a typing speed test. These tests are easy to find online and will help them
determine if their typing speed is good or needs to be improved. Having a good typing speed is
useful for the exam because it will allow candidates to complete their answers before the time
runs out. If a candidate finds out that their typing speed is low, there is no need to be alarmed:
it is possible that their speed is still good enough to answer the questions in time and if it is not,
typing speed is something that can be improved. Doing the practice test on the CASPER website
will help candidates determine if they need to improve their speed or not.

Practice scenario questions

Practicing CASPER questions will not only help candidates improve their answers but also
improve their speed. The more one practice, the more scenarios they will encounter and the
more they will get used to answering new scenarios. Some ways to practice scenario questions
include but are not limited to:
- Using the free online CASPER test on the CASPER website
- Researching some free scenarios online (YouTube, Vimeo etc.)
- Researching some free written scenarios online
- Create your own written scenarios and practice answering them with a timer.
- Use PrepMatch a free online practice platform
- Take the CASPER Prep Program!

TLDR: To prepare for the CASPER exam, we advise candidates to test their typing speed and try
to improve it if it is very low. It is also important to do a lot of self-reflection in order to be
prepared for the personal experiences and beliefs questions. Practicing scenarios online and
doing the CASPER practice test on the CASPER website are good ways to become familiar with
the format of the exam.
Section 2: Types of Questions on the CASPER Exam
Preparing for the CASPER test also requires becoming familiar with the type of questions
presented during the exam.

● Personal experience

The best way to prepare for personal experiences questions is by doing some self-reflection.
One way to do so is to create a detailed autobiographical sketch. Candidates can make a list of
all their experiences and reflect on what they learned from them, situations that they were
confronted with during the experience, a positive and negative point about that experience, a
conflict or problem they had to solve during this experience. Having that sketch is useful
because, once presented with a personal experience question, they will have an example ready
if asked for one.

Another way to prepare for personal experiences questions is to think about the possible
questions they could be asked, make a list of these questions, and try to answer them by
thinking of their own experience. It is easy to think about these questions as they are typical
questions one could be asked at a job interview such as:
- What is your biggest strength? Your biggest weakness?
- Think about something you regret.
- Think about an obstacle you had to face.
- Think about a time when you had to make a sacrifice
- What is your biggest success?
- Think about a time when you had to express your disagreement to a superior.

When answering these questions, candidates must talk about what they learned from them
or how they empowered them.
A common acronym used to answer personal questions such as ‘’Think about a time when …’’
is the STARR acronym (3):
Situation: describe the context of the event. What was it? Where was it? When was it? Who
was involved? It might not be necessary to answer all these questions. Use your judgment to
decide which ones are relevant depending on the situation that was presented and the way the
question was phrased.
Task and reasoning: explain what you were asked or needed to do. In the reasoning, candidates
should explain why it was important for them to act. What values, principles motivated the
action they took?
Action: describe what you did.
Result: describe the outcome.
Reflection: criticize your action and its result. Was the action the right one? Did you get the
expected result? Would you have done something differently? What did you learn?

As mentioned above, each CASPER scenario is followed by 3 questions. The questions following
a personal situation scenario might each cover a different part of the STARR acronym. If that is
the case, make sure you answer all three CASPER questions.
Example of scenario: Think about a time you had to choose between two commitments.
Question 1: What was it? (Situation, Task and Reasoning)
Question 2: What did you do? (Action, Result and reflection if relevant)
Question 3: What do you do to avoid time conflicts in your life?

● Conflicts and Problem solving

Reflecting on one’s own experiences can also help prepare for these scenarios. Candidates can
think about conflictual situations and problems they faced at their workplace, with some friends
or family members or at school, and how they solved the situation. Even if at the moment they
did not have the best approach to solve the situation, they can think about what they did at the
time, why it was not the best approach and what they could have done differently.
Create a template to approach these types of questions and practice yourself applying this
template to different possible scenarios. Consider the possible scenario of two colleagues
arguing because one of them keeps coming late to work. An example of approach to these
questions is the following:
1) State your understanding of the situation by discussing why the situation raises a
conflict, problem or dilemma: ‘’ The conflict in this situation is that person A is angry
because person B keeps coming late to work which makes it difficult for Person A’’

2) Discuss both points of views: ‘’I understand that person A is angry because having to
work longer hours due to another co-worker not coming one time can be frustrating.
However, it is important to inquire about the reasons why person B comes late. It is
possible that they have a time conflict, a personal situation or an inconvenience that
makes them unable to come on time’’.

3) Gather additional information: ‘’Before anything, I will try to calm person A, tell them I
understand their position and encourage them to calmly communicate to person B how
this situation affects them. I will go see person B in a private and quiet place. I will tell
them in a non-judgemental way that I noticed that they often come late. I will ask them
if they feel comfortable sharing with me the reasons why they are unable to come on
time if there are any. I will explain to them why this delay disturbs their colleague and
why it is important that they come on time. Finally, if there is a reason why they cannot
 come on time, I will try to find a solution with them and guide them towards resources if
necessary’’.

4) Describe your approach. For this specific example, you could describe the solutions you
would offer person B (ie., asking the supervisor to change their schedule).

5) Explain why you chose this approach. In this step, try to think about why this approach is
the best and what result to expect from this approach: ‘’ By approaching the situation
this way, I will avoid any complications by showing person A that their feelings are valid
and that they should communicate. Person B will have an opportunity to explain their
position and we can together find a solution that will accommodate everyone’’.

This template is only an example. One-way candidates can prepare is by practicing CASPER
scenarios by themselves and creating a template that works the best for them. As mentioned
before, the questions following the scenario might touch a specific point and they must ensure
that they answer the question asked.

● Beliefs

Answering questions on a scenario discussing one’s beliefs requires from them to be informed
about the news or popular controversial subjects (i.e., vaccine mandate, abortion, legal voting
age, phone use at school etc.). Candidates should research controversial subjects of the past
few years and reflect on their opinion. Think about possible subjects that can often divide
people. When answering the question, they should always explore both opinions. Discuss why
someone might be for and why someone might be against a given topic. After exploring both
positions, express your position and explain why you agree or disagree. Lastly, try to think about
compromises that can be made to satisfy both parties. Discussing a compromise is good if the
questions of the scenario allow you to.
Candidates must also be ready to answer a question on a subject that they never heard of. To be
prepared for that situation, knowing your own values, principles and having a good knowledge
of the four pillars of medicine below can be useful.

TLDR: There are many different types of CASPER questions. In this guide, we will discuss personal
experiences questions, belief questions, conflicts questions, and problem-solving questions.
Personal experiences questions ask candidates to discuss a situation they had to face in the past.
An acronym that can be used for these questions is STARR (describe the Situation, explain the
Task that had to be accomplished, the Action that was taken, its Result and the Reflection after
the results). The second type of questions are conflict and problem solving scenarios. Candidates
can approach these scenarios by stating their understanding of the situation first, discussing the
different possible point of views, gathering more information, describing their approach and
explaining why they chose that approach. Lastly, for beliefs questions candidates should be
familiar with different controversial subjects and recognize their own values and principles. They
should be able to explain their position, offer solutions or compromises after exploring both
points of views in an unbiased manner.
Section 3: The Four Ethical Pillars of Medicine
What are they and why are they important?

The four ethical pillars of medicine are Autonomy, Beneficence, Non-Maleficence and Justice.
There are four principles of healthcare used to evaluate a medical procedure, treatment or any
other type of interaction between the patient and the healthcare provider. They provide a
universal guideline on how to approach ethical issues that arise during the practice of medicine.
These principles can direct health care providers and help them make decisions. Ideally, the four
principles would be respected in any type of care given to a patient. However, in medical
practice, an ethical dilemma arises when one or more of these principles are in conflict with the
others. (4)(5)(6)

The four principles are described below (7):

Autonomy

The principle of Autonomy values the patient’s point of view over everything else. The
patient should make his or her own choices and the healthcare provider must make decisions
with the patient. Everything must be done with the patient’s consent and according to their
wishes, values and own principles, without violating any other important moral principles. The
principle of autonomy is not limited to doing what the patient wants but also includes making
sure that the patient has all the information required to make his or her own decisions. The
healthcare provider must understand the patient’s point of view and ask the patient questions
about themselves. Knowing the patient is the key to guiding them and helping them make their
choices.

Beneficence

The principle of Beneficence is the obligation to always do what is the best for the
patient, their health and prevent any harm from happening to the patient. It is often difficult to
distinguish between what is the best for the patient and what the patient wants. Sometimes the
health care provider will assume that something is good for the patient, meanwhile, the patient
has a different opinion. Therefore, beneficence is the act of doing what is the best for the
patient after considering their personal preferences, desires, values, resources, and other
personal factors that might have an impact on the patient's overall wellbeing.

Non-Maleficence

The principle of nonmaleficence is the oldest and least controversial ethical principle in
medicine. The meaning of this principle is to not harm or do anything that could have a negative
impact on the patients. Even though this seems obvious, it is important to understand that even
the routine procedures in medicine could have an adverse effect. A doctor can act maleficently
unintentionally due to ignorance, incompetence, unknown disability or intentionally. However, a
doctor could also harm a patient by giving a treatment or doing a procedure that could have
severe adverse effects. For that reason, it is important for doctors to weigh the risk and the
benefits in every decision they make with a patient, from a scientific and medical point of view,
but also from the patient’s point of view.

Justice

The principle of justice is associated with the healthcare resources allocation and the impact of
medical procedures on the patient, their family, and the healthcare team. The doctor has a
responsibility to ensure that the patient is treated fairly, has access to the best care available
considering their situation, and is not advantaged or disadvantaged in comparison to other
patients.

How to use the four pillars of medicine in the CASPER exam?

During the CASPER exam, the four ethical principles of medicine are useful when you are
presented with a dilemma. The scenario can be in a clinical context or even a daily life situation.
Even though they are principles of medicine, it is an asset to be able to apply those principles in
a non-clinical setting. The first step to use the principles of medical ethics is to recognize the
ones involved in the scenario. After identifying the principles, candidates should be able to
understand how they are in conflict in the situation. Once the conflict is brought out, it is now
possible to weigh both principles and decide which one should be prioritized. Please note that
prioritizing one principle does not mean forsaking the other: when someone prioritizes one
conflict, they should always explain why they made that decision and what they would do to
ensure that the other principle is not completely ignored. To better illustrate this, please
consider the examples below:

Scenario 1: You are the financial director of a student club at your university. A club member
who is also your friend asks you to waive their membership fee because they are unable to pay
but they still wish to take part in the club activities.

Scenario 2: You are the doctor in charge of Mrs. A, a 50-year-old competent patient that is
refusing a lifesaving treatment.

Which principles are in conflict in those two scenarios?

Scenario 1 is a non-clinical scenario. The difficult decision you are asked to make is to decide if
you are going to waive the membership for a club member or not. The first principle that you
can bring out of this scenario is the beneficence principle. By waiving the fee, you are allowing a
colleague to remain a member of the club even if they cannot afford it. It is a good deed.
Discussing the possibility to waive the fee shows that you are empathetic, and you acknowledge
the financial difficulties that someone can face. However, another principle is present in this
situation: the justice principle. Will it be fair to waive the fee for one member when others must
pay? You must discuss the impact this decision could have on the club and on other members. A
few points you could consider are the financial burden this missing fee could cause the club, the
opinion of other members who had to pay the fee, and the feelings of other students who had
to give up their membership because they could not afford it and did not think about asking to
have it for free. What happens if other members ask to have their fees waived as well, would it
be fair to deny their request? In summary, the beneficence principle makes you want to waive
the fee for your friend, but the justice principle makes you realize that it would not be fair to do
so. Ultimately, you would discuss alternatives such as finding grants or external resources to
help your friend pay the membership. Finding a compromise is a good way to not go against any
of the principles in conflict.

In scenario 2, you are in a clinical setting. The first principle that comes out is the principle of
autonomy. The patient is refusing treatment and as a doctor, you must respect her wishes.
However, another principle raises a conflict: the principle of beneficence. You care about the
patient’s well-being and without the treatment, her life will be in danger. From your point of
view, the good thing to do is to give the treatment. When discussing this scenario, you should
mention the reasons that could lead to a patient’s refusal of treatment such as misinformation,
culture, religion, or fear of being a burden to their loved ones. Ultimately, you want to ensure
that the patient has all the required information, do your best to guide them, look for possible
alternatives and respect their choices. Situations that put into conflict autonomy against
beneficence are often hard to navigate because the patient can have their own views of what
would be good for them, and sometimes, they perceive that not having the
treatment/procedure is what benefits them.

Please note that naming the principles during the CASPER exam is not required when answering
a question. Describing how you would approach a situation in detail will allow you to show that
you considered these principles even if you do not name them.

TLDR: The four pillars of medicine are Autonomy, Beneficence, Non-Maleficence and Justice.
These are the four principles of healthcare used to evaluate a medical procedure, treatment or
any other type of interaction between the patient and the care provider. In ethical dilemmas,
one of the principles may conflict with one or many other principles. The CASPER exam can
contain ethical dilemmas which is why candidates must be familiar with the four principles. The
principle of autonomy is the physician’s duty to respect the patient's wishes and allow the
patients to make their own informed decisions. The principle of beneficence is to do what is the
best for the patient and according to the patient. The principle of nonmaleficence is the act of
not doing anything that could harm the patient or be harmful according to the patient’s view.
The principle of justice is the act of treating the patient fairly considering the resources
available, other patients and other healthcare workers.
Section 4: CANMED Roles
What are they and why are they important?

The CanMEDS are a list of 7 roles that bring together the abilities physicians require to
effectively practice medicine and take care of their patients’ health. These roles are:
Professional, Communicator, Collaborator, Leader, Health Advocate, Scholar and Medical Expert
that integrates the previous 6 roles (8). The CanMEDS roles are important because they are the
qualities that one must possess or develop in order to become a competent physician. In the
practice of medicine, physicians are required to take on those roles every day. Since the CASPER
is a situational judgment exam, showing that one had taken those roles in the past and that
they possess those qualities is an asset.

Professional: Professionalism is a strong component of medicine. Physicians must always show

clinical competence, respect for ethics, continuous professional development, integrity, honesty,
altruism, humility, respect for diversity, and transparency with their patients. In other words,
the physician must remain “professional” at all times. The professional role also includes the
necessity for physicians to take care of their own health, and acknowledge when they are not
capable of practicing (due to illness, personal problems or any situation that might affect their
work). Physicians must ensure their well-being first, for their own health and for that of their
patients and colleagues.

Communicator: An important part of the physician’s work is done through communication.

Physicians must discuss with the patient to learn about their symptoms and their worries. The
medical approach is patient-centered; therefore, physicians must know their patients and all the
social, economic and cultural factors (medical history, family history, stage of life, living
situation, occupation, etc.) that may play a role in their experience of the illness. The physician
must also understand the impact of the illness on the patient, their priorities and expectations.
After asking the right questions and doing active listening, the physician must integrate all the
information acquired to provide adequate care to the patient. The physician must also explain
the medical condition to the patient. They must adjust the dialogue to the patient (children,
people with cognitive or hearing disabilities or elders) or the situation (announcing a bad
diagnosis) and ensure that patients understand their conditions and the plan in order to make
decisions. Physicians integrate this knowledge with an understanding of the patient’s context.
The communication role also includes sharing the necessary information with other healthcare
workers and family members involved in the patient’s care. Physicians must communicate in a
clear way and ensure that they share the right information to the right person in the right
setting.
Collaborator: The healthcare approach is multidisciplinary. Several different professionals must
work together in order to provide the necessary assistance to the patient. Many patients suffer
from medical conditions that require a follow-up with different specialists. In other words,
physicians collaborate with other physicians and health care workers such as dieticians, physical
therapists, nurses, social workers and many others. An efficient collaboration is essential to the
patient’s safety and well-being. It requires trust, respect, knowledge sharing between
professionals and shared decision-making. Each professional must know their responsibilities,
be willing to learn and work with others toward a common goal. In summary, medical practice is
also a teamwork where differences in opinion can arise and must be managed professionally
and respectfully. Collaboration skills are therefore essential.

Leader: Physicians engage themselves to work continuously to improve health care and deliver
efficient care. They are in close contact with patients and can be involved in research,
administration as well as training of medical students and residents. The continuous need to
improve and develop those fields for the well-being of patients and the future of medicine falls
into their multiple responsibilities. Physicians must be leaders and work toward improving and
developing all the sectors they are involved in.

Health Advocate: As mentioned above, physicians are in close contact with their patients and
have a privileged access to their needs, experience of their illness, perspective on the medical
system, their socio-economic situation and other determinants of health that play a role in their
medical condition. They also have the knowledge and expertise to understand what changes
could have a positive impact on the communities and populations’ health. For this reason, they
are the primary professionals that can advocate for the patients’ access to needed resources.
Improving health also includes disease prevention, health promotion, health protection, health
equity and assessing the specific needs of sub-populations such as religious or ethnic minorities.
Social factors such as gender, sexual orientation, education and age can make some populations
more vulnerable to specific health problems. Physicians must advocate for the needs of these
groups and have an impact that can go from the health care system to the education system
and policies-makers.

Scholar: The scholar role is the continuous learning and engagement toward teaching and
contributing to the medical literature that physicians demonstrate during their career. They
must evaluate the adopted protocols and results in their practice to ensure the improvement
of health care practices. They continually learn and increase their knowledge but also educate
patients, future physicians and colleagues. They gather information and use critical thinking to
perform evidence-based medicine and make clinical decisions. They integrate their medical
knowledge to patients’ values and preferences to deliver care to each patient. They contribute
to medical research, medical protocols review, creation and translation of knowledge.

Medical Expert: The Medical expert is the integrating role. Physicians integrate all the CanMEDS
roles during medical practice. In a clinical context, physicians put the patients at the center of
the care. They communicate efficiently with patients to not only know the patient and their
situation but also ensure that the patient understands their illness and treatment. They
collaborate with other healthcare workers by sharing information and doing shared
decision-making for the well-being of patients. They are leaders and advocates in the health
care system that thrive to ensure health equity, health care access and resources allocation for
the population according to their needs. They educate themselves to ensure that all the
decisions made are ethical, supported by research and consider the patient’s background and
context. The medical expert is a professional that learns throughout their career, communicates
and collaborates with patients and colleagues to give the best care possible to their patients
and advocate for the needs of their communities as leaders in the health care system.

How to use CANMEDS roles in the CASPER exam?

Candidates can use the CANMEDS roles during the exam to show that they had to fit in those
roles in past experiences. Similar to the ethics principles of medicine, most CANMEDS roles can
be demonstrated in non-clinical settings. The CANMEDS roles can be used when answering
ethical scenarios or self-reflection questions. In an ethical scenario, candidates can demonstrate
how they occupied the role when describing their approach to the situation. In a self-reflection
question they would talk about an experience and show how they occupied the role during that
experience.

In general, one or two roles could be relevant to a scenario. However, it is also possible to get
scenarios that would not require candidates to demonstrate that they occupied some of the
CANMEDS roles. The candidate must be able to recognize when a scenario requires talking
about some specific role. Once they recognize the roles involved, they should make sure to
demonstrate them in their answer. To give a better insight into the use of CANMEDS roles during
the CASPER exam, we will go through each role in the context of a non-clinical situation.

Professional: Someone can demonstrate that they occupied the professional role when talking
about an experience they had at work or any other professional setting (volunteering,
extracurricular activities) or when approaching an ethical scenario in the same setting. Examples
of these could be talking about a time when they had to reproach something to a colleague or
supervisor, a scenario about how they would approach a colleague that they caught stealing or
even how they would react if a customer was screaming at them. Being a professional requires
describing that they remained calm in difficult situations, approached the situation politely and
showed integrity, honesty and respect.
Communicator: This role is one of the simplest to use as communication can be applied in
several aspects of life. To demonstrate the role, candidates must show that they communicated
clearly and respected privacy if applicable. Showing the communicator role can take the form of
a sentence such as “I would take my colleague aside, to a silent and confidential place and
express him my concerns in a non-confrontational manner” or “I would actively listen to the
customer’s worries to show him that his concerns are important to me, and I am trying to help
him”.

Collaborator: Talking about the role of collaborator is easy to do when answering a scenario that
takes place in a group setting. Someone can show that they occupied this role when they talk
about a conflict or a situation that happened during a group project, during a teamwork or with
friends. An example of a collaborator role description is the following: “We made the list of the
tasks that needed to be done and each member chose the task they were most comfortable
doing. Each member discussed their responsibilities and how they were going to complete their
task. After that we worked separately and met twice a week to check on each other’s work. By
distributing the tasks, working on our own responsibilities, remaining open to other members’
feedback and giving each other constructive feedback, we were able to maintain a good
atmosphere in the group and finish the project in time”.

Leader: Just like the collaborator role, the leader role often takes place in a group setting.
Showing leadership requires demonstrating good teamworking skills, abilities to make decisions,
organization skills and ensuring the wellbeing of your colleagues. The exam could ask directly to
talk about a situation when one had to be a leader, or present a scenario in which the leader
role is relevant. Leadership can be demonstrated in the same scenarios in which the
collaborator role is relevant: “I asked the group members their availability and organized a
meeting that would work with all of their availability. During the meeting, I asked the group
members to take turns discussing their concerns about the project”.

Health Advocate: The health advocate requires a scenario in a clinical setting or related to
health. Outside the clinical or healthcare setting, candidates must demonstrate advocacy during
the exam if relevant. Showing the advocate role can be done by defending the interest of a
vulnerable person, speaking out when someone is treated unfairly and questioning a policy
when they think that it could be unfair to a group of people.

Scholar: Applying the scholar role is more challenging than other roles but can be done when
the scenario given takes place in an academic or professional setting or when asked about a
controversial question (e.g. You are asked to discuss your opinion on a policy). Candidates must
show critical thinking, demonstrate that they always make sure to have more information
before making a decision and that they make decisions or take a position after doing some
research and obtaining facts. Example: “Before taking a position, I would do a survey among the
employees to hear about their opinions on the new policy and how it could
advantage/disadvantage them.
TLDR: The CanMEDS roles are 7 different roles that physicians must take continuously during
their medical career. Showing that one has taken these roles when talking about previous
experiences can be an asset during the CASPER exam. The professional role is the ability to
remain professional, honest and exercise the medical profession with integrity and courtesy
towards one’s patients and colleagues. The communicator is the ability to communicate
information to patients in an understandable manner and by adapting the message to the
patient. It is also the ability to listen actively to patients and communicate knowledge to
colleagues. The collaborator role is the ability to work in harmony and respect with other
healthcare professionals. The leader is the professional with good teamwork and organization
skills and that can make efficient decisions. The health advocate is the physician’s responsibility
to be the point of contact from patient to healthcare policy-makers and advocate for the needs
of populations. The scholar role is the physician’s responsibility to educate themselves, teach
others and their ability to practice evidence-based medicine, involve themselves in research and
work toward the amendments and improving of healthcare protocols. The medical expert
integrates the previous 6 roles.
Section 5: The Do’s and Don’ts
Do: Explore many perspectives

When reading or watching scenarios, it is common to have a firm understanding of the situation
and to believe that only one answer can be the right one. However, even if the correct approach
seems obvious, you must always explore several perspectives in order to demonstrate that the
answer is not biased but rather made after reflection. It is even possible to have an opinion but
to see that opinion change upon reflection because the evaluation of other perspectives will
raise points that you had forgotten to consider.

Don’t: Make assumptions

Sometimes the information presented in a scenario is missing key points that should have been
verified before discussing the scenario. When something seems unclear or lacking in detail, be
sure to ask the right questions. Do not take positions based on assumptions. An appropriate
example would be the case of the co-worker caught taking money from the cash register. It is
very easy to conclude that the person was stealing. However, this would be an assumption. In
these situations, it is best to raise the uncertainty: "It is possible that I misinterpreted the
situation". Then, you should discuss the possibilities using "if-then" sentences: "If he was indeed
stealing money, I would ask him to (...)".

Do: Take a stance

Even though it is normal to be divided when looking at a dilemma, after exploring both points of
view, you must always express your position in a clear and concise manner. It is correct to give
alternative solutions and compromise, but before anything, you should describe and justify your
position if the question asks your opinion. Per example, if you are asked about your opinion on
mandatory vaccines at your workplace and you agree that vaccines should be mandatory, you
can discuss the importance of vaccines first, explain that you understand why someone could be
against it since making it mandatory goes against people’s autonomy, state firmly that you are
not against it, explain the reasons why and lastly provide alternatives or solutions for people
against it.

Don’t: Be vague

Every time you discuss a point, make sure to be clear and specific. Take a stance when you are
asked to discuss your opinion, justify your position with facts and examples. Eg. Say “Vaccines
help prevent infections; help protect those who cannot have vaccines for health reasons and
reduce the chances of having severe outcomes when infected.’’ Instead of “Vaccines are good”.

Do: Be concise - Quality over quantity

Because of the time limit, an easy trap to fall into is to find yourself writing an answer without
having fully understood the question or decided what to answer. This can be very
disadvantageous as the written answer will be poorly structured and sometimes incomplete or
even off topic. When you are faced with a scenario and you don't know what the right approach
or answer would be, take a few seconds to think and organize your thoughts before you start
writing. It is better to have a short, well-structured answer than a long one that misses
important points.

Don’t: Ramble endlessly

Just as in the previous point, it is possible that while writing your answer you may start to go in
several directions before focusing on the point of the question. This is quite normal as some
CASPER scenarios require a lot of thought. In such a situation, think about the most important
points and focus on those. Be sure to reread the question (several times if necessary) to provide
a clear and precise answer in your text.

Do: Seek additional information

When discussing a scenario in which information seems to be missing or when exploring

multiple perspectives, it is okay to quote the questions you would want to ask in the real world:
"First of all, I would look to see if (...); I would ask if (...)".

Don’t: Take a polarized stance and use inflammatory words

As mentioned above, you must take a stance. This position must be clear and unmixed. Avoid
giving your opinion in an uncertain way: "I might give him the free membership but I'm not
sure". Also avoid contradicting yourself in your answers by taking a position at the beginning
that is not maintained throughout the answer. Finally, be sure to maintain a peaceful tone in
your responses no matter how serious the scenario. Avoid phrases that might show anger such
as "that's horrible", "that's disgusting", "I'll kick him out" etc.
Section 6: Ethics in Medicine
The role of physicians in medical ethics

The CANMEDs roles (Professional, Communicator, Collaborator, Leader, Health Advocate,

Scholar and Medical Expert) and the four pillars of medical ethics (Autonomy, beneficence,
non-maleficence, justice) were discussed above.

The role of the physician is to continuously develop the CANMEDs roles to become a medical
expert (the last role) that will respect and apply the four principles of medical ethics and ensure
that they are always respected and applied by their colleagues.

Physicians must prioritize their patient’s needs, well-being and desire over everything.
Therefore, they must respect the patients’ autonomy in all medical decisions. As professionals
and communicators, they must give their patients all the required information to allow them to
make informed decisions and give their informed consent. After the patient has made their
decisions, the physician must give them the best care possible (beneficence and
non-maleficence) in collaboration with other healthcare professionals (collaborator). In order to
do so, physicians must remain educated and informed regarding the guidelines and healthcare
protocols (scholar and leader). When deciding on a treatment or procedure with patients,
physicians must take into consideration the resources of the system (justice). Indeed, resources
in the medical system are sometimes limited. It is the physician’s responsibility to ensure that
they provide patients with adequate care that will remain fair when considering their
well-being, other healthcare workers as well as other patients. Lastly, physicians must advocate
for the needs of their patients and be the intermediary between populations and healthcare
policies makers (health advocate).

TLDR: The role of physicians is to practice medicine by respecting the 04 principles of medical
ethics as far as possible and ensuring that their colleagues and other healthcare professionals
do the same. They must take on the different CanMEDS roles to ensure that patient wellbeing is
put first, patients are treated fairly and that decisions made have a positive impact on the
patient’s wellbeing but also the wellbeing of the community.

Managing ethical dilemmas

Ethical dilemma usually involves two or more of the ethical principles of medicine (autonomy,
beneficence, non-maleficence, justice) entering into conflict with each other. Physicians face an
ethical dilemma when respecting one principle might require disregarding another principle.

Each ethical dilemma is different from others because the factors involved (race, gender,
culture, age, context, circumstances) vary from one patient to another. An approach that was
efficient for one patient might harm another. Therefore, the first step of ethical dilemma
management is to listen to the patients and learn about their background (culture, priorities,
what lead them to the position they are in at the moment). Gathering all the important
information is the first step into managing an ethical dilemma.

After obtaining all the details of the situation, physicians must ask themselves what the
dilemma is and why does it represent a dilemma. The answer to that question can be a
sentence such as “The patient does not want to receive care but without the treatment, their
life is at risk”. The next step is to inquire about possible alternatives. Is there an alternative
course of actions? Is it possible that the patient does not completely understand the situation?

After exploring alternatives, the person facing the dilemma should apply the four principles of
medical ethics to that specific situation. What does the patient want, how can we help the
patient, which course of action will cause the least harm and is the patient being treated fairly?

Following the consideration of the four principles, it is important to also consider other parties
involved. How would the decision made affect the patient’s family? What are the guidelines and
protocols? What does the law say?

Finally, the person approaching the dilemma should propose a solution and describe why this is
the best solution. They must also evaluate that solution and consider situations in which they
would change their mind. Considering the choice critically is essential before applying the
solution.

TLDR: Ethical dilemmas arise when ethical principles conflict with one another. The clue to
managing ethical dilemmas is to identify the ethical principles involved, gathering the different
information by asking questions if needed, exploring the different possible course of action and
alternative, proposing a solution and justifying why that solution is the most suitable.
Section 7: Key Ethical Components
1. Breaking bad news:

An important and difficult part of the physician profession is to announce bad news to their
patients. Unfortunately, it is impossible for a physician to go through their medical career
without having once the responsibility to break bad news to a patient or a patient’s family
member. Therefore, medical school applicants must possess the necessary empathy to be able
to take on such responsibility. It is normal to not be totally prepared since this is a skill that
medical students develop along their training but even as a medical school applicant, it is
important to understand and be able to apply the basics to breaking bad news.

First and foremost, we should understand what constitutes bad news. The definition of what is
or is not bad news lies in the patient’s hands and not the physician’s. For this reason, physicians
must never assume that any information, diagnostic or announcement made to a patient is not
“severe enough” to be considered bad news. If the information shared is not entirely positive,
they must be prepared to use the approach to breaking the bad news. In a CASPER exam, the
candidate would describe their approach. A commonly used protocol is defined under the
SPIKES acronym (9).

Setting: Ensure that you and the patient are in a quiet and private place. You can also ask the
patient if they wish to involve anybody else in the conversation. If the scenario mentions that
you must break the news on an online video call (even though it is unusual and its preferable to
give this news in person), reassure the patient about the confidentiality of the call and make
sure that they are also in a setting that allows them to take the call and discuss important health
information.

Perception: Ask the patient what they know about their medical conditions. If you are talking to
a family member, ask them the same question. You must gather information about their
understanding of the situation, their perception and clarify any doubt or misunderstood points.

Invitation: Inform the patient of your intention (i.e. to give medical exams results). Ask them if
they are willing to hear it and if they only want to hear part of the information, enquire about
how much they are willing to know.

Knowledge: Inform the patient that you do not have good news. Share the news in a clear, firm
and empathetic manner. You should not be vague or stumble over your words, but you must not
be insensitive.

Empathy: Using your non-verbal cues and body language, show the patient that you empathize
with their feelings. Remain silent if the patient is not asking any question to give them time to
process the information and express their emotions. If the patient asks questions about the
prognosis, do not make false promises (“We are surely going to cure him”) and do not give
unsensitive answers (“he will most likely die”). Instead, reassure them that you are going to do
your best to provide the necessary care to the patient. Normalize their feeling: “It is normal for
you to feel distressed after hearing this news”.

Summary: The objective of this last point is to close the conversation and clarify any doubts the
patient might have. You must ask them if they have any questions and offer possible resources.

TLDR: Breaking the bad news is an important task that physicians must perform in their practice.
CASPER candidates should know the approach to breaking the bad news since it can be used in a
scenario, and it allows them to become familiar with how to show empathy to a person in a
difficult situation. A popular approach is the SPIKES method that includes ensuring to be in the
right Setting with the patient, inquiring about their Perception and knowledge of the situation,
Inviting the patient to hear the news, ensuring that they have the Knowledge of the fact that
you do not have good news, showing Empathy and closing the conversation with a Summary.

2. Medical error:

A medical error is the result of a human or system’s fault. It is a preventable event or outcome
that may or may not harm a patient. For example, an unnecessary procedure done on a patient
would still be considered a medical error even if it does not have any negative consequence on
the patient. Medical errors can cause psychological harm or a patient's loss of trust in the
system and the physician.

When a medical error is committed, several parties are involved: the person who made the
error, the people who witnessed or found out about the error, the medical facility as a whole
and the patient. It is important to discuss the responsibilities of the first three and their duty
toward the patient.

● The health care provider who made the error: The first responsibility of the person who
made the error is to recognize that a mistake was made. It is within human nature to
become defensive when they realize that they made a mistake. Healthcare workers must
acknowledge their mistake as soon as possible and engage in the next steps because the
patient's trust, health and sometimes life is at risk. After recognizing that a mistake was
made, the healthcare worker’s duty is to signal that medical error to their supervisors.
An often-asked question is whether all medical errors should be reported. The answer to
that is yes. Even the smallest error that did not bear any consequence could result in
harm when committed in another context. Reporting the error is important to ensure
that the proper measures are taken to prevent the error from happening in the future.
For errors such as giving a lower dose of medication to the patient (without any
consequence on the patient’s health), even if there might be no need to report it to a
supervisor, the physician must still record it in the patient file. The third responsibility of
the healthcare worker who made the error is to report the error to the patient. Some
 people argue that minimal errors that did not result in any harm should not be reported
because they will cause unnecessary distress in the patient. Even though it is true that
the bigger the error, the bigger the importance of reporting, we believe that all errors
must be reported to the patient. The reason for that is it is within the patient’s right to
know if an error was committed. Patients put their trust and faith within their physician’s
hands and deserve complete transparency. Unnecessary distress can be avoided by using
the right approach to report the medical error to the patient (described below). The last
responsibility of the person who committed the error is to understand why and how it
happened in order to learn from it and avoid repeating the same mistakes. Mistakes can
happen even in a structured environment such as a clinical context. The most important
is to learn from those mistakes and try to prevent them from reoccurring.

Disclosure of medical error

- Introduce yourself and your responsibilities (if not done already) or remind the patient
of your responsibilities
- Establish rapport with the patient and/or the family member by showing empathy: “I am
sorry that you are still unwell”. If the patient does not suffer any consequences of the
mistake, establish the contact by asking how they are doing.
- Do not wait for the patient to ask why they are not feeling better; disclose the error in a
concise, clear and apologetic manner: “I have something difficult to tell you. While
administering your medication, I made a mistake and (…)”
- Ask the patient if they wish to hear about how the error was made and if yes, provide
the information: “Would you want me to explain how it happened?”.
- Give the patient or their family member an objective narrative. Do not speculate or put
the blame on someone else. In doubt, it is better to acquire the information before
going to the patient. The person disclosing the error should be able to answer the
patient’s questions.
- Apologize and do not be defensive.
- Empathize and normalize the patient’s feelings.
- If the patient is willing to hear about it, give information on how you will ensure that the
mistake does not happen again.
- Describe the next steps that will be taken when it comes to the patient’s care (if they are
willing to hear it).

● The witness: The witness’ responsibility is to ensure that the person who made the error
assumes their responsibilities. They must remain empathetic and non-judgemental
toward their colleague. In a CASPER scenario, candidates can show empathy by using
sentences such as “I understand that my colleague must already be distressed, worried
and feeling guilty after what happened. I will listen to them and try to calm them down”.
After confirming that a mistake was indeed made, the witness must encourage their
 colleague to report the error and inform the patients. In a situation where the
healthcare worker who committed the error refuses to report it, the witness must report
the error to their supervisor after informing their colleague that they will do so and
giving them a chance to report themselves.

● The medical facility: The responsibility of the medical facility is to obtain the necessary
information and details regarding the medical error that occurred and find ways to
prevent it from happening. As mentioned above, the medical error can be due to the
physician’s mistake (Eg. giving the wrong medication to a patient) or a system mistake
(poor organization of the medication that led to the administration of the wrong
medication). The medical facility’s reputation and the trust of all patients using that
medical facility can be affected by the event. Because of that, informing the authorities
of the error that happened cannot be avoided since it is essential to ensure adequate
management of the situation and implementation of preventive measures or guidelines.

TLDR: A medical error occurs when a mistake is made during the administration of care due
to a person’s or a system’s fault. The most important when a medical error happens is to
recognize that an error was made, take responsibility, inform the superiors/authorities of the
healthcare institution of the error or document it, inform the patient and establish a plan to
prevent the error from reoccurring. When someone witnesses an error, they become
responsible for making sure that the person who made the error takes the necessary steps.
During the CASPER (as in real life), it is important to remain empathetic, non-judgemental
and support the person who made the error as they are in a difficult position.

3. Confidentiality:

Confidentiality is the protection of, health related or not, sensitive and personal information
regarding a patient. Healthcare professionals have a duty to respect patient’s confidentiality.
Patients have the right to their medical information and decide who can have access to it.
Nowadays, medicine is multidisciplinary and can sometimes involve several professionals in the
care of patients. The physician duty is to inform the patient of who is involved in their care and
get patients consent to share their medical information with other professionals.

When can a physician breach confidentiality?

There are some situations where a privacy breach is necessary. A physician can only breach
confidentiality when the patient is not capable of making their own decisions or when the
patient or someone is at risk of death or serious bodily harm. This includes situations such as
child abuse or neglect, abuse of a vulnerable adult and public safety (reporting gunshot or stab
wounds, driving impairment or reportable communicable diseases to authorities).
During the CASPER exam, if presented with a situation where it is required to breach someone’s
confidentiality, the first step should always be to verify if there is no other solution. Breaching
confidentiality should always be a last resort. Confidentiality can be used in a question
illustrating a scenario such as:

Scenario 1: You are caring for a 70-year-old man with dementia diagnosed with advanced
leukemia. He tells you that he does not want any family member to know about his condition.
His daughter arrives at the hospital and asks to know what is happening to her father.

Scenario 2: When performing a physical exam on a patient admitted for a fever, you notice signs
of IV drug use on their arm. They ask you to not share this information with anybody else as
they do not want to be judged by the medical team and their family members.

Scenario 3: Your colleague A is not able to come to work because she is going through a severe
depression. When you go to work, colleague B asks you why colleague A did not come. They are
worried but also angry because they were supposed to submit a work report together.

The first two scenarios are in a clinical context but the third one is not. Indeed, confidentiality is
not only limited to medical practice. It is imperative to remember that all the points we discuss
can be applied to non-clinical scenarios.

The main questions to ask are: Is the patient capable of making their own decisions? Is the
patient’s life at risk? In scenario 1, the physician would have to assess the patient’s dementia
(How advanced is it? Are they capable of making decisions?). If the patient is not in capacity to
make decisions, involving the daughter in the care will be required. In scenario 2, it would be
important to discuss with the patient about why the other professionals must know about the
drug use and the fact that the physician is obligated to write it in their medical record which
other workers have access to when providing care. The physician will have to respect the
patient's wish to not involve any family member. However, they can discuss with them the
importance of having family support when someone is battling with an addiction. In scenario 3,
the worker must not share the information regarding their colleague A. Even though colleague B
is angry and telling them about colleague A’s condition would help calm their anger, the
information about colleague A is confidential and must not be shared. Instead, they could offer
to help colleague B finish the report.

Consequences of confidentiality breach

Confidentiality breach must not be taken lightly. A patient whose confidentiality was breached
will lose trust in their doctor. This trust is important to the doctor-patient relationship. A patient
that no longer trusts their doctor can avoid appointments, refuse to cooperate with the medical
team and refuse to follow the treatment or receive care. Ultimately, this would have a negative
impact on the patient’s health. Physicians must also remember that patients might have reasons
that explain why they requested the information not to be shared with a third party. Not
respecting the patient’s wish could cause them distress and possibly harm. When answering a
CASPER question, one must always make sure to have all the needed information. As mentioned
before, when in doubt, the best thing to do is to gather more information.

Confidentiality in the era of technology

During the CASPER exam, it is possible to come across questions asking about one’s opinion.
The use of technology in the practice of medicine is a common debate in the healthcare world.
Are electronic files safe? Is it correct for a doctor to discuss a patient’s condition over the phone
or through email? Points to consider in such scenarios are the following:
- It is better to announce bad news in person as the patient might need the physician
support and empathy which is best communicated in person
- Always verify that the patient is alone and able to discuss their health before starting to
share information over a video or phone call (a person could be outside of the camera’s
field of view, the patient could be on speaker)
- Obtain the patient written consent before sharing any type of information through email
or call
- Clarify what type of information the patient would like to receive through email or call
- Advantages and disadvantages of electronic medical records

TLDR: The respect of patient confidentiality is important for their safety and their trust in the
medical system. Confidentiality must not be breached unless there is risk of severe harm to the
patient or someone else. Other situation in which confidentiality can be breached are situations
such as child abuse or neglect, abuse of a vulnerable adult and public safety (reporting gunshot
or stab wounds, driving impairment or reportable communicable diseases to authorities) or
when the patient is not capable of making their own decisions. During the CASPER, even if
breaching the confidentiality is the last resort and no other option is possible, candidates should
discuss what the breach of confidentiality implies, why this should not be taken lightly and why
it is their only possible option. When the physician is required to breach confidentiality (for
public safety reasons per example), they must ensure that the patient is aware of that.

4. Conflict of interest:

A conflict of interest is a situation in which someone’s duty is influenced by any other interests
(financial, prestige, relationship). In a clinical setting, it is any situation in which the health care
professional’s duty to provide the best care for their patient might be influenced by other
interests. Conflict of interests are serious subjects in the healthcare fields because they can
affect a patient’s safety and health.

Example of situations with a conflict of interest:

- Patient offering money to a physician that is struggling financially
- Family member who is asking a physician to give them an appointment
- Physician receiving an expensive gift from a patient
- Physician invited to a dinner by a pharmaceutical company
There are many possible situations in which a conflict of interest may arise. One can identify the
conflict by asking the question: is there anything that could influence the physician’s decisions?
Physicians must make every decision based on three factors: the resources of the system, the
health and well-being of the patient and the patient’s desire (autonomy, which primes on the
first two). If there is a possibility of an additional factor influencing the physician’s decision,
there is a conflict of interest.

In the case of a patient offering money or an expensive gift to their physician, the factor that
may influence the physician is their gratitude toward their patient. For this reason, they may
feel indebted toward the patient and try to compensate by giving them earlier appointments
per example. This preferential treatment is not only unfair to other patients but also
unprofessional as it breaks a barrier between physician and patient. Similarly, a physician caring
for a family member might give preferential treatment to that family member. They might also
not be able to make a good judgement call when it comes to the patients’ care because of the
personal relationship they have with that patient. This can result in patient harm.

Another popular conflict of interest is the case of physicians invited for dinner or receiving
gifts/compensation from pharmaceutical companies. This situation represents a conflict of
interest because a physician that received a gift or any form of compensation from a
pharmaceutical company might be more inclined to prescribe their products to patients (even if
they are not the most efficient or affordable for the patient).

When confronted with a conflict of interest, physicians should always declare what the conflict
might be. They should politely refuse to give an appointment to a family member, explain to
them the reason why it is not good for a physician to treat someone with whom they have a
personal relationship and if possible, help them find another physician. When it comes to gifts
and money, they should politely decline any offer to receive money from a patient. In terms of
gifts, it is best to decline expensive gifts. When in doubt, they should report the gift and ask
their superior whether it is acceptable to receive a certain gift. Before prescribing a treatment
(including clinical trials) owned by a pharmaceutical company they received any form of gift
(monetary, diners etc.) from physicians who should disclose that information to their patients.
They must perform their own research to verify if that treatment is the best option for their
patients.

In the CASPER exam, candidates can approach a conflict-of-interest scenario by identifying and
naming the conflict of interest, explaining why the situation represents a conflict of interest,
exploring both possibilities (pros and cons of prescribing the treatment/accepting a gift),
describing what they would do and why they would do it. If they chose to do the action that
raised the conflict, they should discuss how they will ensure that their decision will not have a
negative impact on the patient's care and health.

TLDR: A conflict of interest arises when there is a factor other than resources available, patient
wellbeing and healthcare protocols influencing a physician’s decision. Such factors can be
money, gifts, partnership with a company or personal relationship with the person requiring
treatment to cite a few. When navigating a conflict of interest, it is important to explain why the
situation causes a conflict of interest and what must be done. The course of action depends on
the situation. In some situations, the appropriate decision is to redirect the patient toward
another physician, politely refuse the gift and explain why or be transparent with patients and
disclosing the necessary information to patient (when they received gifts or sponsorship from
the company that owns the treatment they are prescribing, Physician’s responsibility is to
practice evidence based medicine, do some research to not be influenced and make sure they
give patients the best options for them.

5. Competency:

Competency is the legal judgment on a patient’s ability to make decisions for themselves. It is
different from capacity, which is the clinical judgment. For this work, we will use them
interchangeably as it is often done in the medical field.

First, it is important to understand that competency doesn’t equal diagnosis. In other words, a
medical diagnosis is not enough to decide whether a patient is competent. Two patients could
have the same diagnosis but not the same level of competency. In the case of dementia, for
example, some patients’ condition is less advanced than others. Even though they have
dementia, they are still competent.

The second important point is that not all medical procedures require the same level of
competency. A patient could be competent enough to decide if they want to receive a flu shot,
but not competent enough to decide if they want to receive a surgery.

In this section, we will address competency in adults. By default, all adults are presumed
competent until proven otherwise. The most common causes of incapacity are cognitive
disorders. These disorders can be congenital (Down syndrome), degenerative (Alzheimer’s
disease) or due to a severe illness. Another cause of incapacity in adults is the loss of
consciousness or any physical condition making the patient unable to express themselves due to
trauma or acute illness. The role of the physician is to assess the patient’s competency by
evaluating if the patient can understand the information regarding a treatment/procedure and
if the patient can appreciate the foreseeable consequences of such treatment/procedure. The
assessment can be done by the physician themselves or by another specialist. It takes the form
of a discussion between the professional and the patient. In some cases, the professional will
ask questions to verify the patient’s understanding. If the patient is qualified as incompetent
after the assessment, physicians will have to involve a substitute decision maker that must be
an adult.

In the CASPER, any competency scenario must be addressed by avoiding stereotypes and bias
and exploring the situational factors that could influence a patient’s behaviour. A person that is
agitated is not necessarily incompetent. The behavior could be due to a temporary state of
shock following a major event. Before concluding that the patient is incompetent, the candidate
must mention that they will assess the patient’s capacity. Common signs of incapacity are
agitation, violent behavior, irrational thinking, confusion, and aggressive refusal of treatment.
These signs can however lead to stereotypes. For example, patients’ refusal of treatment is not
always due to incapacity. Sometimes, they have reasons to refuse a lifesaving treatment
(culture, religion, misinformation). The physician must discuss with the patient, ensure that they
have the right information, assess their capacity, and offer alternatives. If the patient is
competent and still refusing treatment, it is not a case of incapacity and there is no need to
involve a substitute decision maker.

Involving a decision maker

- Make sure that the decision maker contacted is the one who has the right to make
decisions
- Inquire about the relationship between the patient and their relative
- Gather relevant information to ensure that the substitute decision maker will act in the
patient’s best interests

6. Children and competency:

It was mentioned above that adults are considered competent until proven otherwise. In any
individual that is a minor (referred here as children), it is the opposite: they are considered
incompetent until proven otherwise. Therefore, the parent or legal guardian of the child must
be the decision maker. There are two exceptions: 1) the competent child’s choice differs from
their parent/guardians, 2) the competent child does not want their parent/guardian involved. In
other words, once the child is deemed competent, they are the decision maker, and we apply
the same rules as adults. In Canada, the only exception is Quebec where the legal age of
consent is 14 years old. In all other provinces and territories, competency depends on children
maturity and not their age. In summary, if a child is refusing treatment, the physician must
assess their competency. Once the child is deemed competent, their decision must be respected
if they are not being forced or pressured by a family member.

What happens when the parent is refusing the treatment? In Canada, parents cannot refuse
lifesaving treatment to a child based on their cultural or religious beliefs. In a CASPER scenario,
the candidate must remember that the goal is not to have the right answer but to show
empathetic and appropriate thinking. In this case, the proper way to address the scenario would
be by listening to parents’ position and beliefs, showing them that they understand and respect
their beliefs, explaining the importance of the treatment/procedure for the child, exploring
alternatives, ensuring that the parents have all the right information, explaining to the parent
that their duty is to do what is best for the child and ultimately giving the care to the children
despite the parents’ refusal. What matters the most in the exam is not the ultimate decision the
candidate would make but how they will come to that decision. Even though the physician is
obliged to do what is best for the patient, they must also do their best to bring parents to agree
or reduce their discontent by showing that their views were not disregarded.

TLDR: Competency is a patient’s ability to make decisions for themselves. Not all medical
procedures require the same level of competency and not all medical conditions result in the
same level of competency. In other words, competency must be assessed for each patient and
each procedure. Adults are deemed competent until proven otherwise. When an adult is not
competent, a substitute decision maker must be involved. Physicians must ensure that the
decision maker has the patient's best interest in mind. For children, the decision maker is the
parent or guardian. However, when an assessment shows that a child is competent (able to
understand a procedure/treatment and appreciate its risk and consequences), they are in a
position to make their own decisions regardless of parent/guardian wishes. Physicians must
always show empathy toward parents, reassure them and maintain a good relationship with
them especially when the child's decision opposes theirs. Even though they must respect the
choices of competent children, they must also provide support to parents and not disregard
them.

7. Paternalism and Patient Centered Approach:

Paternalism in healthcare occurs when a healthcare professional makes a decision for a patient
(regarding a treatment or procedure) without their explicit consent (10). Paternalism can also
occur when a physician hides certain information from a patient regarding their health
treatment or procedures. The physician using paternalism while treating a patient believes that
they are acting in the patient’s best interest. This goes against the principle of autonomy and
the patient centered approach.

A patient-centered approach is the incorporation of patients’ views, desires, values and

priorities in health care. The notion of well-being and benefit depends on patients’ experience
rather than the physician’s opinion. In paternalism, the physician decides what they think is best
for the patient. Since physicians do not always know what is best for the patient (as each
patient has their own definition of what their well-being is), paternalism can sometimes hurt
patients and does not respect their autonomy.

The patient-centered approach however does not imply that the patient is always right. Indeed,
there is a hierarchy in the physician-patient relationship. Since physicians have the experience
and all the knowledge, they are in a position of power when it comes to patient’s care. Their
duty is to get rid of that power imbalance, reduce the gap of knowledge between their patient
and themselves to put themselves at the same level with their patient. This can be done by
sharing all the information with patients and by explaining the options in an understandable
manner. By doing so, they give patients the “power” to make their own decisions.
An example of paternalism scenario is when a healthcare professional’s opinion differs from
patients. The healthcare professional is torn between doing what the patient wants (autonomy)
or doing what they believe is best for the patient (paternalistic approach). The paternalistic
approach is never the best choice. When there are obvious reasons why the patient’s desire
might result in harm (refusing life saving treatment), physicians should always prioritize
discussing with the patient, inquiring about the reasons that motivate their choice and trying to
convince them or finding an alternative. If the patient’s decision remains unchanged, it is the
physician duty to respect that choice. The only situations when a physician might not respect a
patient's autonomy are the following:
- Patient requesting an illegal or unprofessional care
- Patient incapacity (in this situation the physician must involve a substitute decision
maker rather than making the decision for the patient)
- Resources are limited
- The physician does not have the knowledge or expertise to give the care
- Social welfare or public health interest

TLDR: Paternalism in healthcare occurs when a healthcare professional decides for a patient
(regarding a treatment or procedure) without their explicit consent. The paternalistic approach
opposes the patient-based approach and violates the patient's autonomy. Physicians must
remember that what they deem best for the patient is not always what the patient considers
best for themselves. Their responsibility is to inform patients of their conditions, options and
guide them toward what they believe is best. But in the end, the decision is the patient’s.

8. Language barriers:

It is possible for healthcare workers to have to take care of patients that do not speak their
language. A patient and healthcare provider that do not speak the same language can not
communicate. This implies that the provider cannot explain the diagnosis to the patient, the
treatment or procedure and therefore can not obtain the patient's consent. When there is a
language barrier, the physician cannot provide care because the patient cannot express their
autonomy and give their informed consent.

In some cases, it is possible to find a translator. This translator can be a professional translator
hired by the hospital, or another employee of the hospital (that may or may not be a healthcare
professional) that speaks the patient’s language. Their first responsibility would be to explain to
the patient who they are, why they are here and obtain the patient’s consent. Indeed, the
translator will have access to the patient's personal information through the communication.
They must ensure that the patient is comfortable with that idea.

Often, the translator is a friend or family member of the patient. Since the patient is competent
and able to make their own decisions, involving a relative causes a risk of letting that relative
make decisions for the patient. The relative could do so by translating something different from
the patient’s words. Even though it seems highly unethical, and it would be easy to pass
judgement and criticize the relative (especially in a CASPER scenario), the motive behind such
an act is rarely an ill intent. Sometimes, the relative believes that they are doing what is best for
their loved one even if their views differ from the patient’s. Unfortunately, it sometimes
happens that the relative does not have the patient’s best interest at heart (cases of abuse). For
this reason, physicians must be careful when asking a relative to act as a translator. Ways to
protect the patient’s autonomy include:
- Inquiring about the relationship between patient and relative
- Observing the patient’s facial expressions, body language. A patient that is not
comfortable and does not feel safe will show it even if they cannot communicate it
- Questioning radical decisions such as total refusal of lifesaving treatment. Why is the
patient refusing treatment? Should another relative be contacted?
- Continue looking for a professional translator
Sometimes, there is no translator available. In that situation, the healthcare provider (or
candidate in the context of the CASPER) must show creativity and think about the software and
technological tools that can help the communication between health care provider and patient.
When mentioning those tools, it is important to discuss the limit to their accuracy. For this
reason, physicians must use them only when all other options are exhausted. They must also
test the software accuracy firsthand (asking the same questions in different ways to ensure the
message is properly translated, testing different software to see if there is concordance in
translations).

TLDR: When the physician and patient do not speak the same language, they cannot
communicate, and the administration of care is not possible. The first and best option is to
involve a translator (professional or other worker of the healthcare facility) with the patient's
consent. The second option is to involve a family member if possible. However, physicians must
be careful since it is not possible to guarantee that the third party will translate the patient’s
wishes and not theirs (with or without ill intent). The last option is to use translation software
with care since these softwares are not always perfectly accurate and reliable.

9. Cultural and religious barriers:

As mentioned before, one of the reasons for patients’ refusal of treatment is cultural and
religious beliefs. Some healthcare workers do not share those beliefs or perceive that health
should come before anything. No matter their position, they should learn about patients’
beliefs, respect them and find ways to incorporate them in the treatment plan. Since each
patient is different, there is no universal approach that is the most adequate. In the CASPER
exam, the steps to approach such a scenario are the following:
 1) Ask questions and get information: discuss with the patient to understand their reasons
and do some research. Physicians must educate themselves on the things affecting their
patients to provide the best care.
2) Give more information: it is possible that the patient misunderstood the procedure. Do
not assume that they do but ask questions to make sure that there are no
misconceptions and if there are, clear them out.
3) Respectfully try to convince the patient. If possible, offer them to talk with a doctor that
shares the same beliefs or cultural background.
4) Look for alternatives and propose them to the patient. For example, for the case of a
Jehovah's witness refusing blood transfusion for an operation, alternatives include
preoperative autologous blood transfusion or using blood substitutes.
5) Respect the wishes of the patient: if the patient is competent and refuses treatment
despite the physician’s effort, their wish must be respected
Refusal of treatment is not the only situation in which culture or religion affect a patient's
choice. Another important situation is the case of a patient that cannot adhere to treatment or
a specific diet because of fasting or restrictions.

Scenario 1: A patient has been prescribed a medication that they must take 4 times a day for a
month. They inform their physician that they will be fasting for the next month and therefore
will not be able to take the medication more than twice a day.

Scenario 2: Mr X is a patient with severe iron and B12 deficiency. He was prescribed
supplements and informed that he should eat more meat products. He replies that in his
religion they strictly follow a vegan diet (no animal products including seafood, milk and eggs).

In both scenarios, the patient cannot follow the physician’s recommendation. The best thing to
do would be to look for alternatives. For the patient in scenario 1, the physician could look for
another prescription that only requires 2 doses. For the patient in scenario 2, the physician
could increase the supplement dose if it is safe to do so. In both scenarios, physicians must
learn about their patient’s diet/fasting rules and make sure it will not put their health at risk in
the long term (per example whether fasting is safe with a patient 1 condition). If no alternative
is available, physicians should explain to their patient why there are no alternatives, why
following the treatment is important for their health and offer discussing with a religious leader
or a person from the same cultural group. That person will be able to answer some questions
that the patient might have.

Other situations involve patients refusing to hear about their diagnosis or family members
asking you to withhold information regarding a competent patient’s diagnosis. Even though the
health care provider has a duty to share all information with patients, they must also respect a
patient’s wish to not receive information on their health. In that situation, the healthcare
provider must try to explain to patients the importance of having the information and try to find
a common ground with the patient. If the patient refuses, they must ensure to have a written
consent from the patient. They should also explain to the patient what it implies, what
information should be withheld and whether they wish to continue treatment. When it is a
family member that does not want the patient to receive the information, the physician should
discuss with them to make them understand that it is the patient’s decision. They should show
empathy, acknowledge the family member’s beliefs, and explain to them why they are required
to inform the patient without disregarding their culture.

TLDR: Culture and religion are a big part of a patient's identity. It is normal for a patient to
refuse care because it goes against their beliefs. Physicians must remain respectful of that and
do their best to accommodate their patients. Accommodating the patients means trying their
best to find a solution that will allow the patient to follow their treatment without going against
their beliefs. Examples of that are looking for blood substitutes for patients refusing blood
transfusion, considering a patient’s fasting schedule when prescribing a drug or understanding
when a patient asks for a physician from a specific gender and ethnic group when reasonable
and possible.

Section 8: Additional Resources

Bioethics: Ethics in Medicine | UW Department of Bioethics & Humanities
(washington.edu)
PrepMatch→ platform to practice Scenario examples
 References

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20Babies/EthicVoc.htm
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[Internet]. [cited 2022 Feb 25]. Available from:
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https://canadiem.org/breaking-bad-news/
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nship