This scenario is professionally challenging because it requires the clinician to navigate a patient’s complex presentation with potentially overlapping symptoms, while also ensuring that diagnostic efforts are efficient and evidence-based, avoiding unnecessary investigations that could lead to patient anxiety, financial burden, or iatrogenic harm. The physician must balance thoroughness with judicious use of resources and patient well-being. The approach that represents best professional practice involves formulating a focused differential diagnosis based on initial findings and then systematically investigating the most likely causes. This hypothesis-driven approach ensures that the history taking and physical examination are directed towards confirming or refuting specific diagnoses. It prioritizes high-yield questions and targeted physical exam maneuvers, maximizing diagnostic yield while minimizing patient discomfort and time. This aligns with ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm), as well as professional guidelines emphasizing efficient and evidence-based medical practice. An approach that begins with an exhaustive, unfocused history and a broad, non-specific physical examination is professionally unacceptable. This strategy lacks direction and can lead to the collection of irrelevant data, potentially overwhelming the clinician and delaying the identification of the true underlying pathology. It fails to adhere to principles of efficient resource utilization and can be perceived as a lack of clinical focus, potentially eroding patient trust. Another professionally unacceptable approach is to immediately order a wide array of expensive and invasive diagnostic tests without a clear diagnostic hypothesis. This is not only financially wasteful but also exposes the patient to potential risks associated with these investigations without a strong clinical rationale. It demonstrates a failure to apply critical thinking and a lack of hypothesis-driven reasoning, which are fundamental to sound medical practice. Finally, an approach that relies solely on patient-reported symptoms without attempting to objectively assess and correlate them with physical findings is incomplete. While patient history is crucial, it must be integrated with objective data from the physical examination to form a comprehensive diagnostic picture. This approach risks misinterpretation of symptoms and can lead to diagnostic errors. Professionals should employ a decision-making framework that begins with an open-ended inquiry to understand the patient’s chief complaint, followed by targeted questioning to elicit details about the symptom’s onset, character, location, radiation, alleviating/aggravating factors, timing, and severity (the OLDCARTS mnemonic or similar). This is then coupled with a focused physical examination guided by the initial differential diagnosis. Investigations are then ordered strategically to confirm or exclude the most probable diagnoses, iteratively refining the diagnostic process.

Scenario Analysis: This scenario is professionally challenging because it requires a physician to navigate the evolving landscape of specialized board certifications and understand the specific criteria for eligibility, particularly in a relatively new or niche subspecialty like Critical Women’s Health Internal Medicine. Misinterpreting or misapplying eligibility requirements can lead to significant professional setbacks, including wasted time and resources, and potentially impact patient care if the physician is practicing outside their certified scope. Careful judgment is required to ensure adherence to the established standards for certification. Correct Approach Analysis: The best professional practice involves meticulously reviewing the official documentation and guidelines published by the certifying board for Critical Women’s Health Internal Medicine. This documentation will clearly outline the specific educational requirements, clinical experience, examination prerequisites, and any other eligibility criteria. Adhering to these official guidelines ensures that the physician is pursuing certification through the established and recognized pathway, thereby maximizing their chances of success and validating their expertise in the field. This approach is correct because it directly aligns with the regulatory framework established by the certifying body, which is the ultimate authority on who qualifies for the certification. Incorrect Approaches Analysis: Pursuing certification based solely on anecdotal evidence from colleagues or informal discussions is professionally unacceptable. This approach risks misinterpreting requirements, as informal advice may be outdated, incomplete, or inaccurate. It bypasses the official channels of information, leading to potential disqualification. Relying on information from a general medical journal article that discusses the *concept* of critical women’s health without referencing the specific certifying board’s requirements is also professionally flawed. Such articles may provide a broad overview but lack the precise details necessary for eligibility assessment. Furthermore, assuming eligibility based on holding another, unrelated board certification (e.g., general internal medicine) is incorrect. While general internal medicine provides a foundation, specialized certifications have distinct and often additional requirements that must be met independently. Each certification is governed by its own set of rules. Professional Reasoning: Professionals should employ a systematic approach to board certification eligibility. This involves: 1. Identifying the specific certifying board for the desired subspecialty. 2. Locating and thoroughly reading the official eligibility criteria and application handbook published by that board. 3. Consulting directly with the certifying board’s administrative office if any ambiguities arise after reviewing the official documentation. 4. Documenting all steps taken and ensuring all submitted materials precisely meet the stated requirements. This structured process minimizes the risk of errors and ensures a professional and compliant pursuit of specialized certification.

Scenario Analysis: This scenario is professionally challenging because it requires the physician to balance the immediate need for diagnostic clarity with the potential risks and resource implications of various imaging modalities. The patient’s presentation is suggestive of a serious underlying condition, necessitating prompt and accurate diagnosis, but the choice of imaging must be guided by clinical suspicion, patient factors, and established best practices to avoid unnecessary radiation exposure or cost. The physician must also consider the patient’s individual circumstances and preferences. Correct Approach Analysis: The best professional practice involves a systematic approach that begins with a thorough clinical assessment to formulate a differential diagnosis. Based on this, the physician should select the imaging modality that offers the highest diagnostic yield for the suspected pathology while minimizing patient risk and resource utilization. This often means starting with less invasive or lower-radiation options if they are likely to provide sufficient information. For suspected appendicitis in a reproductive-aged female, ultrasound is frequently the initial modality of choice due to its lack of ionizing radiation and ability to visualize pelvic organs, which can help differentiate appendicitis from gynecological causes. If ultrasound is inconclusive or the clinical suspicion remains high, then CT scan, with its higher sensitivity for appendicitis, becomes the next logical step, with appropriate consideration of radiation dose. This approach aligns with principles of evidence-based medicine and responsible resource stewardship. Incorrect Approaches Analysis: Proceeding directly to a CT scan without an initial ultrasound, especially in a reproductive-aged female, represents an overreliance on a higher-radiation modality when a less invasive option might suffice. This could lead to unnecessary radiation exposure for the patient without a clear clinical indication that the ultrasound would be insufficient. Opting for an MRI as the first-line imaging modality for suspected appendicitis is generally not the most efficient or cost-effective approach. While MRI offers excellent soft-tissue contrast and avoids ionizing radiation, it is typically more time-consuming, expensive, and less readily available than ultrasound or CT for this specific indication. Its use is usually reserved for cases where ultrasound and CT are contraindicated or inconclusive, or for evaluating specific complications. Delaying imaging altogether until the patient’s symptoms significantly worsen would be a failure to act promptly on concerning clinical signs. This could lead to delayed diagnosis, progression of the condition, increased risk of complications such as perforation or abscess formation, and poorer patient outcomes. It neglects the physician’s duty to investigate potentially serious conditions in a timely manner. Professional Reasoning: Decision-making in diagnostic imaging selection should follow a framework that prioritizes clinical relevance, patient safety, and resource efficiency. This involves: 1) Comprehensive clinical evaluation to establish a differential diagnosis. 2) Risk-benefit analysis of available imaging modalities, considering diagnostic accuracy, radiation exposure, cost, availability, and patient factors (age, pregnancy status, contraindications). 3) Sequential selection of imaging, starting with the most appropriate modality that balances diagnostic yield with risk, and escalating to more advanced or resource-intensive options only when necessary. 4) Clear communication with the patient about the rationale for the chosen imaging and potential findings.

Scenario Analysis: This scenario is professionally challenging because it requires balancing a patient’s deeply held personal beliefs and values with established medical best practices and the physician’s ethical obligations. The patient’s refusal of a potentially life-saving intervention, based on religious grounds, creates a conflict between patient autonomy and beneficence. Navigating this requires careful communication, thorough understanding of the patient’s capacity, and adherence to ethical and legal principles governing informed consent and refusal. Correct Approach Analysis: The best professional practice involves a comprehensive assessment of the patient’s understanding and capacity to make such a decision, coupled with a thorough exploration of the patient’s beliefs and the implications of their choice. This approach prioritizes patient autonomy while ensuring the patient is fully informed and capable of making a voluntary decision. It involves open dialogue, providing all necessary information about the risks and benefits of the proposed treatment and the consequences of refusal, and confirming the patient’s decision is free from coercion. This aligns with the ethical principle of respect for autonomy and the legal requirement for informed consent or refusal. Incorrect Approaches Analysis: One incorrect approach involves overriding the patient’s stated refusal based on the physician’s belief that the intervention is medically superior. This fails to respect patient autonomy, a cornerstone of medical ethics and law. It assumes the physician’s judgment supersedes the patient’s right to self-determination, even when the patient has capacity. Another incorrect approach is to proceed with the intervention without further discussion or confirmation of the patient’s understanding and consent, assuming the initial refusal was a temporary or uninformed reaction. This constitutes a violation of battery and a failure to obtain informed consent, disregarding the patient’s right to refuse medical treatment. A third incorrect approach is to withdraw from the case entirely without ensuring continuity of care or exploring alternative, acceptable treatment options. While a physician is not obligated to provide treatment against their conscience, abandoning a patient without making reasonable efforts to facilitate appropriate care or transfer responsibility is ethically problematic and can be seen as a failure of professional duty. Professional Reasoning: Professionals should employ a decision-making framework that begins with assessing patient capacity. If capacity is present, the next step is to engage in a detailed, empathetic discussion to understand the patient’s reasoning, provide complete information about all options (including risks, benefits, and alternatives), and explore the patient’s values and beliefs. The goal is to ensure the patient’s decision is informed, voluntary, and free from undue influence. If the patient maintains their refusal after this process, their decision must be respected, and the physician should document the discussion and the patient’s decision thoroughly. If capacity is in doubt, a formal capacity assessment should be initiated.

Scenario Analysis: This scenario is professionally challenging because it involves a patient with a complex medical history and a potentially life-altering diagnosis, requiring the physician to balance immediate diagnostic needs with the patient’s expressed wishes and potential for future reproductive health concerns. The physician must navigate ethical considerations of patient autonomy, informed consent, and the duty to provide comprehensive care, all within the framework of established medical guidelines and legal requirements. The pressure to make a swift diagnostic decision must be tempered by a thorough understanding of the patient’s values and the long-term implications of any proposed intervention. Correct Approach Analysis: The best professional practice involves a comprehensive, patient-centered approach that prioritizes open communication and shared decision-making. This entails thoroughly discussing the diagnostic uncertainties, outlining all available diagnostic options with their respective risks, benefits, and limitations, and actively eliciting the patient’s values, preferences, and concerns regarding her reproductive health and future fertility. The physician should then collaboratively develop a diagnostic plan that aligns with the patient’s informed choices, ensuring she understands the rationale behind each step and has the opportunity to ask questions. This approach respects patient autonomy and adheres to ethical principles of informed consent and beneficence, ensuring that the diagnostic process is not only medically sound but also ethically congruent with the patient’s overall well-being and life goals. Incorrect Approaches Analysis: One incorrect approach would be to proceed with an invasive diagnostic procedure without fully exploring the patient’s reproductive health concerns or her understanding of the potential impact on future fertility. This fails to uphold the principle of informed consent, as the patient has not been adequately apprised of all relevant factors influencing her decision. It also disregards the ethical imperative to consider the patient’s values and preferences, potentially leading to a diagnostic pathway that is not aligned with her life goals. Another incorrect approach would be to delay necessary diagnostic evaluation due to concerns about potential impact on fertility, without adequately discussing these concerns with the patient and exploring alternative, less invasive diagnostic strategies. This could lead to a delay in diagnosis and treatment, potentially compromising the patient’s health outcomes and violating the physician’s duty to provide timely and appropriate medical care. It also fails to empower the patient with the information needed to make informed trade-offs between diagnostic certainty and fertility preservation. A third incorrect approach would be to unilaterally decide on a diagnostic plan based solely on medical expediency, without engaging the patient in a meaningful discussion about her values and preferences. This paternalistic approach undermines patient autonomy and can lead to a diagnostic process that is not only medically suboptimal but also emotionally and psychologically distressing for the patient. It fails to recognize the patient as an active participant in her healthcare decisions. Professional Reasoning: Professionals should employ a structured decision-making framework that begins with a thorough assessment of the clinical situation, including the patient’s medical history and presenting symptoms. This is followed by a detailed exploration of the patient’s values, preferences, and goals, particularly concerning sensitive issues like reproductive health. The physician should then present all medically appropriate diagnostic and treatment options, clearly explaining the risks, benefits, and uncertainties associated with each. Shared decision-making is paramount, ensuring the patient understands the information and actively participates in choosing the path forward. This framework emphasizes ethical principles, patient-centered care, and adherence to professional standards, guiding the physician to make decisions that are both medically sound and ethically justifiable.

Scenario Analysis: This scenario is professionally challenging because it involves a physician needing to navigate the internal policies of a certification board regarding exam performance and retake eligibility, while also considering the ethical implications of potentially delaying a physician’s ability to practice independently in a critical specialty. The physician’s personal circumstances add a layer of complexity, requiring a balance between adherence to rules and compassionate consideration. Careful judgment is required to ensure the physician understands the board’s policies accurately and pursues the most appropriate course of action. Correct Approach Analysis: The best professional practice involves proactively and directly contacting the certifying board to obtain official clarification on the specific blueprint weighting, scoring, and retake policies as they apply to the physician’s situation. This approach is correct because it ensures the physician is acting based on accurate, authoritative information directly from the source. Relying on hearsay or general knowledge can lead to misinterpretations and incorrect decisions. The certifying board’s policies are the definitive guide, and direct communication is the most reliable method to understand their nuances, including any provisions for extenuating circumstances or specific retake limitations. This aligns with principles of professional integrity and due diligence. Incorrect Approaches Analysis: Seeking advice from colleagues or mentors, while well-intentioned, is an incorrect approach because it relies on potentially outdated or incomplete information. Colleagues may have personal experiences that do not reflect the current policies or may have misunderstood the rules themselves. This can lead to the physician making decisions based on flawed premises, potentially jeopardizing their certification pathway. Assuming the retake policy is standard and universally applied without verification is also an incorrect approach. Certification boards often have specific, detailed policies that can vary significantly. Failing to confirm these details directly from the board means the physician is operating under assumptions that may not hold true, leading to potential eligibility issues or missed opportunities for specific retake procedures. Waiting for the official notification from the board before taking any action is an incorrect approach because it is reactive rather than proactive. While official notification is important, delaying inquiry could mean missing critical deadlines for retake applications or appeals, especially if the physician’s initial performance was borderline or if there are specific conditions attached to retakes. A proactive approach allows for timely planning and action. Professional Reasoning: Professionals facing situations involving certification requirements should always prioritize direct communication with the certifying body. A decision-making framework would involve: 1) Identifying the specific policy area in question (blueprint weighting, scoring, retake policies). 2) Recognizing the need for authoritative information. 3) Prioritizing direct contact with the certifying board as the primary source of information. 4) Documenting all communications and received information. 5) Acting based on the confirmed official policies.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the candidate’s desire for efficient preparation with the need for comprehensive and evidence-based learning. The rapidly evolving nature of women’s health internal medicine, coupled with the high stakes of board certification, necessitates a strategic approach to resource utilization and time management. A candidate must navigate a vast array of materials, distinguishing between foundational knowledge, current best practices, and exam-specific strategies, all within a finite preparation period. The pressure to perform well can lead to suboptimal choices, such as over-reliance on single resources or inefficient study schedules. Correct Approach Analysis: The best approach involves a multi-faceted strategy that integrates a structured review of core internal medicine principles relevant to women’s health, active engagement with current guidelines and landmark studies, and targeted practice with board-style questions. This method is correct because it mirrors the comprehensive nature of the board examination, which assesses not only knowledge recall but also the ability to apply that knowledge in clinical scenarios. Utilizing a combination of reputable textbooks, professional society guidelines (e.g., ACOG, AHA, ASCO), peer-reviewed journals, and question banks provides a robust and balanced preparation. The timeline recommendation of starting 9-12 months prior allows for systematic coverage of all topics without undue haste, incorporating spaced repetition and regular self-assessment. This aligns with best practices for adult learning and knowledge retention, ensuring a deeper understanding rather than superficial memorization. Incorrect Approaches Analysis: Focusing exclusively on board-style questions without a solid foundation in core principles is professionally unacceptable. This approach risks superficial learning, where candidates memorize question patterns without truly understanding the underlying pathophysiology, diagnostic reasoning, or management strategies. It fails to equip them to handle novel or slightly altered clinical scenarios not directly represented in practice questions. Relying solely on a single, comprehensive review textbook, while seemingly efficient, can be professionally limiting. Textbooks, by their nature, may not always reflect the most up-to-date guidelines or recent significant research findings. This can lead to preparation based on outdated information, which is a critical failure in a field as dynamic as internal medicine, particularly in women’s health. Cramming in the final 2-3 months before the exam is professionally unsound. This method promotes rote memorization and is highly ineffective for long-term knowledge retention and clinical application. It creates immense stress and significantly increases the likelihood of burnout and poor performance, as the brain is not given adequate time to process and integrate complex medical information. Professional Reasoning: Professionals facing this decision-making process should adopt a framework that prioritizes comprehensive understanding and strategic planning. This involves: 1) Self-Assessment: Identifying current knowledge gaps and learning style. 2) Resource Curation: Selecting a diverse range of high-quality, current resources including foundational texts, professional guidelines, and reputable question banks. 3) Structured Planning: Developing a realistic study schedule that allocates sufficient time for each topic, incorporates review, and allows for practice questions. 4) Active Learning: Engaging with material through note-taking, concept mapping, and teaching concepts to others. 5) Regular Evaluation: Using practice questions and self-testing to monitor progress and adjust the study plan as needed. This systematic approach ensures thorough preparation and fosters the development of critical thinking skills essential for board certification and effective patient care.

This scenario presents a professional challenge due to the inherent complexity of integrating foundational biomedical sciences with clinical decision-making in a critical women’s health context. The physician must navigate potential diagnostic uncertainty, patient autonomy, and the ethical imperative to provide optimal care, all while considering the evolving nature of medical knowledge and the potential for rare presentations. Careful judgment is required to balance immediate clinical needs with long-term patient well-being and to ensure that diagnostic and therapeutic strategies are evidence-based and ethically sound. The best professional approach involves a systematic and comprehensive evaluation that integrates the patient’s presenting symptoms with relevant biomedical principles and diagnostic modalities. This includes a thorough history and physical examination, followed by judicious selection of laboratory and imaging studies informed by the differential diagnosis derived from the biomedical sciences. Crucially, this approach emphasizes shared decision-making with the patient, ensuring her values and preferences are central to the care plan. This aligns with ethical principles of patient autonomy and beneficence, as well as professional standards that mandate evidence-based practice and continuous learning. The physician’s responsibility extends to explaining the rationale behind diagnostic and therapeutic choices clearly, fostering informed consent and trust. An incorrect approach would be to rely solely on a single diagnostic test or a superficial assessment without considering the underlying pathophysiology. This fails to acknowledge the interconnectedness of biomedical sciences and clinical presentation, potentially leading to misdiagnosis or delayed treatment. Such an approach neglects the ethical duty to thoroughly investigate and could violate professional standards of care by not employing a comprehensive diagnostic strategy. Another professionally unacceptable approach would be to proceed with treatment based on a presumptive diagnosis without adequate investigation, especially when the symptoms are atypical or suggest a more complex underlying condition. This bypasses the critical step of confirming the diagnosis through appropriate biomedical investigations and could expose the patient to unnecessary risks or ineffective therapies. It demonstrates a failure to uphold the principle of non-maleficence and a disregard for evidence-based medicine. Furthermore, making treatment decisions without adequately involving the patient in the process, or by dismissing her concerns, represents a significant ethical failure. This undermines patient autonomy and can lead to non-adherence and dissatisfaction with care. Professional decision-making in such complex cases requires a framework that prioritizes a thorough, evidence-based diagnostic workup, open communication with the patient, and a collaborative approach to treatment planning, always grounded in the principles of beneficence, non-maleficence, autonomy, and justice.

This scenario is professionally challenging because it involves a patient with a complex medical condition and a caregiver who may have differing priorities or a different understanding of the patient’s best interests. Navigating these dynamics requires careful judgment to ensure the patient’s autonomy is respected while also considering the caregiver’s role and potential influence. The physician must balance providing comprehensive medical information with understanding and addressing the emotional and practical concerns of both the patient and the caregiver. The best approach involves a structured, patient-centered shared decision-making process. This begins with assessing the patient’s understanding of their condition and treatment options, identifying their values and preferences, and then collaboratively exploring potential treatment pathways. The physician should actively involve the caregiver in discussions, as appropriate and with the patient’s consent, to ensure they are informed and can support the patient’s decisions. This approach aligns with ethical principles of patient autonomy and beneficence, and regulatory frameworks that emphasize informed consent and patient-centered care. It promotes a therapeutic alliance built on trust and mutual respect, leading to decisions that are more likely to be adhered to and result in better outcomes. An approach that focuses solely on the patient’s stated preference without thoroughly exploring their understanding or the implications of their choices is ethically deficient. It risks overlooking potential misunderstandings or external pressures that might influence the patient’s decision, thereby failing to uphold the principle of true informed consent. Another unacceptable approach is to prioritize the caregiver’s wishes over the patient’s expressed preferences, even if the caregiver appears more knowledgeable or insistent. This undermines patient autonomy and can lead to a breakdown of trust, potentially resulting in suboptimal care and patient distress. Finally, an approach that presents treatment options in a biased manner, subtly steering the patient towards a particular choice, is unethical. It violates the principle of providing unbiased information necessary for true informed consent and compromises the physician’s professional integrity. Professionals should employ a decision-making framework that prioritizes patient understanding, values, and preferences. This involves: 1) Eliciting the patient’s concerns and goals. 2) Providing clear, unbiased information about the condition, prognosis, and all reasonable treatment options, including risks, benefits, and alternatives. 3) Exploring the patient’s values and preferences regarding treatment outcomes. 4) Collaboratively developing a treatment plan that aligns with the patient’s informed choices, involving caregivers as appropriate and with patient consent. 5) Documenting the shared decision-making process and the agreed-upon plan.

Scenario Analysis: This scenario presents a professional challenge due to the inherent conflict between a patient’s expressed wishes, which may be influenced by personal beliefs or external pressures, and the physician’s ethical and professional obligation to ensure the patient’s well-being and provide comprehensive, evidence-based care. The physician must navigate the complexities of informed consent, patient autonomy, and the potential for coercion or misunderstanding, all while upholding professional standards and the patient’s right to make decisions about their health. The urgency of the situation, coupled with the sensitive nature of reproductive health decisions, amplifies the need for careful judgment and ethical deliberation. Correct Approach Analysis: The best professional practice involves a thorough, empathetic, and non-judgmental exploration of the patient’s decision-making process. This approach prioritizes understanding the patient’s values, beliefs, and the specific reasons behind their request for a procedure that conflicts with their known medical history and current health status. It requires open communication, active listening, and the provision of comprehensive information about all available options, including the risks and benefits of the requested procedure, as well as alternatives and the implications of delaying or refusing treatment. This aligns with the core ethical principles of autonomy, beneficence, and non-maleficence, and the legal requirement for truly informed consent, which necessitates that the patient understands the nature, purpose, risks, and benefits of the proposed treatment and alternatives. The physician must also assess for any signs of coercion or undue influence that might impair the patient’s capacity to make a voluntary decision. Incorrect Approaches Analysis: One incorrect approach involves immediately acceding to the patient’s request without further exploration. This fails to uphold the physician’s duty of beneficence and non-maleficence, as it bypasses the opportunity to ensure the patient fully understands the potential risks and consequences, especially in light of their pre-existing conditions. It also risks undermining the principle of informed consent by not confirming the patient’s comprehension and voluntary decision-making. Another incorrect approach is to dismiss the patient’s request outright based on the physician’s personal beliefs or a perceived conflict with the patient’s medical history, without engaging in a dialogue to understand the patient’s perspective. This violates the principle of patient autonomy and can be perceived as paternalistic or discriminatory, failing to respect the patient’s right to make decisions about their own body, even if those decisions are not what the physician would recommend. A third incorrect approach is to present only the physician’s preferred course of action and strongly advocate for it, while downplaying or omitting information about the patient’s requested procedure. This constitutes a failure in providing complete and unbiased information, which is a cornerstone of informed consent. It also infringes upon the patient’s autonomy by attempting to unduly influence their decision rather than empowering them to make an informed choice. Professional Reasoning: Professionals should employ a decision-making framework that begins with active listening and empathetic engagement to understand the patient’s perspective and the context of their request. This should be followed by a comprehensive assessment of the patient’s understanding, values, and any potential external influences. The physician must then provide clear, unbiased information about all relevant medical options, including risks, benefits, and alternatives, ensuring the patient comprehends this information. Finally, the physician should support the patient in making a voluntary and informed decision, documenting the process thoroughly. This framework ensures that patient autonomy is respected while fulfilling the physician’s ethical obligations to promote well-being and avoid harm.