Scenario Analysis: This scenario presents a common challenge in surgical practice where a deviation from expected outcomes necessitates a thorough review process. The professional challenge lies in balancing the need for objective quality assurance and learning from adverse events with the potential for individual blame and the impact on team morale. Careful judgment is required to ensure the review process is constructive, evidence-based, and focused on systemic improvements rather than individual punitive action, aligning with the principles of patient safety and professional development. Correct Approach Analysis: The best professional practice involves initiating a formal morbidity and mortality (M&M) review. This approach is correct because it directly addresses the core principles of quality assurance in healthcare. Nordic healthcare systems, like many others globally, emphasize a culture of safety and continuous improvement. An M&M review, conducted by a multidisciplinary team, systematically analyzes the case to identify contributing factors, which can range from technical surgical issues to communication breakdowns, equipment malfunctions, or systemic process flaws. This process is ethically mandated to protect patient welfare by learning from errors and preventing future occurrences. It aligns with the overarching goal of reducing morbidity and mortality through structured, evidence-based analysis, fostering a learning environment without immediate punitive measures. Incorrect Approaches Analysis: Initiating an immediate disciplinary investigation against the lead surgeon without a formal review process is professionally unacceptable. This approach fails to adhere to established quality assurance protocols. It bypasses the systematic analysis required to understand the root causes of the adverse outcome, potentially leading to an unfair judgment based on incomplete information. Ethically, it can create a climate of fear, discouraging open reporting and collaboration, which are essential for patient safety. Focusing solely on the surgeon’s technical skill during the procedure, without considering other potential contributing factors, represents a significant failure in quality assurance. This narrow focus ignores the complex interplay of human factors, team dynamics, and environmental influences that can impact surgical outcomes. A comprehensive review requires examining all potential elements, not just the actions of one individual, to identify systemic weaknesses that could be addressed. Delaying any review until a formal complaint is filed by the patient or their family is also professionally unacceptable. This reactive approach undermines proactive quality assurance efforts. Patient safety requires continuous monitoring and review of outcomes, regardless of whether a formal complaint arises. Waiting for a complaint means potential learning opportunities are missed, and systemic issues may persist, increasing the risk to future patients. Professional Reasoning: Professionals should approach unexpected adverse outcomes with a commitment to a structured, non-punitive review process. The decision-making framework should prioritize patient safety and continuous improvement. This involves: 1) Recognizing the event as an opportunity for learning and system enhancement. 2) Initiating a formal M&M review process as per institutional or national guidelines. 3) Ensuring the review is multidisciplinary, objective, and evidence-based, considering all potential contributing factors. 4) Focusing on identifying systemic issues and developing actionable recommendations for improvement. 5) Maintaining confidentiality and fostering a culture where reporting and discussion of adverse events are encouraged.

This scenario presents a professional challenge due to the inherent conflict between a surgeon’s desire to advance their practice and the ethical imperative to prioritize patient well-being and avoid conflicts of interest. The need for objective, evidence-based decision-making in adopting new surgical techniques is paramount, especially in a specialized field like Nordic Foot and Ankle Surgery where patient outcomes can be significantly impacted. Careful judgment is required to ensure that any new technique is not only technically feasible but also demonstrably safe and effective, supported by robust data, and aligned with professional standards. The best approach involves a rigorous, evidence-based evaluation of the new surgical technique. This includes a thorough review of existing peer-reviewed literature, analysis of data from pilot studies or early adopters, and consultation with established experts in the field. The surgeon should also consider the potential benefits and risks specific to their patient population and their own surgical experience. This methodical process ensures that the adoption of the technique is driven by patient benefit and sound scientific principles, rather than solely by commercial interests or the desire for innovation without adequate validation. This aligns with the ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm), as well as professional guidelines that emphasize evidence-based practice and continuous quality improvement. An incorrect approach would be to adopt the technique based primarily on the manufacturer’s promotional materials and the perceived novelty. This fails to acknowledge the need for independent, critical assessment of the evidence. Regulatory and ethical failures here include a potential breach of the duty of care by not adequately vetting the safety and efficacy of the procedure, and a conflict of interest if the surgeon stands to gain personally or professionally from early adoption without sufficient justification. Another incorrect approach is to proceed with adoption after a brief discussion with the manufacturer’s representative, without seeking independent peer review or consulting broader scientific literature. This bypasses crucial steps in the evidence-based adoption process, potentially exposing patients to unproven risks and neglecting the responsibility to contribute to the collective knowledge base of the surgical community. This approach prioritizes convenience over due diligence. A further incorrect approach would be to implement the technique on a limited number of patients without a formal plan for data collection and outcome monitoring. While seemingly a cautious step, the absence of a structured evaluation framework means that the actual effectiveness and safety in the surgeon’s hands remain unquantified, hindering objective assessment and the ability to identify potential issues early. This falls short of the professional obligation to contribute to the scientific understanding of new procedures. The professional decision-making process for similar situations should involve a structured framework: 1. Identify the innovation and its potential benefits/risks. 2. Conduct a comprehensive literature search for existing evidence. 3. Critically appraise the quality and relevance of the evidence. 4. Consult with experienced colleagues and mentors. 5. Consider the specific patient population and practice setting. 6. Develop a plan for data collection and outcome monitoring if adoption proceeds. 7. Make an informed decision based on the totality of evidence and professional judgment, always prioritizing patient safety and well-being.

The assessment process reveals a common challenge in professional board certifications: balancing the desire for broad recognition with the specific requirements of a specialized certification. In this scenario, the challenge lies in determining whether a candidate’s existing international credentials and extensive experience in foot and ankle surgery are sufficient to meet the specific eligibility criteria for the Comprehensive Nordic Foot and Ankle Surgery Board Certification, which is governed by the Nordic Medical Association’s guidelines. Careful judgment is required to ensure that the certification process upholds its standards while remaining accessible to qualified professionals. The best professional approach involves a thorough review of the candidate’s qualifications against the explicit eligibility criteria outlined by the Nordic Medical Association for the Comprehensive Nordic Foot and Ankle Surgery Board Certification. This includes verifying the equivalence of their international training and experience to the specific requirements for Nordic practitioners, such as the duration and content of surgical training, specific procedural competencies, and any required local clinical experience or language proficiency. This approach is correct because it adheres strictly to the established regulatory framework and guidelines set forth by the certifying body, ensuring fairness and consistency in the assessment process. It prioritizes the integrity of the certification by confirming that all candidates meet the defined standards for practice within the Nordic region. An incorrect approach would be to assume that extensive international experience automatically equates to meeting the specific requirements for Nordic board certification. This fails to acknowledge that board certifications often have unique, jurisdiction-specific criteria that may not be directly transferable. The regulatory failure here is the disregard for the explicit guidelines of the Nordic Medical Association, potentially leading to the admission of candidates who may not possess the precise knowledge or practical experience deemed essential for safe and effective practice within the Nordic healthcare system. Another incorrect approach would be to grant provisional eligibility based solely on the candidate’s reputation or the prestige of their international training institution without a detailed, documented verification of their qualifications against the Nordic criteria. This approach is ethically problematic as it bypasses due diligence and could compromise patient safety by certifying individuals who have not met the established standards. It undermines the principle of meritocracy and fairness inherent in board certification processes. Finally, an incorrect approach would be to suggest that the candidate should pursue a full re-training program in the Nordic region, even if their existing qualifications are demonstrably equivalent. This is inefficient and potentially discriminatory, as it imposes an unnecessary burden on a qualified candidate and fails to recognize the value of their prior extensive training and experience. It deviates from the principle of recognizing equivalent qualifications, which is often a component of international professional mobility. The professional reasoning framework for such situations involves a systematic evaluation process. First, clearly identify the specific requirements of the board certification in question. Second, meticulously compare the candidate’s existing qualifications against these requirements, seeking documented evidence of equivalence. Third, consult the relevant regulatory body or its guidelines for clarification on any ambiguities. Fourth, make a decision based on objective evidence and adherence to the established framework, ensuring fairness and upholding the standards of the certification.

This scenario presents a professional challenge due to the inherent risks associated with operative principles, instrumentation, and energy device safety in complex foot and ankle surgery. The surgeon must balance the need for effective surgical intervention with the paramount duty to minimize patient harm, adhering strictly to established best practices and regulatory guidelines. Careful judgment is required to select the most appropriate energy device and technique, considering patient-specific factors and the potential for complications. The best professional practice involves a thorough pre-operative assessment and a clear understanding of the specific energy device’s capabilities and limitations. This includes confirming the device is properly maintained, calibrated, and that all safety features are functional. The surgeon should select the energy device and settings that are most appropriate for the specific tissue type and surgical objective, prioritizing monopolar or bipolar cautery with appropriate tip selection and activation duration to achieve hemostasis with minimal collateral thermal damage. This approach aligns with the fundamental ethical principle of non-maleficence and the regulatory expectation of providing care that meets the accepted standard of practice, ensuring patient safety through informed decision-making and meticulous technique. An incorrect approach would be to use an energy device without confirming its operational status or suitability for the intended procedure. This could involve using a device with a damaged tip, incorrect settings, or one not designed for the specific tissue being manipulated. Such an action would violate the professional duty of care, potentially leading to unintended thermal injury to surrounding structures, delayed healing, or increased risk of infection. This failure to adhere to basic safety protocols constitutes a breach of professional responsibility and regulatory compliance. Another unacceptable approach is to rely solely on the device manufacturer’s default settings without considering the specific surgical context or patient anatomy. While manufacturers provide guidelines, the surgeon’s clinical judgment is essential in adapting these settings to individual patient needs and surgical requirements. Deviating from this principle without a clear, evidence-based rationale risks suboptimal outcomes and potential harm, failing to meet the standard of care expected in specialized surgical fields. Finally, an incorrect approach would be to proceed with the use of an energy device without adequate training or understanding of its specific safety mechanisms and potential complications. This demonstrates a lack of due diligence and a disregard for patient safety, potentially leading to iatrogenic injury. Professional decision-making in such situations requires a systematic approach: first, a comprehensive understanding of the patient’s condition and surgical goals; second, a thorough knowledge of available instrumentation and energy devices, including their safety profiles and indications; third, a critical evaluation of the risks and benefits of each option; and finally, the selection and meticulous application of the safest and most effective technique.

This scenario presents a professionally challenging situation due to the inherent urgency and potential for rapid deterioration in a patient with severe lower limb trauma and signs of shock. The critical need to stabilize the patient hemodynamically while simultaneously addressing the orthopedic emergency requires a coordinated and evidence-based approach. Careful judgment is required to prioritize interventions, manage resources effectively, and ensure patient safety. The best professional practice involves immediate initiation of a structured resuscitation protocol tailored to trauma patients, focusing on airway, breathing, circulation, and disability (ABCDE approach), while concurrently involving the orthopedic team for definitive fracture management. This approach ensures that life-threatening conditions are addressed first, preventing irreversible organ damage, before proceeding to surgical intervention. The ATLS (Advanced Trauma Life Support) guidelines, widely adopted in Nordic countries and internationally, provide a robust framework for this initial management. Ethical considerations mandate prompt and effective care, prioritizing the patient’s immediate survival and well-being. An incorrect approach would be to solely focus on the orthopedic injury without adequately addressing the signs of shock. This failure to prioritize systemic resuscitation risks further hemodynamic compromise, leading to multi-organ dysfunction and potentially death. It violates the ethical principle of beneficence by not acting with sufficient urgency to stabilize the patient’s overall condition. Another incorrect approach would be to delay orthopedic assessment and intervention until the patient is fully resuscitated and hemodynamically stable, without considering the potential for ongoing hemorrhage from the fracture site contributing to the shock. While resuscitation is paramount, a prolonged delay in addressing a source of significant blood loss can hinder resuscitation efforts. This approach may not align with the principle of timely intervention, especially if the fracture itself is a major contributor to the shock state. A further incorrect approach would be to proceed directly to surgical fixation of the fracture without a thorough ABCDE assessment and initial resuscitation. This would be a grave ethical and professional failing, as it prioritizes a specific injury over the patient’s immediate life-threatening systemic instability. It directly contravenes established trauma care protocols and could lead to catastrophic outcomes. Professionals should employ a systematic decision-making process that begins with rapid primary survey (ABCDE), followed by secondary survey and definitive care. In this case, the initial focus must be on establishing adequate airway, ensuring oxygenation and ventilation, and initiating aggressive fluid resuscitation and blood product transfusion if indicated. Concurrent communication with the orthopedic team is crucial to facilitate a timely, yet appropriately sequenced, surgical intervention once the patient is sufficiently resuscitated. This integrated approach ensures that both immediate life threats and the underlying traumatic injury are managed effectively.

Scenario Analysis: This scenario presents a professional challenge due to the inherent risks associated with complex reconstructive foot and ankle surgery, specifically the potential for deep infection post-operatively. Managing such a complication requires a delicate balance between aggressive treatment to preserve the limb and patient well-being, and adherence to established surgical protocols and ethical considerations regarding informed consent and patient autonomy. The surgeon must act decisively while ensuring all actions are justifiable and documented. Correct Approach Analysis: The best professional practice involves immediate, thorough surgical debridement of all necrotic and infected tissue, irrigation and lavage of the surgical site, and obtaining appropriate cultures for targeted antibiotic therapy. This approach is correct because it directly addresses the source of the infection, minimizes the spread of pathogens, and provides crucial information for effective antibiotic selection, thereby maximizing the chances of limb salvage and patient recovery. This aligns with the fundamental ethical principle of beneficence (acting in the patient’s best interest) and the professional obligation to provide competent care. It also implicitly upholds the principle of non-maleficence by taking swift action to prevent further harm. Incorrect Approaches Analysis: Delaying definitive surgical intervention to observe the patient’s response to systemic antibiotics alone is professionally unacceptable. This approach fails to address the primary source of infection (necrotic tissue and bacterial load within the wound) and risks allowing the infection to progress, potentially leading to systemic sepsis, further tissue destruction, and ultimately, limb loss. This violates the principle of beneficence and demonstrates a failure to provide timely and appropriate care. Administering broad-spectrum antibiotics without obtaining intraoperative cultures and proceeding with wound closure without adequate debridement is also professionally unacceptable. While broad-spectrum antibiotics can be a temporizing measure, their effectiveness is limited without identifying the causative organism. Closing a potentially infected wound without thorough debridement traps bacteria and devitalized tissue, creating an ideal environment for infection to flourish, directly contradicting the principle of non-maleficence. Initiating surgical intervention without re-confirming the patient’s understanding of the risks, benefits, and alternatives, particularly if the initial consent was for a different procedure or if the complication significantly alters the treatment plan, is ethically problematic. While emergent situations necessitate swift action, a brief re-orientation or confirmation of understanding regarding the revised surgical approach and its implications is crucial for respecting patient autonomy, especially if the patient is capable of participating in decision-making. Failure to do so, even in an emergency, can undermine informed consent principles. Professional Reasoning: Professionals facing such a complication should first activate their emergency response protocols, which typically involve immediate assessment of the patient’s vital signs and the surgical site. A rapid, yet thorough, evaluation of the extent of infection is paramount. The decision-making process should then prioritize interventions that directly address the pathological process, guided by established surgical principles and evidence-based practices for managing surgical site infections. This involves a tiered approach: source control (debridement), appropriate diagnostic sampling (cultures), and targeted antimicrobial therapy. Throughout this process, clear communication with the patient and their family, as well as meticulous documentation of all findings and interventions, are essential for ethical and legal compliance.

This scenario presents a professional challenge due to the inherent risks associated with complex foot and ankle surgery, particularly when dealing with a patient who has multiple comorbidities. The requirement for structured operative planning with risk mitigation is paramount to ensure patient safety, optimize surgical outcomes, and adhere to professional standards of care. Careful judgment is required to balance the patient’s desire for surgical intervention with the potential complications arising from their health status. The best approach involves a comprehensive pre-operative assessment that extends beyond the immediate surgical site. This includes a thorough review of the patient’s medical history, current medications, and any pre-existing conditions that could impact surgical risk or recovery. Crucially, it necessitates a multidisciplinary consultation process, engaging specialists such as cardiologists, endocrinologists, and anesthesiologists, to identify and manage potential peri-operative risks. Developing a detailed operative plan that anticipates potential intra-operative challenges, includes contingency strategies, and outlines a robust post-operative care pathway, including pain management and rehabilitation, is essential. This structured approach aligns with the ethical principles of beneficence and non-maleficence, ensuring that all reasonable steps are taken to maximize benefit and minimize harm. It also reflects the professional obligation to practice within the bounds of competence and to seek appropriate expert advice when necessary. An approach that solely focuses on the surgical technique without adequately addressing the patient’s systemic health issues is professionally unacceptable. This oversight fails to acknowledge the interconnectedness of a patient’s overall health and surgical outcomes, potentially leading to unforeseen complications and a breach of the duty of care. Similarly, proceeding with surgery based on the patient’s strong desire alone, without a thorough risk-benefit analysis informed by multidisciplinary input, disregards the surgeon’s responsibility to act in the patient’s best medical interest, even if it means advising against or delaying surgery. Relying solely on post-operative management to address potential complications, rather than proactively planning for them, represents a failure in risk mitigation and demonstrates a reactive rather than a proactive approach to patient safety. Professionals should employ a systematic decision-making framework that begins with a thorough patient evaluation, followed by an objective assessment of surgical risks and benefits in the context of the patient’s overall health. This framework should incorporate consultation with relevant specialists, collaborative development of a detailed operative and post-operative plan, and clear communication with the patient regarding all identified risks and potential outcomes. The decision to proceed with surgery should be a shared one, grounded in evidence-based practice and ethical considerations.

The review process indicates a scenario involving a complex surgical decision with potential implications for patient outcomes and professional conduct. This situation is professionally challenging due to the inherent uncertainty in predicting the precise course of a complex foot and ankle deformity, the need to balance immediate surgical intervention with long-term functional goals, and the ethical imperative to ensure patient autonomy and informed consent. Careful judgment is required to navigate these competing demands. The best professional practice involves a comprehensive pre-operative assessment that includes detailed imaging, biomechanical analysis, and a thorough discussion with the patient regarding all viable treatment options, including their respective risks, benefits, and expected outcomes. This approach prioritizes evidence-based decision-making and patient-centered care. Specifically, it entails a detailed discussion of the proposed surgical plan, including the rationale for specific techniques, potential complications, and the expected rehabilitation process. This aligns with the ethical principles of beneficence (acting in the patient’s best interest) and autonomy (respecting the patient’s right to make informed decisions). Furthermore, adherence to established surgical guidelines and best practices for complex foot and ankle reconstruction ensures a high standard of care. An approach that proceeds with a less definitive surgical plan without fully exploring alternative reconstructive strategies or without a detailed discussion of potential staged procedures would be professionally unacceptable. This failure to fully investigate and present all reasonable options violates the principle of beneficence by potentially overlooking a more optimal or less invasive solution. It also compromises patient autonomy by not providing them with the complete information necessary for truly informed consent. Another professionally unacceptable approach would be to proceed with surgery based solely on the surgeon’s personal preference or past experience with similar cases, without a robust discussion of the specific nuances of the current patient’s anatomy and deformity, or without considering the patient’s individual functional demands and lifestyle. This deviates from evidence-based practice and risks a suboptimal outcome if the chosen technique is not the most appropriate for the unique presentation. Finally, an approach that delays definitive surgical planning or execution due to uncertainty, without actively pursuing further diagnostic information or consulting with colleagues, would also be professionally deficient. While caution is warranted, prolonged indecision without a clear plan for moving forward can lead to disease progression and potentially more complex surgical challenges later, negatively impacting the patient’s prognosis. Professionals should employ a structured decision-making framework that begins with a thorough understanding of the patient’s condition, followed by an exploration of all evidence-based treatment options. This should include a collaborative discussion with the patient, ensuring they understand the rationale, risks, benefits, and alternatives for each option. The chosen course of action should be the one that best aligns with the patient’s goals and values, while adhering to the highest standards of surgical practice and ethical conduct.

This scenario presents a professional challenge because it requires the candidate to navigate the established policies of the Nordic Foot and Ankle Surgery Board Certification regarding examination performance and retakes, while also considering the ethical implications of seeking an advantage based on perceived blueprint weighting. The core of the challenge lies in understanding and adhering to the official scoring and retake policies, which are designed to ensure fairness and standardization for all candidates. The best professional approach involves a thorough understanding and strict adherence to the published blueprint weighting, scoring, and retake policies of the Nordic Foot and Ankle Surgery Board Certification. This means accepting the official scoring mechanism as presented and planning retake strategies based solely on the stated criteria for eligibility and frequency. This approach is correct because it aligns with the principles of academic integrity and fair assessment. The certification board’s policies are the definitive framework governing the examination process. Deviating from these established rules, even with a perceived understanding of blueprint weighting, undermines the validity of the certification and creates an unfair advantage or disadvantage for oneself and other candidates. Ethical conduct in professional certification demands transparency and adherence to the established rules of engagement. An incorrect approach would be to attempt to infer or rely on unofficial interpretations of blueprint weighting to strategize for a retake. This is professionally unacceptable because it bypasses the official communication channels and established policies of the certification board. Such an approach risks misinterpreting the examination’s intent and structure, potentially leading to ineffective preparation and a failure to meet the actual requirements for passing. Furthermore, it demonstrates a lack of respect for the established governance of the certification process. Another incorrect approach would be to focus solely on the number of attempts allowed without considering the underlying performance metrics or the board’s stated reasons for retake policies. While the number of retakes is a policy component, understanding the scoring and feedback mechanisms is crucial for effective remediation. Relying only on the numerical limit without addressing performance gaps is a superficial strategy that fails to promote genuine learning and improvement, which is the ultimate goal of professional certification. A further incorrect approach would be to assume that a lower score on a specific section, even if perceived as having a higher blueprint weight, automatically dictates a retake strategy without consulting the official feedback provided by the board. The board’s feedback is designed to guide candidates on areas needing improvement. Ignoring this official guidance in favor of personal assumptions about weighting is a failure to engage with the structured assessment process and can lead to inefficient and misguided preparation. The professional decision-making process for similar situations should begin with a comprehensive review of all official documentation provided by the certifying body. This includes understanding the examination blueprint, scoring methodology, and retake policies in their entirety. Candidates should then reflect on their performance based on the official feedback received. If there are ambiguities or a need for clarification, direct communication with the certifying board is the appropriate next step. Strategies for improvement should be developed in alignment with the board’s guidelines and based on a clear understanding of the assessment criteria, rather than on speculation or unofficial interpretations.

Scenario Analysis: This scenario presents a common challenge for candidates preparing for rigorous board certification exams. The core difficulty lies in balancing the vast amount of information required with limited time and the need for effective learning strategies. Misallocating study time or relying on suboptimal resources can lead to inadequate preparation, increased stress, and ultimately, exam failure. The pressure to perform well in a high-stakes examination necessitates a strategic and evidence-based approach to preparation. Correct Approach Analysis: The most effective approach involves a structured, multi-modal study plan that begins well in advance of the examination date. This includes systematically reviewing core surgical principles, relevant anatomical and physiological knowledge, and current best practices in Nordic foot and ankle surgery. Utilizing a combination of established textbooks, peer-reviewed literature, and reputable online learning modules provides a comprehensive knowledge base. Regular self-assessment through practice questions and mock examinations is crucial for identifying knowledge gaps and refining exam technique. This approach aligns with the ethical obligation of medical professionals to maintain competence and ensure patient safety through thorough preparation for practice. It also reflects the implicit understanding within professional certification bodies that candidates are expected to engage in diligent and comprehensive study. Incorrect Approaches Analysis: Focusing solely on practice questions without a foundational understanding of the subject matter is a significant failure. This method treats the exam as a rote memorization task rather than an assessment of applied knowledge and clinical reasoning. It neglects the ethical imperative to build a deep understanding of surgical principles, which is essential for safe and effective patient care. Relying exclusively on anecdotal advice from colleagues or outdated study materials also presents a professional failing. Such an approach risks incorporating misinformation or outdated practices, which is contrary to the commitment to evidence-based medicine and continuous professional development expected of certified surgeons. Furthermore, cramming in the final weeks before the exam demonstrates a lack of foresight and discipline, failing to acknowledge the complexity of the subject matter and the time required for genuine learning and retention. This approach can lead to superficial understanding and increased anxiety, compromising the candidate’s ability to perform optimally. Professional Reasoning: Professionals facing high-stakes examinations should adopt a proactive and systematic preparation strategy. This involves: 1) Early assessment of the examination syllabus and scope. 2) Development of a realistic study timeline, allocating sufficient time for each topic. 3) Selection of high-quality, current, and authoritative study resources. 4) Integration of active learning techniques, including regular self-testing and critical evaluation of knowledge. 5) Seeking feedback on performance and adjusting the study plan accordingly. This methodical approach ensures comprehensive coverage, deep understanding, and the development of confidence, all of which are critical for successful examination outcomes and the responsible practice of medicine.