David J. Doukas

The Family Covenant and Genetic Testing

The physician-patient relationship has changed over the last several decades, requiring a systematic reevaluation of the competing demands of patients, physicians, and families. In the era of genetic testing, using a model of patient care known as the family covenant may prove effective in accounting for these demands. The family covenant articulates the roles of the physician, patient, and the family prior to genetic testing, as the participants consensually define them. The initial agreement defines the boundaries of autonomy and benefit for all participating family members. The physician may then serve as a facilitator in the relationship, working with all parties in resolving potential conflicts regarding genetic information. The family covenant promotes a fuller discussion of the competing ethical claims that may come to bear after genetic test results are received.

Perspective:Medical Education in Medical Ethics and Humanities as the Foundation for Developing Medical Professionalism

Medical education accreditation organizations require medical ethics and humanities education to develop professionalism in medical learners, yet there has never been a comprehensive critical appraisal of medical education in ethics and humanities. The Project to Rebalance and Integrate Medical Education (PRIME) I Workshop, convened in May 2010, undertook the first critical appraisal of the definitions, goals, and objectives of medical ethics and humanities teaching. The authors describe assembling a national expert panel of educators representing the disciplines of ethics, history, literature, and the visual arts. This panel was tasked with describing the major pedagogical goals of art, ethics, history, and literature in medical education, how these disciplines should be integrated with one another in medical education, and how they could be best integrated into undergraduate and graduate medical education. The authors present the recommendations resulting from the PRIME I discussion, centered on three main themes. The major goal of medical education in ethics and humanities is to promote humanistic skills and professional conduct in physicians. Patient-centered skills enable learners to become medical professionals, whereas critical thinking skills assist learners to critically appraise the concept and implementation of medical professionalism. Implementation of a comprehensive medical ethics and humanities curriculum in medical school and residency requires clear direction and academic support and should be based on clear goals and objectives that can be reliably assessed. The PRIME expert panel concurred that medical ethics and humanities education is essential for professional development in medicine.

Family physicians’ perspectives on genetics and the human genome project

The objective of the study was to determine family physicians’ attitudes and beliefs about human genetics research and the human genome project (HGP). The design of the study involved qualitative, semi‐structured interviews. Primary variables of interest included family physicians’ training; their attitudes about the HGP; requests for genetics counseling; and their approaches to counseling requests. The setting was a medium‐sized, Midwest, US city. The participants were 16 university‐affiliated, community‐based family physicians. For contents analysis, we used a coding scheme to identify illustrative themes and subthemes. While most of the family physicians reported familiarity with genetics and the HGP, and experiences with counseling requests, nearly all (15) reported little training in genetics counseling. Four major themes were identified: 1) impact on clinical care; 2) educational issues relevant to genetics and the HGP; 3) ethical concerns; and 4) family medicine responsibilities. These family physicians do not perceive genetics as having a substantial impact on their practice, but do expect major clinical changes in the future. Many feel there have been inadequate educational opportunities to learn about genetics, and some indicate reluctance to invest in self‐education until genetic problems become more clinically relevant. These practitioners envision a role for family medicine the specialty to shape priorities in genetics research.

The essential role of medical ethics education in achieving professionalism: the Romanell Report.

This article—the Romanell Report—offers an analysis of the current state of medical ethics education in the United States, focusing in particular on its essential role in cultivating professionalism among medical learners. Education in ethics has become an integral part of medical education and training over the past three decades and has received particular attention in recent years because of the increasing emphasis placed on professional formation by accrediting bodies such as the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education. Yet, despite the development of standards, milestones, and competencies related to professionalism, there is no consensus about the specific goals of medical ethics education, the essential knowledge and skills expected of learners, the best pedagogical methods and processes for implementation, and optimal strategies for assessment. Moreover, the quality, extent, and focus of medical ethics instruction vary, particularly at the graduate medical education level. Although variation in methods of instruction and assessment may be appropriate, ultimately medical ethics education must address the overarching articulated expectations of the major accrediting organizations. With the aim of aiding medical ethics educators in meeting these expectations, the Romanell Report describes current practices in ethics education and offers guidance in several areas: educational goals and objectives, teaching methods, assessment strategies, and other challenges and opportunities (including course structure and faculty development). The report concludes by proposing an agenda for future research.

Reforming Medical Education in Ethics and Humanities by Finding Common Ground With Abraham Flexner

Abraham Flexner was commissioned by the Carnegie Foundation for the Advancement of Teaching to conduct the 1910 survey of all U.S. and Canadian medical schools because medical education was perceived to lack rigor and strong learning environments. Existing proprietary schools were shown to have inadequate student scholarship and substandard faculty and teaching venues. Flexners efforts and those of the American Medical Association resulted in scores of inadequate medical schools being closed and the curricula of the survivors being radically changed. Flexner presumed that medical students would already be schooled in the humanities in college. He viewed the humanities as essential to physician development but did not explicitly incorporate this position into his 1910 report, although he emphasized this point in later writings. Medical ethics and humanities education since 1970 has sought integration with the sciences in medical school. Most programs, however, are not well integrated with the scientific/clinical curriculum, comprehensive across four years of training, or cohesive with nationally formulated goals and objectives. The authors propose a reformation of medical humanities teaching in medical schools inspired by Flexners writings on premedical education in the context of contemporary educational requirements. College and university education in the humanities is committed to a broad education, consistent with long-standing tenets of liberal arts education. As a consequence, premedical students do not study clinically oriented science or humanities. The medical school curriculum already provides teaching of clinically relevant sciences. The proposed four-year curriculum should likewise provide clinically relevant humanities teaching to train medical students and residents comprehensively in humane, professional patient care.

Professionalism: a framework to guide medical education

Despite considerable advances in the incorporation of professionalism into the formal curriculum, medical students and residents are too often presented with a mechanical, unreflective version of the topic that fails to convey deeper ethical and humanistic aspirations. Some misunderstandings of professionalism are exacerbated by commonly used assessment tools that focus only on superficially observable behaviour and not on moral values and attitudes.

Role-modeling and medical error disclosure: a national survey of trainees.

Purpose To measure trainees’ exposure to negative and positive role-modeling for responding to medical errors and to examine the association between that exposure and trainees’ attitudes and behaviors regarding error disclosure. Method Between May 2011 and June 2012, 435 residents at two large academic medical centers and 1,187 medical students from seven U.S. medical schools received anonymous, electronic questionnaires. The questionnaire asked respondents about (1) experiences with errors, (2) training for responding to errors, (3) behaviors related to error disclosure, (4) exposure to role-modeling for responding to errors, and (5) attitudes regarding disclosure. Using multivariate regression, the authors analyzed whether frequency of exposure to negative and positive role-modeling independently predicted two primary outcomes: (1) attitudes regarding disclosure and (2) nontransparent behavior in response to a harmful error. Results The response rate was 55% (884/1,622). Training on how to respond to errors had the largest independent, positive effect on attitudes (standardized effect estimate, 0.32, P < .001); negative role-modeling had the largest independent, negative effect (standardized effect estimate, −0.26, P < .001). Positive role-modeling had a positive effect on attitudes (standardized effect estimate, 0.26, P < .001). Exposure to negative role-modeling was independently associated with an increased likelihood of trainees’ nontransparent behavior in response to an error (OR 1.37, 95% CI 1.15–1.64; P < .001). Conclusions Exposure to role-modeling predicts trainees’ attitudes and behavior regarding the disclosure of harmful errors. Negative role models may be a significant impediment to disclosure among trainees.

Attitudes and beliefs concerning prostate cancer genetic screening

This quantitative study determines the values, beliefs, and attitudes influencing the intention of men to undergo or defer genetic testing for prostate cancer risk using a model based on components of the Theory of Reasoned Action and Health Belief Model. Telephone interviews of a community sample of 400 men in a large, East Coast metropolitan area of diverse educational, ethnic, and age backgrounds were conducted to rank key values and beliefs about genetic testing for prostate cancer risk in anticipation of its future availability. Descriptive statistics, univariate analyses, and logistic regression were used in data analysis. The factors of values attached to consequences, motivation from self, beliefs in benefits, and a motivation to comply with others (borderline) were statistically significant for testing intention. Of all demographics, only increased education was associated with diminished interest in testing. Desire to be tested varied widely across groups of men. Based on these identified values, health professionals can better understand mens values and beliefs on the risks and benefits of testing. The relationship of men to others, family and society, require further investigation in this and other aspects of genetic testing.

How men view genetic testing for prostate cancer risk: findings from focus groups

Objective: To determine the values, beliefs, and attitudes that influence a mans intention to undergo or defer genetic testing for prostate cancer risk. 
Design: Qualitative, using focus group interviews – 12 focus groups were conducted to identify key values and beliefs about genetic testing for prostate cancer risk in anticipation of its future availability. 
Setting: Medium‐sized, mid‐west, US city. 
Participants: Community sample of 90 lay men of diverse educational, ethnic, and age backgrounds. 
Analysis: Descriptive statistics and immersion/crystallization to identify themes and sub‐themes. 
Results: The major areas of concern were distilled into the following themes: beliefs about consequences, expectations, benefits for patients, beliefs about barriers, and susceptibility concerns. 
Conclusion: Identifying these mens values will help health professionals anticipate the informational and ethical needs of patients in the informed consent process. Men will need to understand how such testing may affect their planning regarding future prostate health, and how medical information is used outside of the physician–patient relationship.

The challenge of promoting professionalism through medical ethics and humanities education.

Given recent emphasis on professionalism training in medical schools by accrediting organizations, medical ethics and humanities educators need to develop a comprehensive understanding of this emphasis. To achieve this, the Project to Rebalance and Integrate Medical Education (PRIME) II Workshop (May 2011) enlisted representatives of the three major accreditation organizations to join with a national expert panel of medical educators in ethics, history, literature, and the visual arts. PRIME II faculty engaged in a dialogue on the future of professionalism in medical education. The authors present three overarching themes that resulted from the PRIME II discussions: transformation, question everything, and unity of vision and purpose.The first theme highlights that education toward professionalism requires transformational change, whereby medical ethics and humanities educators would make explicit the centrality of professionalism to the formation of physicians. The second theme emphasizes that the flourishing of professionalism must be based on first addressing the dysfunctional aspects of the current system of health care delivery and financing that undermine the goals of medical education. The third theme focuses on how ethics and humanities educators must have unity of vision and purpose in order to collaborate and identify how their disciplines advance professionalism. These themes should help shape discussions of the future of medical ethics and humanities teaching.The authors argue that improvement of the ethics and humanities-based knowledge, skills, and conduct that fosters professionalism should enhance patient care and be evaluated for its distinctive contributions to educational processes aimed at producing this outcome.