Edward M. Hundert

Context in medical education: the informal ethics curriculum

As some formal bioethics instruction has become the norm in American medical schools, a trend has emerged toward increased attention to context in both bioethics education and bioethical decision‐making. A focus on classical dilemmas and a textbook knowledge of principles is yielding its previous dominance to permit a more detailed examination of ethical behaviour in actual practice in medicine. After documenting and analysing this emerging trend in bioethics education and its parallel in bioethics theory and research, we turn to the context of medical education itself to look beyond formal bioethics instruction to the ‘informal curriculum’ that is so central to the moral development of medical students and residents.

A controlled study of phenomenology and family history in outpatients with bulimia nervosa

We administered structured diagnostic interviews and family history evaluations to 69 outpatient women meeting the new DSM-III-R criteria for bulimia nervosa. This group was compared with 50 women with DSM-III bulimia, 24 women with major depression, and 28 nonpsychiatric control women, all recruited during previous studies. On both phenomenologic and family history assessments, the women with DSM-III-R bulimia nervosa closely resembled the women with DSM-III bulimia, and both groups differed significantly from controls in their prevalence of personal and familial major mood disorders. These data support a relationship between bulimia nervosa and major mood disorders, consistent with that suggested by studies of bulimia assessed by earlier diagnostic criteria.

Microethics: the ethics of everyday clinical practice.

Over the past several decades, medical ethics has gained a solid foothold in medical education and is now a required course in most medical schools. Although the field of medical ethics is by nature eclectic, moral philosophy has played a dominant role in defining both the content of what is taught and the methodology for reasoning about ethical dilemmas. Most educators largely rely on the case-based method for teaching ethics, grounding the ethical reasoning in an amalgam of theories drawn from moral philosophy, including consequentialism, deontology, and principlism. In this article we hope to make a case for augmenting the focus of education in medical ethics. We propose complementing the traditional approach to medical ethics with a more embedded approach, one that has been described by others as “microethics,” the ethics of everyday clinical practice.

Boundaries in psychotherapy: Model guidelines.

THE maintenance of boundaries in psychotherapy is now one of the most critical areas of ethical inquiry for psychiatrists and other mental health professionals. Sexual contact between therapists and patients-the most egregious example of boundary violation-has received a good deal of attention (Gabbard 1994), and a firm consensus regarding its inappropriateness has developed (American Psychiatric Association 1992b; American Psychological Association 1992). But public concern over nonsexual boundary violations is growing, as witnessed by highly publicized cases in the media (Kagan 1988; Karel 1993), rulings by licensure bodies (In the Matter of Aronoff 1992), and lawsuits (Jorgenson and Sutherland 1993). Evidence from all of these sources suggests that the task of defining appropriate boundaries in psychotherapy is complex and confusing for therapists, regulators, and the public alike.

Looking a gift horse in the mouth: the ethics of gift-giving in psychiatry.

&NA; The first time a patient offered me a gift was just before Christmas, 6 months into my residency in psychiatry. When she arrived for her weekly psychotherapy hour, she handed me a medium‐sized box wrapped with Christmas paper and said, “This is just a little something for you and your family to help celebrate the holiday.” I remember feeling my anxiety level rise as I decided how to respond. Part of this was the usual reaction to finding oneself in a new clinical situation. But I must admit that quite a bit of my anxiety stemmed from the context of my role as a resident under supervision. I had “inherited” this patient from a graduating resident 3 years ahead of me who was in training to become a psychoanalyst. The case had been billed as one of my “psychodynamic psychotherapy” cases; each week following the therapy session I met for an hour with a supervisor, who used the process of the session to help me understand psychoanalytically oriented treatment, paying considerable attention to both transference and countertransference issues.

An Integrated Preclerkship Curriculum in Neuroscience, Psychiatry, and Neurology

The study’s objective was to promote understanding of the integration of preclerkship learning in neuroscience, psychiatry, and neurology and to share the authors’ experience with such a program. A dualism, which may have survived in the past for lack of robust evidence of mind-brain relationships, is now increasingly outmoded. Medical school education should reflect the increasing coherence to be found in these fields. The authors describe curricular and course innovations and revisions at Harvard Medical School that have been implemented in successive iterations over the past decade. These changes have depended upon multidisciplinary leadership, planning, and faculty participation, as well as faculty development and closer coordination between classroom- and hospital-based activity. A hybrid, problem-based block course in the second year integrates basic science with neurologic and psychiatric topics that are aligned with practice of relevant clinical skills. The authors have achieved a high level of integration and coordination of these subjects at preclerkship levels in the domains of both knowledge and skills. The students, as well as the faculty, strongly endorse an intellectually coherent and clinically relevant program of integrated preclerkship learning in neuroscience, psychiatry, and neurology.

Thoughts and feelings and things: A new psychiatric epistemology

Epistemology — the study of knowledge — is a philosophical discipline with close ties to psychiatry. When epistemologists address specific questions about how knowledge is actually realized by human beings, their philosophy must be informed by empirical studies of the sort psychiatrists now take up in a variety of forms. As this paper describes, psychiatrists can likewise improve their understanding of human psychology through a deeper appreciation of philosophical analysis in epistemology.The aim of this article is to introduce a unifying framework within which the experience from different approaches to psychiatry — (1) the conceptual schemas of cognitive psychiatry, (2) the mental structures of psychoanalytic psychiatry, (3) the categorical forms of existential psychiatry, and (4) the neural pathways of biological psychiatry — can all be applied productively to the central question of epistemology. By establishing a broad understanding of the problem of knowledge, this new view of epistemology is developed within the idiom of each psychiatric approach. In addressing themselves to a unitary problem, these diverse psychiatric approaches are themselves revealed, not as competing points of view, but as complementary views of a single subject. The result is a new epistemology that can not only bring the insights of psychiatry to philosophy, but can also contribute to the care of patients when psychiatrists bring this broader view to their clinical work.

Neurologic education for the future: a decade of curricular reform at Harvard Medical School

The field of neurology is undergoing significant changes to which curricular reform is both responding and contributing. We reflect on a decade of experience at Harvard Medical School with integration of neuroscience, behaviour, pathophysiology and introductory clinical skills. As part of Harvards “New Pathway” curriculum, this coordinated, pre‐clerkship program embraces a “hybrid” form of problem‐based learning. A variety of methods are employed synergistically to meet the two broad goals of preparing for competency in neurologic clerkships and for career‐long learning in clinically relevant neuroscience. We articulate specific ways of elevating the level of intellectual inquiry, involving multi‐disciplinary faculty more productively, and vertically integrating the learning experience through the years of medical school.

Is Ethical Practice Good Clinical Practice

You would probably be surprised by the variety of answers given by respected psychiatrists to the question posed by this column’s title. “If you mean honesty is the best policy, I think that depends on the patient’s condition and how much of the truth he or she can handle,” “Even though we have to follow them, I think ethical standards actually sometimes interfere with good clinical practice,” and “Of course-isn’t that all we mean by those words?” are just three examples. One psychiatrist responding to this question saw ethical practice and good clinical practice as a Venn diagram with “a lot of overlap” between the two spheres but with some “perfectly ethical practice that would not make sense clinically” and some “perfectly good clinical practice that would be quite unethical.’’ (You might want to pause here and construct your own answer before you continue reading this column.) Definitions, of course, make all the difference in this

Competing Medical and Legal Ethical Values

If there is one feature that is shared by all ethical dilemmas, it is the anxiety we feel even after making what we are sure is the best decision. Unlike other problems, anything worthy of the name “dilemma” almost requires the absence of a really good solution. When we explore the reasons why ethical dilemmas are worthy of their (unfortunate) name, we uncover an important truth about the nature of these difficult problems.