Stephen Wear

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.

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.

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.

Transforming educational accountability in medical ethics and humanities education toward professionalism.

Effectively developing professionalism requires a programmatic view on how medical ethics and humanities should be incorporated into an educational continuum that begins in premedical studies, stretches across medical school and residency, and is sustained throughout ones practice. The Project to Rebalance and Integrate Medical Education National Conference on Medical Ethics and Humanities in Medical Education (May 2012) invited representatives from the three major medical education and accreditation organizations to engage with an expert panel of nationally known medical educators in ethics, history, literature, and the visual arts. This article, based on the views of these representatives and their respondents, offers a future-tense account of how professionalism can be incorporated into medical education.The themes that are emphasized herein include the need to respond to four issues. The first theme highlights how ethics and humanities can provide a response to the dissonance that occurs in current health care delivery. The second theme focuses on how to facilitate preprofessional readiness for applicants through reform of the medical school admission process. The third theme emphasizes the importance of integrating ethics and humanities into the medical school administrative structure. The fourth theme underscores how outcomes-based assessment should reflect developmental milestones for professional attributes and conduct. The participants emphasized that ethics and humanities-based knowledge, skills, and conduct that promote professionalism should be taught with accountability, flexibility, and the premise that all these traits are essential to the formation of a modern professional physician.

The Commercialization of Human Body Parts: A Reappraisal from a Protestant Perspective

The idea of a market in human organs has traditionally met with widespread and emphatic rejection from both secular and religious fronts alike. However, as numerous human beings continue to suffer an uncertain fate on transplant waiting lists, voices are beginning to emerge that are willing at least to explore the option of human organ sales. Anyone who argues for such a option must contend, however, with what seem to be largely emotional rejections of the idea. Often it seems that rebuffs offered on a secular ground are rooted in nothing more than vague discomforts. We suspect that these discomforts are often based in religious sentiments that have wound their way into the fabric of secular America. Therefore, in order to contribute further to those voices heard in favor of human organ sales, it is worthwhile to show that from a religious perspective, it is just as possible to affirm the appropriateness of human organ sales as it is from a secular basis. Since Protestantism has historically had a powerful influence in American society it is a proper starting point for such an investigation.

Medical professionalism: what the study of literature can contribute to the conversation

Medical school curricula, although traditionally and historically dominated by science, have generally accepted, appreciated, and welcomed the inclusion of literature over the past several decades. Recent concerns about medical professional formation have led to discussions about the specific role and contribution of literature and stories. In this article, we demonstrate how professionalism and the study of literature can be brought into relationship through critical and interrogative interactions based in the literary skill of close reading. Literature in medicine can question the meaning of “professionalism” itself (as well as its virtues), thereby resisting standardization in favor of diversity method and of outcome. Literature can also actively engage learners with questions about the human condition, providing a larger context within which to consider professional identity formation. Our fundamental contention is that, within a medical education framework, literature is highly suited to assist learners in questioning conventional thinking and assumptions about various dimensions of professionalism.

Challenging the Hidden Curriculum

The findings of Dr. Santen, Dr. Rotter, and Dr. Hemphill1 regarding physician disclosure of training level to patients may well contain few surprises for most readers. Not surprisingly, they found that such disclosure is rare and vague at best, and that patients consequently have little sense of their physician’s level of training. They also found that patients did indicate, when asked, that it was important to them to have such knowledge, which is also not surprising once you think about it for a moment. There can be merit in documenting something in black and white, however, and I believe there are considerations here that are disturbing enough to emphasize by way of an editorial comment. In sum, I submit that this research highlights an area of physician behavior that merits serious challenge. On the face of it, such behavior is disingenuous, if not deceitful, and fails to properly respect patients as fellow human beings with their own clear informational needs. If any of us were patients, we would surely require such information, if it was not otherwise apparent. Now as Santen et al. notes, the American Medical Association2 and the American College of Physicians3 have long since made clear that such disclosure should be regularly supplied to patients. Why, then, is such disclosure not occurring? One might suspect this is so because of the fear that patients may be less cooperative and compliant with treatment offered by residents, that patients (and families) may inconveniently insist on only dealing with the attending physician, that they may refuse to be treated by residents, or simply that such disclosure will trigger all sorts of further questions from the patient and waste valuable time. One might also worry that medical training and credentialing might suffer, as patients reject the idea of procedures being done by physicians in training. In short, medical education might come to a screeching halt and valuable time be routinely wasted. Not that any of these potential downsides have been documented, especially as to their frequency and actual disruptiveness, but one can imagine that if one challenged any particular non-disclosing physician, one would get some version of the above, an appeal to the fact that patients are routinely informed on admission to teaching hospitals that medical students and residents will be involved in their care and, perhaps, something about seeing no advantage to going there. One might hope that such unsubstantiated views not be allowed to so quickly overrule the desiderata of being respectful to and candid with patients, but Santen et al. have done us the service of documenting that this is the case. They have also provided us with the citations that show that, as a matter of fact, patients do not tend to reject care by physicians in training when they are aware of this, even to the point of allowing inexperienced residents to do spinal taps on them.4 But what should we think of this state of affairs? The point of this editorial is to argue that there is a good deal more at stake here than just being respectful of and honest with patients, even though I personally feel this should be decisive. In sum, such behaviors also heighten litigation risk, can undermine patient trust, and teach physicians in training that it is permissible to be disingenuous with patients for the sake of expediency. More specifically: Heightening litigation risk: The distorting effects of the current malpractice climate are clear; defensive medicine is pervasive. It thus becomes alarming when one sees physician behaviors that further heighten such risk, and this is one such behavior. Consider the common patient who suffers a complication. What will their tendency be, as the complication is explained to them, if they also learn that (unbeknownst to them, as Santen et al. have documented) the procedure that generated the complication was performed by someone who was still in training? I submit it takes little imagination to conclude that it will significantly heighten the patient’s tendency to feel abused and mis-treated, etc. A conversation that might often (and in my experience does) result only in an acknowledgment that a known risk has occurred, and something about how anyone can make a mistake gets redirected to the patient searching his or her memory for where that billboard is with the word “injured?” featured so prominently. This point relates not only to how this will play in court; it also keys to the arguably more important issue of whether the patient even considers litigation in the first place. Undermining trust: Volumes have been written about the crucial need for patients to trust their physician. Just the other day, a surgeon friend of mine was marveling out loud about how interesting it is that patients remain so willing to trust complete strangers and allow them to perform all sorts of profound and dangerous procedures. But whence goes trust for the patient above, now or in the future? Part of trust surely involves the belief that the other person will be honest with oneself; it also involves believing that that person will not allow simple expediency to trump one’s own interests and concerns. Such nondisclosure risks jeopardizing all this. I recently accompanied a family member through trauma care and noted that the receiving resident spoke as if he would be managing that care, with no reference to the attending at any point; I was left wondering what else he might later be disingenuous about; in effect, I no longer trusted him. Somehow, the most alarming feature of all this, to my mind, is that we are training our future colleagues to be disingenuous with patients for the sake of expediency or convenience. Never mind that it is not clear that how expedient any of this is, the punch line seems to be that this is all right, part of the hidden curriculum regarding how one can and should practice. I used to see this in case conferences with medical students where they reported being uncomfortable with being introduced as a doctor. At least in my area, this behavior has mainly evaporated but not so the somewhat more subtle behavior that Santen et al. document. My suggestion to these students is generally as follows: “You should all recognize by now that medical education involves seeing both how and how not to practice. Please consider that this behavior falls in the latter category and that your discomfort is not something to grow out of, but to hold onto until you are more your own masters. Much more than expediency and convenience are at stake here.” Another way I have approached this is to comment: “Generally respect for and honesty to other people is considered the rule, what is expected. Rather than begin medicine with the opposite default, please consider starting off with respect and honesty and see if patient care and medical education can still proceed effectively. You may find that, as some studies have suggested, that it does and will have no need to incorporate behaviors that your patients would surely condemn if and when they become aware of them.” For such reasons, I commend the article by Dr. Santen, Dr. Rotter, and Dr. Hemphill to you all.

TRUTH TELLING TO THE SICK AND DYING IN A TRADITIONAL CHINESE CULTURE

Traditionally and currently, Chinese medicine has generally not embraced the notion that the sick and dying should be told the truth about their situation and prospects, opting instead for conveying this information to family members who assist practitioners in making medical decisions (Chan, 2004; Cong, 2004; Fan and Benfu, 2004). Interestingly, in Taiwan specifically, informed consent, by law, can be secured from either the patient, or a family member, with (I am informed by local authorities) a vast preference for the latter approach by most parties. Western bioethics appears to have an ambivalent attitude about such a practice. On the one hand, extensive discussions in the West over the past three decades have generally enshrined truth telling as a basic ethical principle with strong and detailed argument in support of this primacy. (Annas, 1975; Parsons, 1975; Ramsey, 1970) At most, in the West, current discussions regarding truth telling relate mainly to possible exceptions to the generally held rule, and are seen by many to be quite difficult to establish (Meisel, 1979; Wear, 2004). This is not, furthermore, merely a scholarly consensus. At least in the USA, the primacy of truth telling is enshrined in prominently displayed patients’ rights statements, institutional policies, and in the standards of hospital accreditation organizations, e.g. the Joint Commission for the Accreditation of Hospitals (JCAHO). Simply, it is uncontroversial and expected. (Wear, 1993) On the other hand, western bioethics, and ethics generally, certainly comes with the basic caveat that “ethical principles” such as truth telling, are culturally conditioned, and may well have meaning and force only in a culture that shares basic western assumptions regarding personal autonomy, independence, and the subjectivity of the values. If we move to a different culture, e.g. traditional Chinese culture, that emphasizes contrary values such as seeing families as the decision making unit, and the objectivity of values, then truth telling may well have no special status, and its opposite, viz. lying to, deceiving or not being candid with patients, may well be the guiding ethical principle (Fan and Benfu, 2004).

Ethical issues in health care on the frontiers of the twenty-first century

Dedication. Ethical Issues in Health Care on the Frontiers of the Twenty First Century S. Wear, et al. Preface: The Continued Role of Biomedical Ethics in the Next Millenium J. Naughton. Keynote Address: Bioethics at the End of the Millenium: Fashioning Health Care Policy in the Absence of a Moral Consensus H.T. Engelhardt. Part I: The Dilemma of Funding Health Care. The Dilemma of Funding Health Care S. Wear. Toward Multiple Standards of Health Care Delivery: Takin Moral and Economic Diversity Seriously H.T. Engelhardt, Jr. A Preventive Ethics Approach to the Managed Practice of Medicine: Putting the History of Medical Ethics to Work L.B. McCullough. Saving Lives, Saving Money: Shepherding the Role of Technology E.H. Morreim. Part II: The Human Genome Project. The Human Genome, Difference, and Disease: Nature, Culture, and New Narratives for Medicines Future J.J. Bono. Concepts of Disease After the Human Genome Project E. Juengst. From Promises to Progress to Portents of Peril: Public Responses to Genetic Engineering D. Nelkin. PKU and Procreative Liberty: Historical and Ethical Considerations D.B. Paul. Everybodys Got Something J.D. Moreno. Part III: The Physician/Patient Relationship. The Physician/Patient Relationship G. Logue. A Medicine of Neighbors K. Montgomery. Trust, Institutions, and the Physician-Patient Relationship: Implications for Continuity of Care J.R. Rosenbaum. Can Relationships Heal - At a Reasonable Cost? H. Brody. Values and the Physician-Patient Relationship S. Devito. General Bibliography A. McEvoy. Notes on Contributors. Index.

Nuancing the Healer's art — The epistemology of patient competence

The programmatic thrust of Thomasma and Pellegrino [5] is clarified and underscored and is interpreted as an attempt to introduce a fixed point into the ethical dimension of medicine by specifying some regulative principles for the medical profession. Two important features of this type of enterprise are noted: on the one hand, it may lead the profession to distinguish between technically identical actions on the basis of the normative principles it produces, thus excluding some morally permissible actions as duties constitutive of the art. It is argued that the formulation of the grounds for this ethic given by Thomasma and Pellegrino is insufficient. In order to speak to the clinical situation, medical ethics must not be based on merely the ‘living human body’ alone, but on the patientqua person.