Ethics Issues Specific to Medical Trainees

Transcript

• 00:00Good afternoon, friends,
• 00:01and welcome to the Program for Biomedical
• 00:04Ethics and the Yale Pediatric Ethics Program.
• 00:06This is a combined seminar this evening.
• 00:09My name is Mark material.
• 00:10I'm the direct director of the programs
• 00:12and the letter that you can join us for
• 00:16Doctor Malone's presentation today.
• 00:17We're going to get started in just a minute,
• 00:19and I'll lay out how this goes.
• 00:21But before we start,
• 00:22I do want to say a word about something that
• 00:24somebody on this call are already aware of.
• 00:26Doctor Tom Duffy passed
• 00:28away earlier this week.
• 00:30Doctor Duffy was a friend of this
• 00:32program from the very beginning.
• 00:34He was a truly an icon,
• 00:36both in clinical medicine and hematology,
• 00:39as well as in bioethics.
• 00:41We're here at Yale for decades,
• 00:43and there'll be much more about
• 00:45Doctor Duffy in the weeks to come,
• 00:47including a named a lectureship that
• 00:49we're beginning next month in his honor.
• 00:52But I did want to let you folks
• 00:54know that you've seen Tom at so many
• 00:56of these sessions over the years,
• 00:58and he will be greatly missed.
• 00:59He was,
• 01:00I can still recall the very first
• 01:02meeting now more than 10 years
• 01:03ago when we began this program.
• 01:05And Tom was there at the table as ever,
• 01:07providing a helpful guidance and support.
• 01:09He will be greatly missed.
• 01:11He was a wonderful friend and
• 01:13teacher and an exemplary physician.
• 01:15There'll be more about Tom in
• 01:17the weeks to come,
• 01:18but I did want to let you know about
• 01:20his passing for those who were unaware.
• 01:22And there will be a funeral.
• 01:23Yes,
• 01:23tomorrow at Saint Thomas Moore
• 01:26in New Haven at 10:00 AM.
• 01:29I want to turn my attention this
• 01:31evening and it is not a totally
• 01:33inappropriate segue to talk about
• 01:35Doctor Jay Malone for a moment.
• 01:37Tom was so much about education and
• 01:41medical ethics and in particular,
• 01:43properly training the next generation
• 01:46of physicians and others that I wanted
• 01:49this to be a subject we addressed this fall.
• 01:51And I could think of no one
• 01:53better than Doctor Jay Malone.
• 01:55Doctor Malone is an assistant professor
• 01:56of pediatric critical care medicine.
• 01:58At Saint Louis Children's Hospital
• 02:00and at Washington University,
• 02:02and also an adjunct decision
• 02:04professor of healthcare ethics
• 02:05at Saint Louis University.
• 02:07He obtained a Masters of Health
• 02:09Science and Healthcare ethics from
• 02:11Creighton and a PhD in healthcare
• 02:12ethics from Saint Louis University.
• 02:14He's the medical director of ethics
• 02:16for Saint Louis Children's Hospital,
• 02:17where he's also the chair of
• 02:19the Hospital Ethics Committee.
• 02:21Doctor Malone teaches medical ethics at
• 02:23the Washington University School of Medicine,
• 02:25where he has redesigned the ethics
• 02:27curriculum to focus on the moral
• 02:29development of trainees throughout
• 02:30all four years of medical training.
• 02:32It's been my privilege to work with
• 02:35Jay in recent months on revisiting so
• 02:38many fundamental aspects of pediatric
• 02:41ethics with other leaders in the field.
• 02:43And and Jay has truly been a very
• 02:45influential person as well as
• 02:46an up and coming leader in our
• 02:48field. So I'm honored that you took
• 02:50the time to join us this evening.
• 02:52Hi, Jay. And with that,
• 02:54I will turn the turn this
• 02:55over to Doctor Jay Malone,
• 02:57but not before I do.
• 02:58Let me just remind the folks please,
• 02:59I'm sorry. The way this will work
• 03:01is Jay will speak for about 45 minutes,
• 03:04give or take a little bit,
• 03:06and after that we'll have a session
• 03:07for available for question and answers
• 03:09and for discussion among the crew that
• 03:11will go on for another 45 minutes.
• 03:13We'll stop sharp and no later
• 03:16than 6:30 New Haven time.
• 03:20If you have questions or comments
• 03:21you'd like to share with Doctor Malone,
• 03:23I ask you to put them through the Q
• 03:25and a portion of the zoom function
• 03:27and then I'll be reading those
• 03:29to Jay after his presentation.
• 03:30So over with and he'll respond to those.
• 03:32So please any questions or comments,
• 03:34type them into the Q&A and I'll
• 03:36read those to J.
• 03:37And with that I will turn this
• 03:38over to my colleague and friend,
• 03:40Doctor Jay Malone.
• 03:43Thank you, Mark,
• 03:44for the kind introduction and
• 03:46for the opportunity to be here.
• 03:48Very much appreciated.
• 03:49Let me go ahead and get
• 03:52my slides up here. Ohm.
• 04:00OK. Hopefully you're just
• 04:01seeing my slides, if not
• 04:02now seeing your slide, yeah, that looks good.
• 04:07So as as Mark mentioned,
• 04:10I'm going to be talking today
• 04:12about ethical challenges for
• 04:14contemporary medical trainees.
• 04:16First have to say that I receive a
• 04:19professional honorarium from this
• 04:20organization, which I think several
• 04:22others on this call do as well.
• 04:24I won't be discussing fasting
• 04:26in particular during this talk.
• 04:28So what I want to do here is to
• 04:32start by laying out a vision of.
• 04:36Medical education and moral development,
• 04:39and I want to argue essentially
• 04:42that medicine is,
• 04:43in addition to a technical undertaking,
• 04:46a moral practice,
• 04:47and that medical education and medical
• 04:50training play an important role in.
• 04:53That process.
• 04:55Once I've gone through some
• 04:57of this background,
• 04:58we'll move into some particular
• 05:00ethics cases that I think are
• 05:02emblematic of the types of dilemmas
• 05:04that our trainings are faced with.
• 05:07So many people.
• 05:08Consider medicine to be a
• 05:11primarily technical undertaking,
• 05:14and certainly our students are now
• 05:17trained into medicine in this sort of
• 05:21mode of very technocratic vision of medicine,
• 05:24where the things that are emphasized
• 05:27during training are the acquisition of
• 05:29technical skills and consequentialism.
• 05:32The outcomes to our patients are
• 05:35prioritized all over almost anything else.
• 05:39But I believe that medicine is
• 05:41better understood as a moral
• 05:43engagement or a moral practice
• 05:45which simply benefits from,
• 05:47requires technical expertise.
• 05:50That that understanding,
• 05:51I think,
• 05:52is supported by a variety of
• 05:54professional organizations and.
• 05:57The reason for that is that medicine,
• 06:00by necessity deals in.
• 06:02In moral exchanges,
• 06:04because the goods that we're talking
• 06:06about in medicine are things like life
• 06:09and health and relief from suffering
• 06:11that can't actually be fully understood
• 06:13or addressed by simple technical
• 06:15skill divorced from moral skill.
• 06:18So the practice of medicine soundly
• 06:23is dependent on character traits like
• 06:26compassion and honesty, maybe courage.
• 06:29Definitely humility.
• 06:32And I would argue then that.
• 06:33Someone like, say,
• 06:35a dishonest physician can't
• 06:36be a truly good physician,
• 06:38even if they're technically competent,
• 06:40because.
• 06:40For instance,
• 06:41the development of trust is necessary
• 06:44prior to the exercise of technical expertise.
• 06:48So this.
• 06:49Engagement of medicine happens within
• 06:52a patient physician relationship,
• 06:55which is an interaction
• 06:57between two moral agents,
• 06:58and so therefore the relationship
• 07:01itself is unavoidably moral.
• 07:03And Edmund Pellegrino famously
• 07:05called this a covenant of trust.
• 07:08That understanding of medicine as a
• 07:11as covenantal goes back to sort of
• 07:15Hippocratic formulation of what medicine
• 07:17ought to be as a covenantal rather than.
• 07:20A business or technical exchange.
• 07:24That moral nature of medicine.
• 07:28Should entail that medical
• 07:30training serves 2 functions.
• 07:32One is of course teaching things like
• 07:36pathophysiology and pharmacology this
• 07:38sort of technical aspects of medical science.
• 07:41But our training systems should also be
• 07:45assisting students in the attainment of.
• 07:48Moral expertise,
• 07:49which which involves attaining
• 07:51and refining virtues over time.
• 07:54I would argue then,
• 07:55that a medical school that graduates
• 07:58physicians who are technically
• 08:00competent with a large knowledge base,
• 08:02but without any sort of.
• 08:06Virtue has not actually succeeded
• 08:09in producing good physicians that
• 08:11we need to do both of these things.
• 08:14At the same time,
• 08:15virtue development is not spontaneous.
• 08:17It's certainly not inborn.
• 08:19Virtues are best understood as
• 08:22something that has to be practiced
• 08:24Rep repeated and practiced over time.
• 08:28Medical students do this initially by
• 08:31following the their role models or exemplars,
• 08:34which are typically the people
• 08:36above them in a medical hierarchy.
• 08:38And as you move up through training,
• 08:40each sort of level of training
• 08:42tends to follow.
• 08:43The example of the person ahead of them,
• 08:47and they do this within,
• 08:48of course, the hospital.
• 08:50And the hospital then,
• 08:52can be conceived of as a moral
• 08:54space where medical students,
• 08:56residents,
• 08:57fellows are training to be competent
• 09:00physicians.
• 09:00So we would hope that.
• 09:03Curricula for ethics would acknowledge
• 09:07this and would help students to
• 09:10develop their moral formation.
• 09:12We have a lot of research that
• 09:14suggests that students are not
• 09:16actually developing the character
• 09:17traits or dispositions that
• 09:19they need for good practice.
• 09:20In part is what people refer
• 09:22to as the hidden curriculum.
• 09:24The Hidden curriculum is certainly part of,
• 09:26but not the entirety of,
• 09:27what I'm talking about.
• 09:29We we know that many medical
• 09:31schools are starting to focus a
• 09:33renewed effort on ethics education,
• 09:35but we still have evidence over
• 09:38the last couple of decades that
• 09:40medical students are actually
• 09:42failing to develop moral reasoning.
• 09:43And worse than that,
• 09:46medical trainees probably regress morally
• 09:48when we survey a bunch
• 09:50of different professions.
• 09:51Like law, for instance,
• 09:53people who enter those professions tend to
• 09:57progress along the expected developmental.
• 10:01Continuum in the development of
• 10:03their moral skills.
• 10:05Medicine is unique, not in a good way.
• 10:08As a profession,
• 10:09as the only profession in which trainees
• 10:12regularly demonstrate moral regression.
• 10:15Chris Hutner calls this ethical erosion.
• 10:19I think that a key determining
• 10:22factor underlying this moral
• 10:24deformation is a lack of attention
• 10:27directed at these types of ethical
• 10:30issues during medical training.
• 10:32Umm. Unfortunately,
• 10:33what we're starting to see is that
• 10:36medical training is really doubling down
• 10:38on training and the technical aspects.
• 10:41That's maybe not unexpected,
• 10:43given the rise of incredible
• 10:46medical technologies and AI,
• 10:48organ transplantation and
• 10:49a variety of other things.
• 10:51But if you divorce the technical
• 10:53training from the moral training,
• 10:55you wind up with some weird conclusions,
• 10:58as I sort of.
• 11:00Was thinking about this presentation
• 11:02I attended last week,
• 11:04the American Society of Bioethics
• 11:05and Humanities Conference,
• 11:06and I was at a talk where a surgeon
• 11:09was discussing ex vivo versus in vivo
• 11:11organ perfusion and she said something
• 11:14that really caught my attention
• 11:16related to death determination,
• 11:18which was that.
• 11:20She said you can perfuse the
• 11:22heart in a box or in the body,
• 11:25but do we really care whether the box
• 11:27is the box or the body is the box?
• 11:29Well, I would argue that we do care,
• 11:32we should care,
• 11:33and that that impression of the
• 11:36body as a box for the sustainment
• 11:38of the organs is totally indicative
• 11:41of what I'm talking about,
• 11:43which is a sort of technocratic view of
• 11:46medicine divorced from moral development.
• 11:48So I would argue then that we need
• 11:50to pay some attention to the ethical
• 11:53issues that our trainees are faced with,
• 11:55because it's in training that these
• 11:57ethical issues are first encountered,
• 12:00and maybe that they're most
• 12:02acutely encountered.
• 12:03It's also an environment where
• 12:04if we don't address the ethical
• 12:06and moral issues early,
• 12:08we'll train residents,
• 12:09fellows and attendings who never develop
• 12:12this type of virtuous concern for their
• 12:15patients that I think they should.
• 12:17OK,
• 12:18so with that as background.
• 12:20I want to move into some specific ethical
• 12:23challenges that I see for trainings.
• 12:26I'm going to talk about four
• 12:27different things that the first three
• 12:29challenges I'm going to talk about,
• 12:31I'm going to illustrate with case examples.
• 12:34The 4th challenge I want to talk
• 12:36about more broadly because I think
• 12:38it's really a foundational challenge
• 12:39to medical education and training.
• 12:41So we're going to talk about a
• 12:44conflict between commitment to
• 12:45education and commitment to patients.
• 12:47This particular conflict is
• 12:49probably unique to students.
• 12:52Almost by definition,
• 12:53we're going to talk about a conflict
• 12:56rooted in evaluative scrutiny and why
• 12:58this is different than conflict number one,
• 13:01and then I'm going to talk about a
• 13:04conflict and a paradox in training that
• 13:07results from the medical hierarchy.
• 13:09Once I've gone through those three cases,
• 13:11I'm going to talk about what
• 13:12I regard as a
• 13:13central challenge,
• 13:13which is restoring morality to training.
• 13:16This could be thought of as an imbalance
• 13:19between dual professional obligations.
• 13:22To the patient and to sort
• 13:26of extra professional.
• 13:28Non patient related obligations.
• 13:30So let's let's jump into a case.
• 13:35Susie is a. 3rd year Medical Student
• 13:39on her General Medical rotation.
• 13:42She's been following a patient
• 13:43with in stage renal disease who's
• 13:46transitioning to Hospice after discharge.
• 13:48This morning, Susie presents her patient
• 13:50to the medical team at the bedside.
• 13:52She's the last person to
• 13:54leave the room after rounds,
• 13:55and on her way out of the room,
• 13:56the patient calls out to her.
• 13:58She says. I know you're busy,
• 13:59but I'd love to talk with you later
• 14:00in the afternoon if you have time.
• 14:02Nothing in particular,
• 14:03I just want to chat.
• 14:05Susie's developed wonderful rapport
• 14:07with this patient and knows that
• 14:09her time would be appreciated,
• 14:10possibly even therapeutic.
• 14:11But she hasn't examined 2 days and
• 14:13her resident told her that she could
• 14:16leave early in the afternoon to study.
• 14:20This dilemma seems almost like a.
• 14:24Non dilemma I think to
• 14:26many practicing physicians.
• 14:27But when we talk to our students,
• 14:29they report this type of question
• 14:32as quite morally concerning.
• 14:34It draws out attention that a lot of
• 14:37medical students have experienced
• 14:39in their in their clinical training,
• 14:42which is that we draw students
• 14:45into our clinical teams.
• 14:47We tell them they're part of the team,
• 14:48we treat them as part of the team.
• 14:50We open up to them opportunities
• 14:53to engage in direct patient care.
• 14:56And it's true that the medical students
• 14:58are part of the clinical care team.
• 15:00It remains important to note that
• 15:03they're not yet professionals,
• 15:05and because of this,
• 15:06their primary commitment is actually
• 15:08to their own education so that they
• 15:11can become competent professionals.
• 15:13They're first and foremost learners.
• 15:16That is in some ways of
• 15:19challenging assertion.
• 15:20And part of the reason that it's
• 15:23challenging assertion is that
• 15:24students are developing professionals,
• 15:27so they do have strong commitments
• 15:30to patients.
• 15:31At the same time,
• 15:32their student role entails,
• 15:33priorities that aren't shared
• 15:35by the remainder of the team.
• 15:38So why is this such a difficult problem?
• 15:41Well,
• 15:41this prioritization of education over
• 15:44patient care commitments seems to
• 15:46fly in the face of what it is that
• 15:49we're trying to train students to be.
• 15:52The AMA Code of Medical
• 15:54Ethics says physicians have,
• 15:55quote,
• 15:56an ethical responsibility to place
• 15:59patients welfare above the physicians own
• 16:02self-interest or obligations to others.
• 16:04End Quote.
• 16:05And of course,
• 16:07part of medical education is that
• 16:09students should be learning how to
• 16:12be excellent doctors who can respond
• 16:14compassionately to patients in times of need.
• 16:17But.
• 16:18There is this tension between
• 16:20the educational role of the
• 16:22student and the professional role.
• 16:24Without guidance, this is really,
• 16:26really distressing.
• 16:27Albert Johnson says that
• 16:29insidiously and overtly,
• 16:31medical education encourages the tension
• 16:34between self-interest and altruism.
• 16:37Been talking to our students
• 16:38and surveying them.
• 16:39We found that most students
• 16:41report this type of dilemma and
• 16:43they don't have guidance about
• 16:44what to do in these situations,
• 16:47so they do find themselves very
• 16:49distressed when this occurs.
• 16:53There's a risk here that the risk with
• 16:57delineating these roles like I'm talking
• 16:59about is that practicing professionals,
• 17:01including residents and fellows,
• 17:04might fail to recognize that their
• 17:07primary obligation is to their patients.
• 17:10We can easily envision that if we
• 17:13train students to think that there's
• 17:16some non patient care related.
• 17:18Thing that can take priority
• 17:20over patient care.
• 17:21We might train interns and residents
• 17:23and fellows who go down that road of
• 17:26thinking that they can prioritize
• 17:28extra professional concerns.
• 17:31If we believe that,
• 17:33that would represent a compounded
• 17:36misunderstanding of roles,
• 17:37but one that's easily envisioned.
• 17:41There's I think some things
• 17:42that contribute to this.
• 17:43One is that we haven't done a good
• 17:47enough job of setting expectations
• 17:49for various members of our teams
• 17:50too is that we certainly even if
• 17:53we've identified the expectations,
• 17:55we certainly haven't done an adequate
• 17:58job of explaining the ethical rationale
• 18:00of these expectations to people.
• 18:02So the the moral underpinnings of
• 18:05the patient physician relationship
• 18:07versus the students relationship to
• 18:09their education and their patients.
• 18:11Is not robustly explored, I think,
• 18:14in most medical education environments.
• 18:17The other behavior,
• 18:17and this this may be a little
• 18:19bit controversial,
• 18:20but the other behavior that I think
• 18:22actually makes this confusion much,
• 18:24much worse is that students are
• 18:26often now asked to say oaths at
• 18:29their white coat ceremony instead of
• 18:32just at their graduation ceremony.
• 18:34Maybe there's something beneficial
• 18:37about that.
• 18:38I would argue that that it's
• 18:39problematic for a variety of reasons.
• 18:41But one of the reasons for the purposes
• 18:44of this talk today is that it it
• 18:47confuses the role of the student with
• 18:51the role of the active professional.
• 18:54So we have to be very clear when
• 18:56we're doing things like taking
• 18:58oaths that our students aren't
• 19:00professing that they have professional
• 19:02level obligations to their.
• 19:04Patients before that's actually true.
• 19:08This this problem I think is
• 19:10superficially similar to case number
• 19:12two that I'm going to move to now,
• 19:14but we're going to spend a little bit
• 19:16of time talking about why case two
• 19:18is actually different from case one.
• 19:22So David is a fourth year medical
• 19:24student on the 1st week of his surgery
• 19:27sub internship earlier this morning,
• 19:29David participated in a difficult gastric
• 19:31bypass surgery on an obese patient.
• 19:34Later in the afternoon,
• 19:35the medical team is meeting in the
• 19:37workroom before rounding on patients.
• 19:39One of the residents begins
• 19:41joking about the patient,
• 19:42laughing about the patient's
• 19:44weight and appearance.
• 19:45He specifically makes jokes about
• 19:47how David had to hold the patients
• 19:50panniculus throughout the surgery.
• 19:52David finds these jokes crass and offensive,
• 19:55but also notices that he's the only
• 19:57person in the workroom who's not laughing.
• 19:59He's heard from the classmates that
• 20:01most of the residents in this workroom
• 20:03have admitted to grading students
• 20:05based on whether or not they like them,
• 20:07and he wonders the keys at risk of
• 20:09not fitting in and therefore getting
• 20:10a bad grade if he does not want.
• 20:15So here we have what I would call
• 20:17a conflict of evaluative scrutiny
• 20:19and this is one of the most frequent
• 20:21that when we surveyed our students,
• 20:24this was number one,
• 20:25this was the thing that they
• 20:26reported was most troubling to
• 20:28them during their clinical years.
• 20:30And the dilemma that they're facing is
• 20:33how do I do what I know is right when
• 20:35the people with evaluative power are
• 20:38acting immorally or at least inappropriately?
• 20:41So this dilemma lies at the
• 20:45interplay of three factors.
• 20:47Trainees have the need to learn medicine.
• 20:49But they also have the need to
• 20:51be a part of a healthcare team,
• 20:53and that includes inculcating
• 20:55themselves to the culture of the team.
• 20:59And they have a need to learn
• 21:02to respect patients.
• 21:04At the same time.
• 21:06Students and trainees have
• 21:07basically every incentive to mimic
• 21:10the behavior of their superiors.
• 21:12First,
• 21:12they're told that they should be
• 21:14mimicking the behavior of their superiors.
• 21:16They're taught that that's the
• 21:18way to learn medicine through
• 21:20modeling their exemplars.
• 21:22But second,
• 21:23they know that ingratiating themselves
• 21:25as part of the team is central to the
• 21:29process of receiving favorable evaluations.
• 21:31And I think medical students are nothing
• 21:34if not keen on getting good evaluations.
• 21:38In order to move on to the next big
• 21:41step in their in their training,
• 21:43they're they're competitive,
• 21:44they're going to do what's necessary
• 21:47to make it to the next step.
• 21:49And if we're presenting them
• 21:51with opportunities to act?
• 21:53Inappropriately.
• 21:53In a way that's linked to their evaluation,
• 21:57they will do it.
• 22:00When we talk to our students here about this.
• 22:03They they reported essentially 2 concerns.
• 22:07One was related to their own
• 22:10evaluation and appraisal.
• 22:11They wanted their residents and attendings
• 22:14to like them and give them good evaluations.
• 22:17But they also reported that.
• 22:21Acting puritanical or morally upright not
• 22:25only jeopardize their evaluation potential,
• 22:27but it also dampened the spirit
• 22:29of their team as a whole.
• 22:31So when one person was sitting
• 22:32in the corner, not laughing,
• 22:34and sort of wagging their finger at the
• 22:36rest of the team for their behavior,
• 22:38it didn't just stop the laughing,
• 22:39it made everyone feel bad in a way
• 22:41that changed the dynamics of the team,
• 22:44and our students didn't know
• 22:46how to manage that either.
• 22:48So. On its surface,
• 22:50this seems similar to case one.
• 22:53There's a student choosing between
• 22:55personal interests and some sort
• 22:57of patient related interest.
• 22:59This is different, though,
• 23:01because in the first case we're
• 23:03suggesting that as a learner,
• 23:04the student has an important
• 23:06obligation to their education.
• 23:08Even when that obligation is
• 23:10intentional with patient care.
• 23:11In this case,
• 23:12if we simply extrapolated from case 1A,
• 23:15student might say it's OK to laugh
• 23:18because I have an obligation as a
• 23:21learner to get good evaluations.
• 23:23We have to acknowledge that the first
• 23:26case isn't saying that a student can
• 23:28prioritize any interest that they want,
• 23:30it's saying that they can prioritize
• 23:33their education as an interest related
• 23:35to the care of their future patients.
• 23:38That's different from what's happening
• 23:40here in Case 2 where a student is seeking.
• 23:44Evaluative marks it's more self interested.
• 23:49However,
• 23:49even in offering this type of clarification,
• 23:51we can see that to students and
• 23:53to residents who haven't thought
• 23:55deeply about this.
• 23:56This is confusing and challenging.
• 23:59Umm.
• 24:01There's also an important, I think,
• 24:03secondary impact on implicit bias,
• 24:06this type of humor.
• 24:07Some people would call this gallows humor,
• 24:10that the example in this case may
• 24:12not strictly be gallows humor,
• 24:14but it's it's something closely related.
• 24:16People often understand that as
• 24:19a defense mechanism to witnessing
• 24:21suffering in the hospital,
• 24:22but it can frequently overstep
• 24:25the bounds of decency.
• 24:27Some people have suggested
• 24:29that gallows humor.
• 24:31Music and element of cohesion that it
• 24:34brings teams together other people with.
• 24:36Actually,
• 24:37probably a greater heft of empirical
• 24:39evidence suggests that gallows
• 24:41humor actually contributes to the
• 24:43moral erosion of medical students.
• 24:45Part of the reason for that is that.
• 24:47In witnessing Gallows humor,
• 24:49medical students are coming
• 24:51implicitly to realize that.
• 24:53They're,
• 24:54they're exemplars and their moral
• 24:56role models actually lack the ability
• 24:59to fully reconcile the complexity
• 25:01of of illness and suffering.
• 25:03And so they have to turn to humor
• 25:06to help to reconcile it.
• 25:08And so there's evidence that not
• 25:10only does the erosion occur,
• 25:12but it happens without the
• 25:14students recognition.
• 25:14So when our students say, well,
• 25:17I know what's right and wrong,
• 25:19but I'm going to laugh at
• 25:20the joke because I need to,
• 25:22but even as I laugh.
• 25:24I'll recognize for myself that
• 25:26that's the wrong thing to do.
• 25:28That's actually not a powerful
• 25:31preventive for the students
• 25:33experiencing moral erosion.
• 25:35It happens without their
• 25:37recognition in this case.
• 25:40Are are. Their student, David,
• 25:44is internalizing possibly biases
• 25:47against patients with obesity,
• 25:49as well as the general idea that
• 25:51an attitude of dismissiveness
• 25:53to the complexity of disease is
• 25:55appropriate in a medical setting.
• 25:58And so we start to see these
• 26:00growing of implicit biases. Now.
• 26:04I am realistic enough to know that.
• 26:08The medical students and residents
• 26:10are going to laugh at the joke when
• 26:12they're superior makes the joke.
• 26:14I I don't expect that they'll
• 26:16stop doing that.
• 26:17So it's possible that the only way that
• 26:19we can address this type of concern,
• 26:21which our students raise so frequently,
• 26:24is through debriefing of clinical
• 26:27encounters after rotations or
• 26:30particular experiences with.
• 26:32Moral exemplars who are not tied into our
• 26:37trainees evaluation or our students grading,
• 26:40and in doing so we might be able
• 26:43to capture that moment where the
• 26:45trainee is still experiencing.
• 26:47A sense, that sort of moral inclination
• 26:50that this behavior is wrong.
• 26:52We might be able to capture that in
• 26:55that moment if we create a space to
• 26:57debrief these types of situations.
• 26:59OK.
• 27:00So the third case.
• 27:02The conflict of hierarchy.
• 27:05Hakeem is a fourth year medical
• 27:07student who is a panelist on a
• 27:10talk regarding physician burnout.
• 27:12A panelist brings up the issue of verbally
• 27:15abusive language in the workplace,
• 27:16and Hakim gives an example of a fellow
• 27:19that constantly made inappropriate
• 27:21comments about colleagues and
• 27:23patients and often made jokes
• 27:25about Hakim's name and ethnicity.
• 27:28Later during Q&A,
• 27:30a senior attending returns to
• 27:31this discussion, saying, frankly,
• 27:33if you can't handle comments like that,
• 27:35you won't be ready for what's coming
• 27:37for you later in your training.
• 27:39Hakeem is unsure how to respond.
• 27:42We've probably all.
• 27:43Heard comments like this one.
• 27:46I think the frequency of them occurring
• 27:49in response to someones name or
• 27:52ethnicity is greatly diminishing.
• 27:54But we do still hear comments
• 27:56in this vein around things like
• 27:58trainees saying that they're tired
• 28:01and attending saying things like,
• 28:03well if you think you're tired now,
• 28:05just wait until you're out of training
• 28:07and there's no work hour restrictions.
• 28:09Those types of comments I think
• 28:10will fall into the same type of
• 28:12analysis that I'm going to do.
• 28:14For this conflict of hierarchy,
• 28:16because they do work to minimize
• 28:20the sort of experience of discomfort
• 28:23that our trainees are going through.
• 28:25So let's talk a little more about this.
• 28:29The importance of this case,
• 28:30I think,
• 28:31rests on the dismissive tone that
• 28:33the attending adopts,
• 28:34but also the idea that that
• 28:37dismissive tone plays into the
• 28:39moral formation of both Hakim and
• 28:42anyone else who's listening.
• 28:45I've said already in this talk that
• 28:47medical education is structured
• 28:49on the concept of the exemplar.
• 28:51Maybe it's worth mentioning
• 28:52briefly what I mean by that,
• 28:54if it's not totally obvious.
• 28:56At each level of training
• 28:58in our system of hierarchy,
• 29:00people are seeking to emulate or mimic the
• 29:03behaviors of the people ahead of them.
• 29:06And that all sort of culminates up to
• 29:08the pinnacle position in the medical
• 29:11hierarchy of the attending physician
• 29:13who's responsible for the plan.
• 29:15The assessment and plan that the that
• 29:17will be used to treat the patient
• 29:20and medical students watch their
• 29:22attendings like a hawk and try to
• 29:24mimic the behaviors that they display.
• 29:27This progression stepwise from person
• 29:30to person within a hierarchical
• 29:34structure places enormous.
• 29:36Emphasis on the habits of the
• 29:38attending physician and.
• 29:40This clearly works very well for
• 29:43attainment of technical skills
• 29:45that are required of physicians.
• 29:47We want people to attain technical
• 29:50skills by mimicking people with
• 29:52greater technical skills.
• 29:54It's not so obvious that this type
• 29:56of structure works as well for
• 29:59the development of moral skill.
• 30:01Part of what's happening is that.
• 30:03People get tagged as exemplars by
• 30:07being technically expert, but.
• 30:09The technical expertise doesn't
• 30:12necessarily import moral expertise.
• 30:15So we have many exemplars.
• 30:17And this is of course not all,
• 30:18but we have many exemplars who
• 30:21are technically expert but maybe
• 30:24morally blind or at least myopic.
• 30:27So if someone like this fails to
• 30:29see a moral dilemma as it's arising,
• 30:32we can't expect them to make
• 30:34a fitting moral choice.
• 30:38That, even as I'm saying it,
• 30:39sort of seems like the banal point,
• 30:41but I think that it can reorient
• 30:43our attention to the idea of
• 30:45the virtues that have to be in
• 30:47place before one can even start
• 30:49to think about making choices.
• 30:53In our case.
• 30:55The with Hakim, the attending,
• 30:57who's the principal exemplar,
• 30:59adopts a dismissive tone.
• 31:00So he proves that he's failing
• 31:02to see the moral matters at hand,
• 31:04which might be the destructive
• 31:07powers of verbal abuse,
• 31:09or the corrosive effects of
• 31:12disparaging our patients,
• 31:14or the damage that we see through
• 31:18failures of inclusion. And.
• 31:20Medical students who sit and
• 31:23witness exchanges like this are
• 31:26then faced with this type of
• 31:28exemplar who might have technical
• 31:30expertise but lacks moral expertise.
• 31:32This is a problem probably for two reasons.
• 31:38I'll say at least two reasons.
• 31:41One is that.
• 31:44It it creates.
• 31:46This sort of training that lacks
• 31:49moral fortitude, as I've mentioned,
• 31:52but two is that it can actually cause our
• 31:57trainees to actively question their own.
• 32:01Ethical formation.
• 32:02So that doesn't always happen.
• 32:04But our medical students and
• 32:06residents often assume that they
• 32:08have medical ignorance about the
• 32:11technical aspects of medicine.
• 32:13They know that. That's why they're here.
• 32:15Many of them, though,
• 32:16feel internally like they've
• 32:17they've already developed a
• 32:18compass on how to live their life.
• 32:20They've got a moral sense of what
• 32:22kind of person they want to be.
• 32:23But when they see the exemplars,
• 32:26who they are following in the
• 32:29attainment of technical expertise?
• 32:30Demonstrate a moral orientation
• 32:32that is different from their own.
• 32:35They may begin to feel that they're also
• 32:37in addition to being medically ignorant,
• 32:40they may feel that they're that
• 32:42they are also ethically ignorant.
• 32:43They may actually cast off appropriately
• 32:47formed moral inclinations in the
• 32:50pursuit of the behavior of an exemplar.
• 32:54So medical curricula that
• 32:55prioritize moral development are
• 32:57actually faced with a paradox.
• 32:59Which is.
• 33:01That.
• 33:03As I've mentioned,
• 33:04attending physicians are granted
• 33:06their authority on the basis of
• 33:08technical expertise or competence,
• 33:10but that that doesn't correlate
• 33:11with moral competence.
• 33:12So we have to think about the way
• 33:15that we structure training we we
• 33:17might tell students that we're
• 33:19focusing more effort on moral
• 33:22development and ethical expertise,
• 33:24and then put them into training
• 33:26environments where the exemplars
• 33:28they're following lack the same
• 33:30training that we're giving to
• 33:32the trainees themselves.
• 33:33This is a paradox because.
• 33:36By focusing more attention
• 33:38on moral development,
• 33:39if we skip the step of providing that
• 33:43same development to attending physicians,
• 33:45we may actually cause more harm
• 33:47than good for our trainees,
• 33:49who are all of a sudden paying
• 33:51heightened attention to their moral
• 33:53development but following exemplars
• 33:54who lack the same moral development.
• 33:57This means,
• 33:58then,
• 33:59that we have to focus some
• 34:02attention on our exemplars,
• 34:04our people who are in more advanced
• 34:07stages of training or in the
• 34:09faculty years of their training,
• 34:11to be more fitting moral exemplars.
• 34:15That's certainly a tall order,
• 34:17and maybe in the conversation we
• 34:18can talk a little bit more about
• 34:21how one might approach that task.
• 34:22I've got a few ideas,
• 34:24but I don't think I have
• 34:25the solution just yet.
• 34:26This is.
• 34:27Maybe a segue into what I think is
• 34:30then the central challenge for
• 34:33contemporary trainings. Umm.
• 34:37I think that there's ongoing confusion
• 34:40about the nature of the physicians role.
• 34:43I mentioned a Hippocratic covenantal
• 34:46view of medicine that focuses
• 34:48on a therapeutic relationship
• 34:50between a physician and a patient.
• 34:53But as we all know,
• 34:55there are expansive and sort of seemingly
• 34:59ever broadening administrative and
• 35:01research oriented goals that detract
• 35:04from primary professional obligations.
• 35:06So we're going to imagine for a second
• 35:09a medical student entering medical
• 35:12school thinks that they are going to
• 35:14learn how to take care of patients.
• 35:16And what they find out quickly is
• 35:18that they need to figure that out.
• 35:20But they also need to figure out how to
• 35:22be a clinical or maybe a bench investigator.
• 35:26And they also need to figure out how
• 35:28to be quality improvement champions.
• 35:31And they also need to figure
• 35:33out how to be social advocates.
• 35:35And they also need to.
• 35:37Figure out how to interface with
• 35:39insurance companies and some of you
• 35:42are having some sort of PTSD reaction
• 35:44to me just listing all of these
• 35:47obligations that physicians now have.
• 35:49The point is that there is
• 35:51just an immense amount of.
• 35:53Professional,
• 35:53hairy professional roles that
• 35:55are vying for the clinicians,
• 35:58time and attention that are outside
• 36:01of simply being with a patient.
• 36:03Umm.
• 36:05All of those roles that I mentioned,
• 36:07by the way,
• 36:08I think are important and I think they're
• 36:12necessary within the context of medicine.
• 36:15But when we teach students that they need
• 36:17to be expert in all of those things,
• 36:20that combination threatens to
• 36:22distract people from their primary
• 36:24commitment as physicians to the
• 36:26sick person in front of them,
• 36:27Leon Kass said.
• 36:30When medicines powers were fewer,
• 36:33it's purpose was clearer and I
• 36:36I think that's probably true.
• 36:39So how can we get a clearer
• 36:41description of the purpose of medicine
• 36:43and the physicians placed in it?
• 36:45There's there's a nice investigation
• 36:48of the phenomenology of the suffering
• 36:50patient that was done by actually a
• 36:53theologian named Stanley Hauerwas.
• 36:55And Hauerwas argues that what we
• 36:58centrally have to understand is suffering.
• 37:01And suffering is a central problem
• 37:04for humans because it threatens our
• 37:07identity and it it it threatens our
• 37:10identity as beings in a community in
• 37:14two ways. First, it isolates the sufferer.
• 37:18The experience of suffering has
• 37:20been experienced by lots of people
• 37:22in lots of different ways.
• 37:24But the internal experience of
• 37:26suffering is always unique to the
• 37:29individual that's experiencing it.
• 37:31That's often recognized by that individual,
• 37:34and that alone can be isolating.
• 37:37Umm. It's.
• 37:38Also very difficult to explain 1
• 37:42suffering to a non sufferer and
• 37:45that is further isolating.
• 37:48At the same time.
• 37:50Witnessing someone who is suffering
• 37:52is a challenge for a non sufferer.
• 37:56It's it further isolates suffer because
• 37:59when we witness someone suffering,
• 38:02we are reminded of our own finitude.
• 38:04It's it's a it's an embodied reminder
• 38:08that we will all at some point, die.
• 38:11We're mortal,
• 38:12and so that can be even more
• 38:15isolating as the
• 38:16non sufferers pull away from
• 38:19people who are suffering.
• 38:21So with that backdrop power,
• 38:23Wasden said it take the activity of
• 38:26the physician to be characterized by
• 38:29the fundamental commitment to be in
• 38:31the presence of those who are in pain.
• 38:34This is something that I think our
• 38:38trainees come into the medical
• 38:40world understanding quite well
• 38:42and then at some point along the
• 38:44way gets muddied with all of these
• 38:47period professional concerns.
• 38:48The the idea that a physician is
• 38:51fundamentally committed to being in the
• 38:52presence of those who are in pain is,
• 38:54I think, captured really nicely
• 38:57by this painting,
• 38:58which many of you are probably familiar with.
• 39:01This is the doctor by Sir Luke fields,
• 39:04and it it depicts a physician,
• 39:08perhaps at the end of his sort
• 39:11of technical armamentarium,
• 39:12simply sitting in the presence
• 39:14of someone who's suffering and
• 39:17trying to understand. Bat.
• 39:19We see in this painting that.
• 39:22The patient's parents are
• 39:24standing behind in the background,
• 39:28disconnected from that suffering and the
• 39:31role of the physician in this sort of.
• 39:35Imaginary of fields is to act as
• 39:38a bridge between the sufferer and
• 39:41the non supperer now. I'm a parent.
• 39:44Many of you are probably parents.
• 39:46And we would, we would all, I think,
• 39:48say that the parents back there
• 39:50are in fact suffering.
• 39:52True enough,
• 39:53but it's a different type of
• 39:55suffering and the physician is
• 39:57meant to serve as a bridge between.
• 39:59The patient and the family members.
• 40:02A A colleague,
• 40:04Brewer Eberly looked at this and
• 40:07updated it for modern times.
• 40:10And his update to this painting
• 40:11looks like this.
• 40:15So here it's quite obvious that the
• 40:18physician has been removed from the sort
• 40:21of primary focus on the patient and is
• 40:24now focusing all of his intense efforts
• 40:27on his administrative responsibilities.
• 40:31When when I show this to medical students,
• 40:34many of them laugh. They think this
• 40:36is just sort of a funny depiction.
• 40:38When I show this to physicians in practice,
• 40:41some of them do laugh.
• 40:42But most of them recognize that
• 40:44this is a poignant depiction of
• 40:47the difference between the sort of
• 40:49laudatory ideal of a physician actually
• 40:52spending time with a patient, imagine,
• 40:54and a physician sitting in front of
• 40:57a computer all day, every day. So.
• 41:03I think that the key to think about
• 41:06here is our ability or inability
• 41:09to be present to suffering.
• 41:12I've argued that the physician's role
• 41:14is at least in part, irreducibly moral.
• 41:17It's not just a technical role,
• 41:20and that that.
• 41:22View of medicine as a moral
• 41:25practice is in keeping with.
• 41:28A more traditional, perhaps Hippocratic,
• 41:31vision of medicine.
• 41:35What we see with our trainees is that all
• 41:38of these competing obligations shelter them
• 41:41from experiencing suffering of patients.
• 41:44They have lack of time to be present.
• 41:46But also the medicine that they're
• 41:49being trained into lacks a robust way
• 41:52to identify and respond to suffering.
• 41:54So we we've failed to develop our ability to
• 41:58identify and respond to suffering patients.
• 42:01At the same time,
• 42:02we can all acknowledge that being present
• 42:04to suffering patients is not easy.
• 42:06It is taxing and power wash again here said
• 42:09none of us have the resources to see too
• 42:12much pain without the pain hardening us.
• 42:15So then I'm left with the question
• 42:17of if presence to suffering is
• 42:19a challenge to trainees,
• 42:21benefit from their relative absence
• 42:23to suffering, or in other words,
• 42:26will increase presence to suffering worsen
• 42:29ongoing mental health crises among trainees?
• 42:32This is a major,
• 42:34major concern for contemporary
• 42:35medical training is as they're hearing
• 42:38about the mental health crisis
• 42:40among their peers and colleagues,
• 42:42and they're seeing stories about.
• 42:46Medical residents committing suicide.
• 42:49Suicide for male residents is
• 42:51now the leading cause of death,
• 42:53and for female residents it's #2.
• 42:56I as I was preparing for this,
• 42:58I came across a Twitter thread
• 43:01actually announcing the death by
• 43:03suicide of a medical resident,
• 43:05and I was reading through comments
• 43:07from other medical trainees.
• 43:09Who? It really struck me.
• 43:12We're saying things like.
• 43:13We have to find a way to minimize
• 43:17our time spent with the insurance
• 43:19company so that we can actually
• 43:21spend time with our patients.
• 43:23They weren't blaming their constant
• 43:25exposure to suffering patients
• 43:27for the mental health crisis.
• 43:29They were blaming their inability
• 43:31to spend time with their suffering
• 43:33patients for the mental health crisis.
• 43:35So I think that the answer to these
• 43:37questions is trainees do not benefit
• 43:40from absence to suffering and increase
• 43:42presence to suffering will help and not
• 43:45hurt the mental health crisis among trainees.
• 43:48In part, that's because patient
• 43:50care or presence to suffering,
• 43:52whether or not we formulate
• 43:53it that way at the outset,
• 43:55is why we enter medicine.
• 43:57So the the real problem for trainees is
• 43:59how to be present in spaces of suffering
• 44:03when presence is being discouraged,
• 44:05implicitly and explicitly.
• 44:08We know that presence to suffering
• 44:11is a burden.
• 44:12But it's also a profound privilege,
• 44:14and I think that our trainees recognize the
• 44:18privilege in their presence to suffering.
• 44:21Umm.
• 44:23Power Wash then concluded that
• 44:26something very much like a church is
• 44:29required to sustain those in medicine
• 44:32who expose themselves to suffering.
• 44:35I I don't think that we should just propose
• 44:38that all of our trainees join a church.
• 44:40That's not what I'm suggesting.
• 44:42But Howard Wass is proposing something
• 44:46called medical moral communities.
• 44:48I'll talk about that a
• 44:49little bit on the next slide,
• 44:50but the reason that we might focus
• 44:53some attention on this is that.
• 44:56The the reason why we do things is so
• 44:59important in giving us our own meaning.
• 45:03And Victor Frankel quoted Friedrich
• 45:08Nietzsche in a reflection on
• 45:11surviving in the concentration camps
• 45:14by saying he who has a why to live
• 45:17for can bear with almost any how.
• 45:20My contention here is that in
• 45:23many areas of modern medicine,
• 45:25by our focus on the sort of technical,
• 45:27technological aspects we've we've lost
• 45:31our ability to give a robust account for
• 45:34why it is that we're doing what we do.
• 45:37Why it is that we spend time
• 45:39in the presence of suffering.
• 45:40And without that we have a real problem
• 45:42that we're seeing that play out now.
• 45:45But if we could re infuse the
• 45:48sort of metaphysical.
• 45:50Medicine with a with a robust vision
• 45:52of why we're doing what we're doing.
• 45:54I think it might actually serve
• 45:57as a corrective for some of this.
• 46:00So briefly,
• 46:01I'll talk about moral communities and
• 46:03then just give a few closing suggestions.
• 46:05And I look forward to hearing
• 46:07your suggestions as well.
• 46:11A A friend of mine who many of you
• 46:13probably know, Donna Zadie pointed
• 46:16me toward this idea in Buddhism that
• 46:20Admiral admirable camaraderie is
• 46:22actually the whole of the holy life.
• 46:26When a person has admirable
• 46:28people as companions,
• 46:29he can be expected to develop and
• 46:31pursue the noble eightfold path.
• 46:33And you know this.
• 46:34This came out of a discussion
• 46:36that that Donnish and I were
• 46:38having about moral communities.
• 46:40And he pointed out that many
• 46:43world religions have taken this,
• 46:45this type of stance.
• 46:47Buddhism here and then a few 100 years later,
• 46:51Aristotle picked up on the same idea.
• 46:55So what is a moral community when I say?
• 46:58Well, a moral community, I think,
• 46:59has three features in common.
• 47:04First,
• 47:04members of a group share a covenantal
• 47:08relationship with each other and society.
• 47:10The community has certain standards
• 47:12that remain constant even as
• 47:14leaders and members change.
• 47:16And the community is more
• 47:17than the sum of its members.
• 47:19So my question then is can we
• 47:22can we regard the profession of
• 47:25medicine as a moral community?
• 47:27Are we able to conceive of this in a
• 47:30way that we can sustain one another in?
• 47:34The moral practice of being
• 47:36present to patients and suffering,
• 47:37I think that the answer is yes.
• 47:39I think that medicine meets these
• 47:42these marks of a moral community.
• 47:46What's left then is.
• 47:47For the profession of medicine to
• 47:50come up with a robust accounting for
• 47:53why we need focus on moral activity,
• 47:57and that's what I'm trying to do
• 47:59in part with today's presentation.
• 48:01So what can be done?
• 48:03Well,
• 48:04ethics curricula need to extend
• 48:06past the preclinical years,
• 48:08ideally throughout training
• 48:10and probably into practice.
• 48:12We've done this sort of odd thing
• 48:14where in the preclinical years
• 48:16before any patient engagement,
• 48:18we're teaching all the sort of
• 48:20technical aspects of medicine that I
• 48:21mentioned at the beginning of the talk.
• 48:23And we also sort of shove ethics
• 48:26into that area of the curriculum
• 48:29devoid of context related to
• 48:31patient encounters then we cast.
• 48:34The students out into the clinical
• 48:36environments where they continue to
• 48:38learn technical aspects of medicine
• 48:39and don't hear much more about ethical
• 48:42and moral development when in fact
• 48:44they most need it at that moment.
• 48:47So we need to figure out a way
• 48:48to incorporate ethics curricula
• 48:50past simply the preclinical years.
• 48:55Clinicians need opportunities
• 48:56to debrief clinical experiences.
• 48:58This I mentioned in
• 49:00relation to case number two.
• 49:02We need to find ways for our
• 49:04trainees to capture those moral
• 49:07sentiments that are so important
• 49:09in their development as both
• 49:12technically competent and
• 49:14morally upstanding physicians.
• 49:18This one may seem a little self-serving,
• 49:20but I do think it's important
• 49:22that medical schools and hospital
• 49:24systems should dedicate resources,
• 49:25both financial and otherwise to
• 49:27the recruitment and retention of
• 49:29ethicists who can think deeply
• 49:30about and help to train people.
• 49:33In what I'm talking about,
• 49:35the the Catholic hospital systems in this
• 49:38country have done actually a great deal
• 49:41of resource dedication towards Ephesus.
• 49:43They have standing ethics roles
• 49:45in most of the Catholic hospital.
• 49:47Systems.
• 49:47Secular hospitals have done
• 49:49less of a good job with this,
• 49:52but probably it deserves some focus.
• 49:57For trainees we need to sort out ways
• 49:59that we can minimize their barriers
• 50:02to being present to suffering.
• 50:04I think it's a major concern that by
• 50:07filling up our trainees time with all
• 50:09sorts of non patient care demands
• 50:12that they are forgetting the call
• 50:14that they first experienced to be in
• 50:16the presence of suffering others.
• 50:18And this is precisely how one could
• 50:22envision becoming an attending
• 50:24physician with the moral myopia
• 50:26that I mentioned before.
• 50:29Finally and.
• 50:32Maybe one of the more important
• 50:34suggestions is that we need to utilize
• 50:37interdisciplinary methods in education.
• 50:39We have spoken.
• 50:42In reference to physicians during this talk,
• 50:44that is not in any way to minimize
• 50:46the impact of other professions
• 50:47or the importance of this on them.
• 50:49It's simply because that's what I've
• 50:51trained in and read the most in reference to.
• 50:55But one can easily imagine that as
• 50:57physicians move away from the bedside,
• 51:00nurses certainly don't.
• 51:01The people who are in the bed spaces
• 51:03dealing with and talking to patients
• 51:05all of the time really being present
• 51:08to suffering, are our nurses.
• 51:10We should recognize this both as a
• 51:12way to leverage their moral expertise
• 51:14in being present to suffering,
• 51:16but also so that we can help to
• 51:18pull them into community as a way of
• 51:21addressing their sort of constant
• 51:22exposure to that suffering.
• 51:24And there are many other professions
• 51:26on whom we can lean chaplains,
• 51:29ethics experts, mission leaders,
• 51:31for instance.
• 51:31So I think that we we owe it to our
• 51:34trainees not just to do the sort of
• 51:36like shadow and nurse for a day type
• 51:39of experience, but a real deep dive.
• 51:42Into the moral expertise of these
• 51:44other professions with whom we work.
• 51:46OK, I'm just a little over 45 minutes,
• 51:49but I'm going to stop there and I'm
• 51:52really looking forward to having a
• 51:54discussion with all of you about this topic.
• 51:58Thank you so much, Jay.
• 51:59That was that was terrific.
• 52:02So I'm going to take the the moderators
• 52:04prerogative and with the and start
• 52:06with the comments and then question.
• 52:08But while I'm doing that to to
• 52:10remind the other folks if you have a
• 52:12comment or a question for Jay please
• 52:14please put it in the Q&A portion and
• 52:17I'll read those in just a minute.
• 52:20First I want to I want to make an
• 52:23observation and and and then ask a question.
• 52:26Of course your comment on the observation
• 52:28and the question would be most welcome.
• 52:30I I really appreciate this talk
• 52:32and this is where I spend.
• 52:33A fair amount of my energy and
• 52:36time is trying to do better in this
• 52:39educational setting if among the
• 52:41medical students in particular,
• 52:42but also other trainees.
• 52:43But I thought one thing that occurred
• 52:45to me as you were talking about
• 52:47this was what's going to help the,
• 52:49the medical students in particular
• 52:51get through.
• 53:00What's going to sustain them
• 53:01through these different things?
• 53:02For many, some,
• 53:03sustenance may come from inspiration,
• 53:05and the inspiration itself can sometimes.
• 53:10Be the response to the presence,
• 53:12to suffering that you refer to,
• 53:14which is to say,
• 53:14when I think back to my medical school years,
• 53:17the most inspiring moments were moments
• 53:20that involve the presence to suffer.
• 53:22We're we're helping the family or
• 53:25helping the patient when there
• 53:26was a great deal of suffering
• 53:27involved or helping a colleague,
• 53:29a fellow student,
• 53:30or a fellow House officer who was
• 53:32himself or herself suffering.
• 53:34So it occurs to me that
• 53:35actually that presence,
• 53:36the suffering that you commented on,
• 53:38could actually be very much central.
• 53:40To their to their training,
• 53:43even if it takes them a little
• 53:44bit away from a test.
• 53:45And in some ways that in itself
• 53:47could potentially be educational,
• 53:49which is to say that maybe you won't
• 53:51have quite as much time to prepare
• 53:53for that in service exam because you
• 53:55stayed with that with that woman who
• 53:57was weeping over her dying husband.
• 54:00That maybe that itself is going to be
• 54:02more educational and better for you
• 54:03recognizing that they need good exam scores,
• 54:05etcetera, etcetera.
• 54:06But I wonder if the presence of suffering
• 54:09that you highlighted so beautifully isn't.
• 54:11Part of not only would education,
• 54:12but we're actually going to sustain them
• 54:15for the difficulties and related to that.
• 54:17I had a specific question to one of
• 54:20your earliest points was that they're
• 54:22not yet professionals and and I would
• 54:24like to push back on that a little
• 54:26bit or challenge that a little bit and say.
• 54:29Why not?
• 54:29Why can't we use their
• 54:31primary rules as learned?
• 54:33I didn't have the primary rule
• 54:34that went through argue that for
• 54:36a second year resident they have
• 54:37a role as a learner as well.
• 54:38Is that when they actually make that
• 54:41frame shift transition from your
• 54:43main concern is your education.
• 54:45I think we can agree that an
• 54:47undergraduate that the primary,
• 54:48their primary mission is to learn.
• 54:51That is,
• 54:52to learn what they're there to learn.
• 54:53They have other missions as well,
• 54:54if you will.
• 54:55But at some point that transition
• 54:57occurs in the life of the physician.
• 54:59And you've suggested that that occurs
• 55:00when perhaps we take the Hippocratic Oath,
• 55:02but not during the white coat ceremony.
• 55:04What I'm wondering is,
• 55:06could in fact or should in fact
• 55:08that transition occur when you
• 55:10start as a medical school,
• 55:11when you first start sitting by
• 55:14the bedside of sick patients?
• 55:16And could that in itself be part of
• 55:18the inspiration that sustains them
• 55:20during their medical education?
• 55:23What's a good question and you and
• 55:26I have in the past period back and
• 55:29forth a little bit on how to define
• 55:32professional and you know I think.
• 55:35I think I think a lot about sort of
• 55:39pelegrino based philosophy when I talk
• 55:41about what it means to be a professional.
• 55:44Maybe that's fallen out of
• 55:46vogue a little bit recently,
• 55:48but I lean a lot on Pellegrino,
• 55:50so Pellegrino suggests that. In part,
• 55:55a professional is marked by their profession,
• 55:59that is their their expression of.
• 56:04Both their competence to provide
• 56:08necessary medical services and
• 56:11also their willingness to do so.
• 56:13And that's professed in two ways.
• 56:15One is in in the taking of an oath,
• 56:19traditionally the oath at the
• 56:21end of medical training.
• 56:22And two is in the sort of engagement
• 56:27in an an individual patient encounter.
• 56:31So when you step into a room and say what,
• 56:33what can I do?
• 56:34To you today,
• 56:36you're you're actually implicitly
• 56:37professing that you have the desire,
• 56:39that interest to try to address the
• 56:42health concerns of the patient.
• 56:44So those two things,
• 56:46now your question is why couldn't
• 56:49the Hippocratic Oath be simply moved
• 56:51to the beginning of Med school?
• 56:54And then they have made a profession,
• 56:56they've entered the profession
• 56:57by that that pronouncement.
• 56:59I think my answer to that is
• 57:01is a little bit fraught.
• 57:03I would say that my answer.
• 57:04That is that that second part of the
• 57:07profession is the profession that
• 57:10you have the necessary knowledge,
• 57:12skills and competence to practice the art.
• 57:14The reason I say that that's fraud is
• 57:17that I think we all recognize that
• 57:19we don't finish medical school as
• 57:21competent providers of medical care.
• 57:23But historically that was sort of
• 57:25the way things were set up as you
• 57:28could finish medical school and
• 57:30go out and practice medicine.
• 57:32So I would say that it's at least clear
• 57:35that at the beginning of medical school.
• 57:38During the White coat ceremony,
• 57:40those students are nowhere
• 57:42near being able to.
• 57:45With fidelity proclaim that
• 57:48they have the competence to.
• 57:50Addressed the health interests
• 57:52of the patient,
• 57:53so I think it makes sense to me that
• 57:55that that profession is deferred until
• 57:57later in the course of training.
• 58:01That is very thoughtful and helpful answer.
• 58:03Thank you. I want to share with
• 58:05you a question from from the
• 58:07audience and remind me of the folks
• 58:08in the audience that if you just
• 58:10type your questions into a Q&A,
• 58:11I'll be glad to read them to Jay.
• 58:14Peter you will position at Duke found
• 58:16that students after their OBGYN
• 58:18clerkship experienced a reduction in
• 58:21interest for patient consent across
• 58:23all OBGYN across all procedures,
• 58:26excuse me not just OBGYN procedures.
• 58:29This reduction was not found within
• 58:31any other clerkship rotations.
• 58:33Something seems to be distinct
• 58:35about the OBGYN rotations.
• 58:37Do you have any insights to
• 58:38offer as to why that might be?
• 58:44I'm I'm not familiar with this research
• 58:46in particular, and I can't say that.
• 58:50I know exactly what's distinct
• 58:53about the OBGYN rotation.
• 58:55You know, my initial inclination was to
• 58:58say that a lot of the intervention that
• 59:01happens during an OB GYN rotation occurs
• 59:04with a great deal of urgency or emergency.
• 59:08And sometimes consent procedures are
• 59:11dismissed in times of emergency.
• 59:14But I'm not sure that that's
• 59:16necessarily distinctive.
• 59:17I mean, that's true in trauma surgery.
• 59:20My specialty of critical care and you're
• 59:24suggesting that this was unique to OB GYN,
• 59:27so I don't, I don't know exactly.
• 59:31I would I'd like to read that
• 59:32research and try to understand
• 59:34what the context for that was.
• 59:38Yeah, I'm, I'm not familiar with that.
• 59:40But, you know, invite my friend to send it.
• 59:42If the e-mail gets sent to me with the
• 59:44reference, I'll be sure it gets forwarded
• 59:46on to you because it's an interesting
• 59:48it's an interesting question, to be sure.
• 59:50I mean, obviously one possible implication is
• 59:53that this has sexist overtones in Pediatrics.
• 59:56Of course I'm not sure you know where
• 59:58consent falls where so often the parents
• 60:00are not present when much is happening.
• 01:00:02So I don't know how this compares
• 01:00:04to pediatric physicians,
• 01:00:05particularly critical care work,
• 01:00:06where you work where you.
• 01:00:08I see you.
• 01:00:11Where there's so many other procedures,
• 01:00:12but there are so many procedures going on,
• 01:00:15it is.
• 01:00:17Because that was my impression that that
• 01:00:20that in fact that was where our field was,
• 01:00:23where consent was less often obtained,
• 01:00:24at least in the critical care setting.
• 01:00:26But I I think that's that's going
• 01:00:28to be a fascinating observation that
• 01:00:29could that could help us unlock a lot
• 01:00:32of questions about what we do with it.
• 01:00:34If we could take a look at that,
• 01:00:35I think that could be helpful.
• 01:00:37I have another question for you.
• 01:00:39This is this would be a controversial
• 01:00:40observation,
• 01:00:41but you know what the hell it's
• 01:00:42already was and that's practically
• 01:00:44the weekend I'm going to tell you
• 01:00:46something about what's changed.
• 01:00:47In the clinical setting traumatically
• 01:00:49and I was commenting on this to
• 01:00:52someone else from my vintage and.
• 01:00:55When I run into.
• 01:00:57Residents who more my residence when
• 01:00:59I was a young attending, you know,
• 01:01:01or people that I worked with when
• 01:01:03I was a young attending.
• 01:01:04Members on the team, what they comment on.
• 01:01:09Is sometimes,
• 01:01:10but more than what comes out is the laughter.
• 01:01:13Now again to set the tone for for those
• 01:01:15of many of the call aren't familiar with it.
• 01:01:17So my clinical work was in
• 01:01:19newborn intensive care.
• 01:01:20So whatever laughter was or wasn't
• 01:01:23happening was not something that that
• 01:01:25that the patients took offense to.
• 01:01:26The patients themselves could not
• 01:01:28be aware of this and at that time
• 01:01:31and place in history.
• 01:01:33Parents weren't allowed in the room.
• 01:01:35Because the room consisted of
• 01:01:3712 intensive care patients,
• 01:01:38there were several rooms,
• 01:01:39but there'd be 10 or 12 intensive
• 01:01:41care patients in a room and as we
• 01:01:44talked about all of the patients.
• 01:01:46So that to protect the privacy of 1 family,
• 01:01:48the other family wasn't allowed in the room.
• 01:01:50So for that time period from 8
• 01:01:52to 11 or somewhere around there.
• 01:01:55There were no families in the room.
• 01:01:56It was the staff.
• 01:01:57And I wondered if it wasn't to
• 01:02:00some extent gallows humor.
• 01:02:02To some extent it might have
• 01:02:03been inappropriate.
• 01:02:04To some extent it might
• 01:02:05have been therapeutic.
• 01:02:06And one would have to go back and
• 01:02:07look at the videotape to decide how
• 01:02:09much of it was each of those things.
• 01:02:10But there was.
• 01:02:15There was no doubt that some of it
• 01:02:16when looking back things I remember
• 01:02:18some of it was clearly inappropriate.
• 01:02:19And and the obvious example
• 01:02:21that you mentioned about the
• 01:02:22making fun of somebody's name,
• 01:02:24that sort of thing which has been which has
• 01:02:25gotten a lot of attention in recent years,
• 01:02:27which I agree with you,
• 01:02:28men that have disappeared as an offense,
• 01:02:30but it's certainly decreased and
• 01:02:33something that's far more awareness of.
• 01:02:36But there was, there was other aspects of it,
• 01:02:38even if they could be self deprecating,
• 01:02:40even if it could be appropriate and not.
• 01:02:43And not, excuse me, I'm sorry about that.
• 01:02:46Quite that down.
• 01:02:48And not even if it was not
• 01:02:51necessarily inappropriate.
• 01:02:52It was a way to relieve pressure.
• 01:02:54It was a way to relax the
• 01:02:55the trainees a little bit,
• 01:02:57that there could sometimes be
• 01:02:59humor used and for better or worse.
• 01:03:01And I think actually it is
• 01:03:03both for better and for worse.
• 01:03:04I'll tell you,
• 01:03:05was one of the old docs that
• 01:03:07in the clinical setting,
• 01:03:09and this may have been unique to neonatology,
• 01:03:11I can't really speak to.
• 01:03:12We certainly didn't laugh as much on
• 01:03:14the adult services because I mean,
• 01:03:15in some settings that would be
• 01:03:18profoundly disrespectful and
• 01:03:19inconsiderate to the patients.
• 01:03:20But when patients are unaware,
• 01:03:22when the patients are newborn babies,
• 01:03:25sometimes to relieve the pressure of
• 01:03:27a moment by poking a little fun at
• 01:03:30oneself was sometimes seen as well.
• 01:03:32Actually,
• 01:03:32this is actually helpful to the spree decor.
• 01:03:34The team, the danger was certainly there,
• 01:03:36though the danger was absolutely there.
• 01:03:38And the reality was there that sometimes
• 01:03:40this stuff was just inappropriate.
• 01:03:42But it's it's an observation when I
• 01:03:44think about medical students and the
• 01:03:46suffering they do and the and the and
• 01:03:49the and the desiring when I think back.
• 01:03:51Fondly to all member used everyone smile.
• 01:03:54We could laugh at ourselves about
• 01:03:55this or that and I think back with
• 01:03:57some of that stuff is probably,
• 01:03:58you know horrendously inappropriate.
• 01:03:59And you know every once in a while
• 01:04:01I'll I'll I'll see somebody at a
• 01:04:03meeting I haven't seen in 30 years.
• 01:04:04And remember we did this and we did that.
• 01:04:06And I'm thinking yeah I'm not so sure
• 01:04:08I'm proud of that moment actually.
• 01:04:10You might remember finally but I'm
• 01:04:11not so sure I remembered fondly
• 01:04:13but of course how we remember
• 01:04:15what really happened 30 years ago
• 01:04:17as a whole separate problem.
• 01:04:18But the gallows humor stuff,
• 01:04:20I think is I think you've you've kind
• 01:04:22of stumbled upon something that's
• 01:04:24valuable to us in understanding
• 01:04:26what we do and how he's.
• 01:04:35Sometimes with students in a really
• 01:04:37difficult situation quietly taking the
• 01:04:38temperature of everybody in the room.
• 01:04:40So when a student is offended, well,
• 01:04:41let me see if everybody else laughed.
• 01:04:43My offense is that much worse if the
• 01:04:46attending, even if the attending,
• 01:04:47this is the part that is attending.
• 01:04:48We had to teach our team and teach ourselves.
• 01:04:50Even if someone says something that we think,
• 01:04:52well, that really wasn't appropriate
• 01:04:54and a student know knew that
• 01:04:56and the attending didn't laugh.
• 01:04:58But also didn't actually point out
• 01:05:00that's not appropriate if the attending
• 01:05:03just became a neutral observer.
• 01:05:05That's still problematic.
• 01:05:06You know that that we have to have
• 01:05:09that rule against inappropriate humor.
• 01:05:11What's come with that in some setting is.
• 01:05:14Much more.
• 01:05:17I don't want to say humorless,
• 01:05:18but but amongst a much
• 01:05:21harsher workplace overall.
• 01:05:22And some of this may be unique
• 01:05:24to a setting where none of our
• 01:05:26patients could ever appreciate or
• 01:05:27take insult in the words we use.
• 01:05:28And now of course what's changed for the
• 01:05:31better is the families are there now often,
• 01:05:33not always, but often the families are
• 01:05:35there even with the newborn patients.
• 01:05:37So consequently.
• 01:05:39You know, if it, if it's,
• 01:05:41if an insightful person might have sensed,
• 01:05:43it would be inappropriate to
• 01:05:45say something funny here.
• 01:05:46Now, even the thickest of
• 01:05:48neonatologists can realize,
• 01:05:49well,
• 01:05:49clearly it would be inappropriate to
• 01:05:51say something humorous here because
• 01:05:52these parents are really frightened.
• 01:05:54So we're not going to,
• 01:05:55we're not going to try and
• 01:05:58say something here.
• 01:05:59I I think that that change in the
• 01:06:01workplace over time has in some ways
• 01:06:03made things better for students,
• 01:06:05in some ways made things worse.
• 01:06:06But that's just an observation from
• 01:06:09from someone who's been around
• 01:06:10it around the game for a while.
• 01:06:12Well,
• 01:06:13I'll just say that.
• 01:06:15I'll say that. Well, one, I mean,
• 01:06:19I've gone through the training as well,
• 01:06:21and I wouldn't want to sit here
• 01:06:24and say that I've never made the
• 01:06:26jokes or laughed at the jokes.
• 01:06:28I've participated in this as well as well.
• 01:06:30And I, you know, I've seen times
• 01:06:32when it was more or less appropriate,
• 01:06:35times when it was team building and
• 01:06:37times when it seems to be over the line.
• 01:06:41So I think one,
• 01:06:42we do have to be careful who's in the room
• 01:06:46because something that might be funny.
• 01:06:48Among seasoned faculty members.
• 01:06:52Might really not hit an early
• 01:06:54medical student that way,
• 01:06:56and that's an important consideration.
• 01:07:02Two, I think that we've
• 01:07:05formed this narrative that.
• 01:07:07Suffering is so intense and hard to
• 01:07:09grapple with that something like gallows
• 01:07:11humor is the only way that we could
• 01:07:14possibly get ourselves through it.
• 01:07:16And people say things like, you know,
• 01:07:19if if you can't laugh at it, what can you do?
• 01:07:22Or if you don't laugh,
• 01:07:24you'll cry, that kind of thing.
• 01:07:26And, and I think that that general
• 01:07:30idea about why we need need
• 01:07:33gallows humor is probably wrong.
• 01:07:36That in some sense.
• 01:07:38Being present to suffering and managing that
• 01:07:42suffering can be dealt with in other ways,
• 01:07:45like through the support
• 01:07:47of moral communities,
• 01:07:48without simply relying on
• 01:07:51something like gallows humor.
• 01:07:53So I'm not,
• 01:07:54I'm not trying to cut it out entirely,
• 01:07:56but I would call into question the
• 01:07:58idea that gallows humor is the only
• 01:08:01possible Ave for dealing with some
• 01:08:03of the difficult things that we see.
• 01:08:06I think that's really insightful.
• 01:08:08I mean and and gallows humor is probably
• 01:08:11overall a bad approach to some extent.
• 01:08:16Perhaps some self deprecating humor
• 01:08:18can be a form of humility that's
• 01:08:20actually necessary even for the
• 01:08:22part educating people that that in
• 01:08:24terms of how we each make mistakes.
• 01:08:25But this is this is actually
• 01:08:27a really complex subject.
• 01:08:28This is something you should write
• 01:08:30about Jake because this is this is
• 01:08:32too complicated for my fiscal because
• 01:08:33on one level this can do this can do
• 01:08:35some harm to patients to families to
• 01:08:38trainees and and I wonder if in the
• 01:08:40right where I'd setting if one can teach
• 01:08:42humility for example just as human
• 01:08:45beings we sometimes teach humility.
• 01:08:47To our kids,
• 01:08:48to us through a self deprecating
• 01:08:49humor in a way that in a way to
• 01:08:51poke fun at myself a little bit.
• 01:08:53But in the Klimek clinical setting
• 01:08:55this is so complicated because you
• 01:08:56don't want to undermine confidence,
• 01:08:58you don't never know.
• 01:08:59You want to project arrogance and it's so
• 01:09:01easy for this stuff to be misinterpreted.
• 01:09:03And you make a really good point here
• 01:09:06that two people who know each other well.
• 01:09:08Can can.
• 01:09:09One can say something to the other,
• 01:09:10and it may refer back to conversations
• 01:09:12they've had over the course of years,
• 01:09:14and it can be interpreted in just the retina.
• 01:09:16I I've had this situation happen to me,
• 01:09:19one of my friends when we
• 01:09:21were teaching together,
• 01:09:22and I have an offhanded and offhanded
• 01:09:24semi up to sway was poking fun at him.
• 01:09:27You know,
• 01:09:28a close friend for decades.
• 01:09:29But someone in the one of the
• 01:09:32students who doesn't is unaware of
• 01:09:34the friendship and unaware of what
• 01:09:36I'm even referring to thinks I'm
• 01:09:37making fun of him and says well I'm
• 01:09:39good for that student for saying
• 01:09:40would you say that for and I say well
• 01:09:42I was thought and then I'd have to
• 01:09:44say well hang on I have to apologize
• 01:09:45to you because that may have been
• 01:09:47my intent but by the way that was
• 01:09:49just a horrible plan and poorly
• 01:09:50delivered and and and the point is
• 01:09:52for everyone student as the first
• 01:09:54to say hey you know I was offended
• 01:09:56by that for everyone who said that
• 01:09:57there's 10 more just stayed quiet.
• 01:09:59So it's it's it's dangerous
• 01:10:02territory to go in.
• 01:10:04But somehow if the sustenance is in
• 01:10:06there somewhere at times but but they're
• 01:10:08so easy to misinterpret you right,
• 01:10:10listen,
• 01:10:10another question from the audience
• 01:10:11that came in which I want to read.
• 01:10:13During the pandemic,
• 01:10:14especially early on,
• 01:10:16there was a lot of suffering and often
• 01:10:19infection control measures that may have
• 01:10:21created distance from suffering such
• 01:10:23as masking and telehealth etcetera.
• 01:10:25Do you see any lessons from the
• 01:10:27pandemic and how the experience of
• 01:10:29suffering relates to moral erosion?
• 01:10:33That's a great question,
• 01:10:34and I think a lot of what I'm talking
• 01:10:37about got worse during the pandemic.
• 01:10:39The first thing that jumps to my mind
• 01:10:42when I hear that question is that
• 01:10:44we've undergone what a lot of people
• 01:10:46are calling the great resignation
• 01:10:48that the distress that people are
• 01:10:51feeling around the practice of
• 01:10:53medicine and the amount of suffering
• 01:10:56that they know is occurring was so
• 01:10:59heightened during this time period.
• 01:11:00And I suspect,
• 01:11:01although I don't have empirical proof of.
• 01:11:04This. I think that our inability to
• 01:11:06be present to suffering patients made
• 01:11:09our experience of this far, far worse.
• 01:11:12I'm a, I'm a pediatric ICU guy.
• 01:11:15I'll say that the pediatric hospitals
• 01:11:17were largely spared early on at least
• 01:11:20from the impact of the pandemic.
• 01:11:22But in 2020,
• 01:11:23our pediatric intensivist got
• 01:11:25floated over to the adult hospital to
• 01:11:28practice in the ICU there and so I,
• 01:11:31I did experience some of this.
• 01:11:34Calling a loved one over zoom and
• 01:11:36telling them that their parent had died,
• 01:11:38those types of things,
• 01:11:40and I will say that I experienced
• 01:11:43that as vastly more distressing than.
• 01:11:46What I had experienced prior to that,
• 01:11:49I I think that in part that was related
• 01:11:52to a constrained ability to actually
• 01:11:55carry out what I perceived to be.
• 01:11:59Foundational fundamental roles of
• 01:12:01a physician in being present to
• 01:12:03suffering and bridging that world of a
• 01:12:07suffering patient to a non sufferer,
• 01:12:09usually the family.
• 01:12:10So I I think the big impact was it is
• 01:12:14being seen by the number of people
• 01:12:16that are leaving medical professions.
• 01:12:19Now more to the point of the question
• 01:12:22which is related to moral erosion.
• 01:12:25I don't, I don't think we know yet.
• 01:12:28I haven't seen.
• 01:12:29Evidence of it,
• 01:12:30yet I think we'll see that sort of in
• 01:12:32the attitudes of learners moving forward.
• 01:12:37One of the one of the concerns
• 01:12:39I've often had, Jay is that.
• 01:12:42And I've I've talked to this about
• 01:12:43the medical students about there's
• 01:12:45there's some lesson in history as
• 01:12:46well and some of the work that you
• 01:12:47and I have a shared interest in
• 01:12:49even in work related to the to the
• 01:12:52Holocaust and and Nazi medicine is
• 01:12:54when we see suffering in our patients
• 01:12:56one at a time as opposed to seeing
• 01:12:59suffering in large numbers and is there
• 01:13:01something numbing or distancing when
• 01:13:04one sees larger numbers of people.
• 01:13:07And I wonder if the pandemic didn't
• 01:13:08somehow relate to that to something
• 01:13:10different about one sick child
• 01:13:11in front of you than an emergency
• 01:13:13room full of sick children.
• 01:13:14Is it?
• 01:13:15Is it possible that the pandemic also
• 01:13:17hardened us simply by virtue of numbers,
• 01:13:19or hardened some of us by virtue of numbers?
• 01:13:21Yeah,
• 01:13:22absolutely. I mean,
• 01:13:23I think no matter how.
• 01:13:25No matter how well developed
• 01:13:27your coping strategies are,
• 01:13:29which I've argued are
• 01:13:31generally not well developed,
• 01:13:34even if you have a good
• 01:13:35strategy in place to deal
• 01:13:37with presents to suffering.
• 01:13:41As I said in the talk,
• 01:13:42it will harden all of us eventually.
• 01:13:46We can simply outpace our ability to
• 01:13:49respond, and one of the interesting
• 01:13:50things about the pandemic was that.
• 01:13:54All of all of the physicians,
• 01:13:56like if I have a moral community of
• 01:13:58physicians who practice critical care,
• 01:14:00who I lean on for support.
• 01:14:02They were all as far underwater as I was,
• 01:14:06so everyone's bandwidth to generate
• 01:14:08a response to people who would
• 01:14:11experience suffering was limited.
• 01:14:12So I think a lot of factors came into
• 01:14:15play all at the same time to really
• 01:14:17generate a problem as it relates to
• 01:14:20what I've been talking about today.
• 01:14:23Thank you. Here's a question,
• 01:14:25please many word teams on our
• 01:14:27medical service over the past
• 01:14:28few years have reduced attending
• 01:14:30obligations to one week at a time,
• 01:14:32being that students could have four
• 01:14:33different attendees in the space of a month.
• 01:14:35Leaving aside the lack of continuity
• 01:14:37and consistency of student evaluation,
• 01:14:39could this phenomenon undermine
• 01:14:41professional commitment on the part
• 01:14:43of students when they see that their
• 01:14:45teachers are unwilling to make a
• 01:14:47sustained commitment to patient care?
• 01:14:50Yeah. The simple answer is yes.
• 01:14:53And I think there's a variety
• 01:14:56of ways that we see that.
• 01:14:59One of the ways that I've highlighted
• 01:15:01that I think is related to that question
• 01:15:04is that I often see our faculty members,
• 01:15:07and I've done this myself, take meetings
• 01:15:11while they're on clinical service,
• 01:15:13something they can't get out of.
• 01:15:14I've got a grant coming up or this or that.
• 01:15:17I need to jump on a phone call.
• 01:15:19I'm going to step out of rounds.
• 01:15:20For a few minutes and do that.
• 01:15:22Umm. That. May be OK.
• 01:15:26It may be fine.
• 01:15:28If you've, you know,
• 01:15:29ensured that the clinical team
• 01:15:31will continue providing good care.
• 01:15:34There's a fellow there, whatever it is,
• 01:15:36whatever arrangements you've made to
• 01:15:37make sure the patients are cared for.
• 01:15:39But without explaining clearly
• 01:15:41the thinking behind it,
• 01:15:43or actually doing the thinking behind it,
• 01:15:45it can easily signal to someone
• 01:15:48who's watching you that you're.
• 01:15:51Extra professional obligations are more
• 01:15:53important to you than the ones in front
• 01:15:56of you now I think everyone in my group,
• 01:15:59when faced with a medical emergency or
• 01:16:01a patient requiring their attention,
• 01:16:03would no show their meeting.
• 01:16:05But.
• 01:16:05The medical student rotating
• 01:16:08through might not assume that.
• 01:16:10So I think there's a variety
• 01:16:13of ideas that we.
• 01:16:14Signal our changing professional
• 01:16:17commitments in ways that students
• 01:16:20incorporate into their moral development,
• 01:16:23maybe without our knowledge at all.
• 01:16:27Perhaps the only way to remedy this,
• 01:16:28in lieu of changing back to
• 01:16:30sort of older ward structures,
• 01:16:33which seems unlikely,
• 01:16:34is to actually talk about this
• 01:16:37with students so that they know
• 01:16:39that their exemplars are being
• 01:16:41thoughtful about the way that
• 01:16:43they approach patient care.
• 01:16:46That's a good point.
• 01:16:46And I have to say looking back on
• 01:16:48it from the longer perspective
• 01:16:49is that when I started out,
• 01:16:50the notion that the attending was going
• 01:16:52to be around all day was ludicrous.
• 01:16:54The attending wasn't even
• 01:16:55there on rounds in the morning.
• 01:16:56That the the attending,
• 01:16:57you know, where was frequently
• 01:16:59there during parts of the day,
• 01:17:01but but the attending presence is
• 01:17:03actually part greater than it was,
• 01:17:04which may account in part for why
• 01:17:06attendings to shorter rotations,
• 01:17:08because there was, it was commonplace,
• 01:17:09the attending to show up after
• 01:17:11work around seeing all spend an
• 01:17:12hour or two with the Fellow of
• 01:17:13the residence and then go back
• 01:17:14to the left of the afternoon.
• 01:17:16That was a common model of back in the day.
• 01:17:20And so I think it was easier for attendings
• 01:17:21to put in longer periods of time.
• 01:17:23But there's also,
• 01:17:24there's something really sort of
• 01:17:26complicated happening right now,
• 01:17:27which is that we're also trying
• 01:17:30to emphasize personal Wellness.
• 01:17:31And so we've had some students complain
• 01:17:34because one of the questions on their
• 01:17:38evaluation of faculty is something like
• 01:17:41was the faculty available after hours to
• 01:17:44answer questions and the students have said.
• 01:17:48Faculty shouldn't be available after hours.
• 01:17:51That's their time to care for themselves.
• 01:17:53They shouldn't be having
• 01:17:55a continued obligation.
• 01:17:57That's their Wellness.
• 01:17:59And and I think to a lot of the
• 01:18:01faculty that that complaint felt odd,
• 01:18:04like of course I should be
• 01:18:06available for my patients.
• 01:18:07These these things can only be
• 01:18:11reconciled by actually digging
• 01:18:13into the moral underpinnings of
• 01:18:14what it is that we're being called
• 01:18:17to when we're doing patient care.
• 01:18:19Because I think,
• 01:18:20I think most faculty members would say,
• 01:18:23of course you can call me after hours
• 01:18:26if it's about one of my patients.
• 01:18:28I would hope anyway.
• 01:18:31Appreciate that one of the faculty
• 01:18:33comments on the on the comments earlier
• 01:18:37about OBGYN clerkship, she says.
• 01:18:39Whatever call is quite distinctive
• 01:18:41about my OBGYN clerkship experience
• 01:18:42was the fact that of course the vast
• 01:18:44majority of patients were women.
• 01:18:46Historically and sadly,
• 01:18:47extending to the current era,
• 01:18:49women have not enjoyed the same degree
• 01:18:51of bodily autonomy as men in our society,
• 01:18:53and this was painfully evident at
• 01:18:55times during my clerkship experience.
• 01:18:57I suspect this may be a large driver
• 01:18:59of ethical erosion and students.
• 01:19:01Though I would be interested to
• 01:19:04read the paper you cited as well
• 01:19:06to get more of an empirical take.
• 01:19:09And another question here from
• 01:19:11from the audience please.
• 01:19:13So this may be a little off
• 01:19:15topic and or a topic unto itself,
• 01:19:18but what are your thoughts on the
• 01:19:20effect of medical assistance in
• 01:19:22dying on our valuation of human
• 01:19:24life and how this may be perceived
• 01:19:27by trainees and professional and
• 01:19:29ethical considerations of us all?
• 01:19:33Questioner is a position from
• 01:19:35Canada where some, but not all,
• 01:19:37are already questioning the seemingly
• 01:19:39liberal and explaining correct and
• 01:19:42expanding criteria for medical aid in
• 01:19:44dying this I I would even expand this
• 01:19:46question a bit if you want to comment
• 01:19:48on how this relates to presence to suffer.
• 01:19:52Right. Well, yeah,
• 01:19:55this it is a big question.
• 01:19:57It could be a talk to itself, but.
• 01:20:01My concern, which is shared by
• 01:20:04some other commenters on the
• 01:20:07recent changes in Canadian law,
• 01:20:10is that the liberalized criteria for
• 01:20:14medical aid and dying create a risk.
• 01:20:18That is a medical community,
• 01:20:20and as a society we might make it easier
• 01:20:25to die than to live with suffering.
• 01:20:30And when you do that,
• 01:20:31you'll have people selecting death
• 01:20:34rather than trying to figure out
• 01:20:36a way to deal with whatever it
• 01:20:39is about their situation that
• 01:20:41caused them to go that route.
• 01:20:43I talked in my talk about Stanley Hauerwas.
• 01:20:47And in one of his books he says
• 01:20:52something like it seems odd that
• 01:20:56our response to suffering would
• 01:20:59be to eliminate the sufferer.
• 01:21:02I think about that quite a bit.
• 01:21:04That's not to say that there should be a
• 01:21:07total prohibition on medical aid and dying,
• 01:21:11but it is to say that if that's
• 01:21:13the route that is a medical
• 01:21:14community we decide to take,
• 01:21:16we have to be very,
• 01:21:17very thoughtful about the
• 01:21:18degree to which we're able to
• 01:21:20actually support suffering.
• 01:21:21People who don't want to choose death
• 01:21:23but are only choosing it because it
• 01:21:26feels like the most viable option.
• 01:21:31And I would say that if
• 01:21:34we create a generation of.
• 01:21:36Clinicians who are uncomfortable
• 01:21:38being present to suffering,
• 01:21:41we will make that problem worse.
• 01:21:44It will be the default position
• 01:21:46of the technologically oriented
• 01:21:48efficient position that medical
• 01:21:49aid and dying is the right
• 01:21:52approach to a suffering patient,
• 01:21:54even before they explore other avenues
• 01:21:57to alleviate the suffering so.
• 01:22:01I I haven't advocated for doing away
• 01:22:03with medical aid and dying entirely,
• 01:22:05but I do think that there are substantial
• 01:22:08problems with the way that we are
• 01:22:11rapidly expanding access to it with
• 01:22:14seemingly literal little little thought
• 01:22:16to how we could otherwise alleviate
• 01:22:18patient suffering or attend to it.
• 01:22:23Thank you. Thank you very much.
• 01:22:25I have the citation on the Belt article
• 01:22:27here for those who are interested.
• 01:22:30And I think what we'll do is you,
• 01:22:32bell and Jepsen at all,
• 01:22:35don't ask, don't tell.
• 01:22:37The change in medical student attitudes
• 01:22:39after OBGYN clerkships towards seeking
• 01:22:41consent for pelvic examination on an
• 01:22:43anesthetized patients in the American
• 01:22:45Journal of his duties and gynecology.
• 01:22:47And Karen, perhaps what we can do is we
• 01:22:49can put this reference on the website
• 01:22:51for those who might be interested in.
• 01:22:53There will be a recording of this
• 01:22:56session available after a few days
• 01:22:57on the website on the program for
• 01:22:59Biomedical Ethics website and I think on
• 01:23:01there we can also make this reference
• 01:23:03available to those who are interested.
• 01:23:05So thank you for that.
• 01:23:08And with that,
• 01:23:08I see our time is about well this has
• 01:23:12been a fascinating conversation with
• 01:23:14the the reference that even better.
• 01:23:15Thank you, Duncan.
• 01:23:16There's the reference right there in
• 01:23:18the chat portion for those of you want
• 01:23:19to jot that down quickly you can see
• 01:23:21that that will be available to you.
• 01:23:23So this was really Jay,
• 01:23:26this was really an interesting and
• 01:23:29very helpful and something that we've
• 01:23:31all thought about to some extent,
• 01:23:33but obviously you you, you are.
• 01:23:35Analysis of it and thoughts have
• 01:23:37gone deeper than for Moses.
• 01:23:39And I think it's it,
• 01:23:40it can really be helpful.
• 01:23:43You know there's there's a historian
• 01:23:44who I quote here at Yale named
• 01:23:46Tim Snyder who just in one of his
• 01:23:48books he had a quote which he
• 01:23:50wrote which I've used as a guide.
• 01:23:52He says humanity sees itself
• 01:23:54in the suffering other,
• 01:23:55which I think is a brilliant
• 01:23:57and it speaks to empathy.
• 01:23:59But I think that I would paraphrase my
• 01:24:02friend that Jay Malone has also adding that.
• 01:24:06That humanity or at least the
• 01:24:08physicians and nurses and see
• 01:24:10themselves not just in the suffering
• 01:24:13other but with the suffering mother.
• 01:24:16And and this was a wonderful lesson for
• 01:24:18this evening and it's terrific session.
• 01:24:19I thank you so much.
• 01:24:21I want to thank all of you who
• 01:24:22took the time to spend it with us.
• 01:24:24We'll be back in two weeks in
• 01:24:26person at the Alliance Center.
• 01:24:27They'll be more than 1,000,000 about that.
• 01:24:29But for tonight please join me in
• 01:24:31thanking Doctor Jay Malone from Saint
• 01:24:34Louis University and I'll speak to you.
• 01:24:36Thank you all.
• 01:24:37Thanks man.