Ethics Issues Specific to Medical Trainees

November 08, 2022

Information

November 2, 2022

Jay R. Malone, MD, PhD, HEC-C

Ubel PA, Jepson C, Silver-Isenstadt A. Don't ask, don't tell: a change in medical student attitudes after obstetrics/gynecology clerkships toward seeking consent for pelvic examinations on an anesthetized patient. Am J Obstetr Gynecol. 2003;188(2):575-9. doi:10.1067/mob.2003.85

ID8241

To CiteDCA Citation Guide

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&amp;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&amp;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&amp;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&amp;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.