Education
Healthcare Education and Christian Faith
Education in the healthcare professions presents particular
challenges in combining education, the profession and the care of the
patient. Christians in healthcare education should look to their faith
for support and guidance in addressing these issues.
Healthcare Trainees
Medical and dental students and residents are partially trained
healthcare professionals. Christian healthcare trainees are subject to
the same standards and guidance as are fully trained Christian
healthcare professionals (see Standards For Life*)
All authority is established by God. Healthcare trainees should
respect the authority of attending clinicians and others responsible for
patient care. In situations where there is a difference of opinion
between a trainee and those professionals in authority, excluding
matters of conscience, the trainee should respectfully state his or her
opinion and reasons, and should then honor the final decision of the
person in authority. If the trainee believes a patient may be harmed by
the decision, he or she should tactfully seek counsel from one or more
experienced professionals.
Professional trainees should not place a patient at physical risk for
the sake of learning, but should seek supervision from others with more
experience or knowledge, when appropriate. They should not put
themselves at moral risk, but rather graciously decline to participate
in any aspect of training or patient care which would violate their
conscience.
Healthcare in a teaching setting requires cooperation and
communication among many members of the professional team. This presents
unique challenges for the trainee in regard to patient privacy and
confidentiality. Special efforts must be made in such settings to retain
and demonstrate the highest respect for patients.
Trainees should be honest with patients about their level of
training; e.g. medical and dental students must not introduce themselves
to patients as "Doctor". They should likewise be honest with their
professional colleagues and in matters of documentation, never
compromising their integrity for the sake of being a "team player". They
need to be honest with themselves and with those to whom they report
when they make mistakes.
Healthcare Educators
Clinicians involved in the training of medical and dental students
and residents should exert proper supervision and authority without
physical, emotional or sexual abuse. Trainees should be treated with
courtesy and respect at all times and should not be asked or expected to
expend themselves to the point of endangering patients or of damaging
their personal or family lives. Conversely, the teacher should model
balance in their personal and professional lives and assist the trainee
in establishing the same. Christian healthcare educators should model
the demeanor of Jesus in His teaching and ministry.
Residents and students should be trained in all aspects of the
well-being of their patients, including physical, mental, emotional,
social, and spiritual aspects of health. The teacher should ensure that
the patient's care is not compromised by the inexperience of the
trainee.
If a trainee in the healthcare professions expresses an unwillingness
to participate in an aspect of training or patient care as a matter of
conscience, that stance should be explored in a non-judgmental manner to
ensure that both parties fully understand the issue. The trainee's
position on matters of conscience should be honored without academic or
personal penalty.
Healthcare trainees and educators should work together with
compassion, competence and integrity to enhance patient care and to
strengthen professional standards. Following the model of our Lord
Himself in equipping and sending disciples, health care education should
ensure the excellence of future practitioners and educators.
· See statements entitled "Principles of Christian Excellence in
Dental and Medical Practice," "Christian Physician's Oath," "Christian
Dentist's Oath," "Biblical Model for Medical Ethics," and "Sharing Faith
in Practice."
Approved 1 May 1999 in Toronto, Ontario, Canada with 56 in favor, 6
opposed, and 3 abstaining
Healthcare Education and Christian Faith
Background
Education in medicine and dentistry has traditionally consisted of
several years of rigorous study and supervised practical experience. The
primary goal has been to prepare students to be competent and caring
professionals. The importance of this goal has led educators to insist
on high standards of performance and to expect personal sacrifice from
trainees.
Increasingly complex technology, an expanded knowledge base and a
broader scope of healthcare have resulted in a vast amount of material
that must be available to healthcare trainees and practitioners.
Tensions are not uncommon in healthcare education because of the
increased demands on trainees and the lofty expectations of the
educators, along with an increased assertiveness of contemporary
healthcare trainees as compared to their predecessors of earlier
generations. These tensions have regrettably led to occasional instances
of strained relationships, even to instances of alleged, perceived or
real student abuse or harassment. In an effort to motivate students to
excellence, educators have on occasion publically degraded or humiliated
those who they judge are inadequately prepared or behaving
inappropriately.
At the same time, there is a new awareness that other tensions may
arise in healthcare education from ethical issues which arise
specifically because healthcare trainees are only partially trained,
e.g. conflicts of interest between doing what is best for the patient
and what is best for one's own education, truth-telling about one's
level of competence and experience, cooperation with other professionals
when one's own values are challenged, etc.
Secular perspective
Health professional educators have responded to these changes with
curriculum revisions and an increased focus on teaching students
efficient means of information acquisition, management, storage, and
retrieval. Even with these changes, they have continued to insist on
high standards of performance from trainees. The development and nurture
of professional values requires mutual respect between student and
teacher. Such trust is difficult or impossible if the educational
environment is one of tension, disrespect, or abuse. While teachers do
have the responsibility to motivate and correct students, when
correction of an individual is needed, this should be done in private
and in a way which does not show disrespect for him or her as a future
colleague.
An important part of the teaching of mutual respect among
professionals is the perception of students as they observe faculty in
their interactions with each other. Therefore faculty should be models
of professionalism in all of their interactions and should avoid
inappropriate behavior or mistreatment of other professionals and staff.
This includes the avoidance of derogatory remarks about or attitudes
toward individual colleagues, services, or departments.
Students also learn professional behavior and demeanor by observing
their teachers as they interact with patients. Such professional
interactions should always be courteous and respectful. Respect for
individuals includes, but is not limited to, such things as punctuality,
thoughtfulness, mindfulness of personal space, as well as manner and
mode of address, appropriately modest draping, tone and content of
verbal interchanges, and body language. In addition, discussion of
patients out of their hearing should continue to show the same degree of
respect and should not include contemptuous, derogatory, judgmental or
demeaning remarks.
In response to the above-mentioned tensions in professional
education, in 1999, the Liaison Committee on Medical Education (formed
in 1942 by the AMA Council on Medical Education and the Association of
American Medical Colleges to establish standards for and accredit U.S.
and Canadian medical schools) mandated that every medical school
establish policy and procedure related to standards of conduct in the
teacher-learner relationship, including issues of student mistreatment.
In addition, some state legislatures have enacted laws limiting the
number of hours that professional trainees are allowed to be on
duty.
Christian Perspective
Christian trainees and educators have not been able to avoid these
changes and tensions. However, in addition to the professional values
and traditions, they have biblical principles and teachings to give
guidance and to assist in the resolution of these tensions.
Christian educators are committed to many fundamental values such as:
compassion, integrity, excellence, freedom, justice,
purity/self-control, and humility. These values may occasionally be
formally taught by faculty, but more often are learned informally by
students through observation of models of professional behavior toward
students, colleagues, and patients.
Christian students in the healthcare professions should likewise
model attitudes, words and deeds consistent with those taught by Jesus
Christ.
Abstracted Articles:
Kopelman, Loretta. "Cynicism Among Medical Students." JAMA 21
Oct, 1983; 250 (15): 2006-10.
"The thesis that medical students become more cynical than students of
other professions seems justified in light of psychological studies and
reports from medical students. This article explores whether this might
be due, in part, to disappointment about how important ideals are
followed. Psychological tests themselves offer an opportunity to examine
this, because the medical profession espouses the goals of gaining
proper consent from all subjects, including students, and of giving
appropriate attention to excellence of research design and method. When
studies used to evaluate medical students' attitudes are viewed from
this perspective, however, weaknesses on both scores seem apparent.
Students seem well aware of some of these flaws. Although such testing
is a small part of medical education, it confirms students' views that
there is cause for disillusionment about how certain goals are realized.
It also suggests a way to cure some students' cynicism. Students should
be taught consistently, both by example as well as by precept of their
profession's sincere commitment to professed goals. In practical terms
this means, for example, that studies using students as subjects should
have a proper review by the institutional review board, with adequate
attention given to excellence of design, confidentiality, and methods of
gaining informed and unpressured consent. Such studies could then serve
as paradigms to students. Other goals of the profession should also be
applied to students, and applied for students."
Silver, Henry K. and Anita Duhl Glicksen. "Medical Student
Abuse: Incidence, Severity, and Significance." JAMA 26 Jan, 1990; 263
(4): 527-32.
"In a survey of the incidence, severity, and significance of medical
student abuse as perceived by the student population of one major
medical school, 46.6% of all respondents stated that they had been
abused at some time while enrolled in medical school, with 80.6% of
seniors reporting being abused by the senior year. More than two thirds
(69.1%) of those abused reported that at least one of the episodes they
experienced was of 'major importance and very upsetting.' Half (49.6%)
of the students indicated that the most serious episode of abuse
affected them adversely for a month or more; 16.2% said that it would
'always affect them.' Students identified various types of abuse and
proposed a number of measures for the prevention and management of abuse
in medical school. We conclude that medical student abuse was perceived
by these students to be a significant cause of stress and should be a
major concern of those involved with medical student education."
Baldwin, Dewitt C. Jr., Steven R. Daugherty, and Edward J.
Eckenfels. "Student Perceptions of Mistreatment and Harassment During
Medical Schools: A Survey of Ten United States Schools." Western Journal
of Medicine Aug 1991; 155 (2): 140-45.
"Senior students at 10 medical schools in the United States responded to
a questionnaire that asked how often, if ever, they perceived themselves
being mistreated or harassed during the course of their medical
education. Results show that perceived mistreatment most often took the
form of public humiliation (86.7%), although someone else taking credit
for one's work (53.5%), being threatened with unfair grades (34.9%), and
threatened with physical harm (26.4%) were also reported. Students also
reported high rates of sexual harassment (55%) and pervasive negative
comments about entering a career in medicine (91%). Residents and
attending physicians were cited most frequently as sources of this
mistreatment. With the exception of more reports of sexual harassment
from women students, perceived mistreatment did not differ significantly
across variables such as age, sex, religion, marital status, or having a
physician parent. Scores from the 10 schools also did not vary
significantly, although the presence of a larger percentage of women in
the class appeared to increase overall reports of mistreatment from both
sexes."
Sitham, Sean. "Education Malpractice." JAMA 21 Aug, 1991; 266
(7): 905-6.
It seems that we have medical education pretty well figured out. Two
years of basic sciences, two years of clinical experience, a minimum of
three years of residency training and then one is a full-fledged doctor
with all the requisite knowledge and responsibilities. But there are
those who don't quite fit into the system mold, those who need extra
help or more attention along the way. The author recalls two students
that the system failed, instances that he calls "medical malpractice."
The problem, the author argues, is that although teaching is billed at
high priority, in reality it is on the back burner. "Part of the
arrogance of medicine is the idea that receiving an MD degree means
acquiring an instant ability to teach. Teaching requires instruction in
education techniques. Teaching takes personnel, time and money. But when
the faculty's primary obsession is whether that NIH grant is coming
through to pay their salaries or whether their latest article has been
accepted so that they can get tenure, teaching will never get the time
it deserves." The author concludes, "I am not sure how best to do the
teaching, nor so I know who is best qualified to teach. But I am sure of
one thing: the present clinical clerkship and residency system of
laissez-faire/sink-or-swim is outmoded and amounts to education
malpractice."
Pellegrino, Edmund D. "In Search of Integrity." JAMA 6 Nov,
1991; 266 (17): 1454-55.
"Any vice practiced often enough and by enough people soon becomes
the moral norm." With this statement, the author begins a discourse on
cheating and its consequences, the practice of which has almost become
ingrained in medical school. Citing some of his experiences with medical
students, the author deplores this trend stating that, "such widespread
tolerance of dishonesty in future physicians is disquieting indeed."
After analyzing the moral deficiency of the most common arguments for
cheating, the author suggests several solutions. He concludes,
"acceptance or indifference is not tolerable in preparation for a
profession in which fidelity to trust is a major obligation."
Dans, Peter E. "Medical Students and Abortion: Reconciling
Personal Beliefs and Professional Roles at One Medical School." Academic
Medicine Mar 1992; 67 (3): 207-11.
"A survey was used from 1983 through 1990 in a required first-year
course, Ethics and Medical Care, at The Johns Hopkins University School
of Medicine, to explore where students drew the line about moral issues.
Starting in 1988, a similar questionnaire was administered to each class
of fourth-year medical students. This report summarizes the students'
attitudes- reported anonymously in both surveys- regarding circumstances
under which they would perform or refer for an abortion. Attitudes
towards abortion changed little in four years. Comfort levels with
patient referral were greatest when the life of the mother was
threatened and in the case of rape. Students' attitudes correlated most
strongly with personal beliefs about when a fetus was considered a human
life and less so with students' genders. The first-year survey results
were shared with the students in the course's annual sessions on
abortion in order to aid them in understanding the assumptions
underlying ethical dilemmas surrounding abortion and to make visible the
class's moral pluralism on the subject. The survey also helped them
determine their tolerance, if any, for patients' views or actions that
conflicted with their personal moral stances."
Andre, Judith. "Learning to See: Moral Growth During Medical
Training." Journal of Medical Ethics Sep 1992; 18 (3):
148-52.
"During medical training students and residents reconstruct their view
of the world. Patients become bodies; both the faults and virtues of the
medical profession become exaggerated. This reconstruction has moral
relevance: it is in part a moral blindness. The pain of medical
training, together with its narrowness, contributes substantially to
these faulty reconstructions. Possible improvements include teaching
more social science, selecting chief residents and faculty for their
attitudes, helping students acquire communication skills, and helping
them deal with their own pain. More importantly, clearer moral vision
requires time and scope for reflection."
Christakis, Dimitri A. and Chris Feudtner. "Ethics in a Short
White Coat: The Ethical Dilemmas That Medical Students Confront."
Academic Medicine Apr 1993; 68 (4): 249-54.
"Many existing ethics curricula fail to address the subtle yet critical
ethical issues that medical students confront daily. The authors report
on the kinds of dilemmas students face as clinical clerks, using cases
that students submitted in 1991-92 during an innovative and
well-received ethics class given at a tertiary care hospital as part of
the internal medicine clerkship. Analysis of these cases reveals that
many dilemmas are intimately tied to the student's unique role on the
medical health care team. Recurring themes included the student's
pursuit of experience, differing degrees of knowledge and ignorance
among team members, and dealing with disagreement within the
hierarchical authority structure of the medical team. The authors
conclude that some components of ethical education must be
participant-driven and developmentally stage-specific, focusing more
attention on the kinds of ethical decisions made by medical students as
opposed to those made by residents or practicing physicians."
Self, D.J., D. E. Schrader, D. C. Baldwin Jr., and F. D.
Wolinsky. "The Moral Development of Medical Students: a Pilot Study of
the Possible Influence of Medical Education." Medical Education 1993; 27
( ): 26-34.
"Medicine endorses a code of ethics and encourages a high moral
character among doctors. This study examines the influence of medical
education on the moral reasoning and development of medical students.
Kohlberg's Moral Judgement Interview was given to a sample of 20 medical
students (41.7% of students in that class). The students were tested at
the beginning and at the end of their medical course to determine
whether their moral reasoning scores had increased to the same extent as
other people who extend their formal education. It was found that
normally expected increases in moral reasoning scores did not occur over
the 4 years of medical education for these students, suggesting that
their education experience somehow inhibited their moral reasoning
ability rather than facilitating it. With a range of moral reasoning
scores between 315 and 482, the finding of a mean increase from first
year to fourth year of 18.5 points was not statistically significant at
the P < 0.05 level. Statistical analysis revealed no significant
correlations at the P < 0.05 level between the moral reasoning scores
and age, gender, Medical College Admission Test scores, or grade point
average scores. Along with a brief description of Kohlberg's cognitive
moral development theory, some interpretations and explanations are
given for the findings of the study."
Komaromy, Miriam. et al. "Sexual Harassment in Medical
Training." The New England Journal of Medicine 4 Feb, 1993; 328 (5):
322-26.
Although sexual harassment has been increasingly recognized in the
medical field, "there is little information on the prevalence of this
problem and whether it is adequately addressed by training
institutions." The authors undertook to examine this problem by
surveying internal medicine residents in a university training program.
73% of the female respondents and 22% of the male respondents reported
"at least one during their training. The women were more likely than the
men to have been physically harassed, and the women's harassers were of
higher professional status." The authors conclude, "Many medical
trainees encounter what they believe to be sexual harassment during
medical school or residency, and this often creates a hostile learning
and work environment. Training institutions need to address the adverse
effects this may have on medical education and patient care."
Crandall, Sonia J. S., Robert J. Volk and Vicki Loemker.
"Medical Students' Attitudes Toward Providing Care for the Underserved:
Are We Training Socially Responsible Physicians?" JAMA 19 May, 1993; 269
(19): 2519-23.
In this study, the authors sought to "investigate the association
between attitudes toward caring for the medically indigent and years of
medical training." They compared the attitudes between first year
medical students (MS-Is) and fourth year medical students (MS-IVs)
through questionnaires at Southwest Medical School. They conclude, "The
MS-IVs are less favorably inclined toward caring for the medically
indigent than MS-Is, though these differences are apparent only for
males. Further research is needed to explore why females appear to be
more resistant to attitude changes, and what educational interventions
are necessary to better train physicians to respond to national health
care issues."
Dwyer, James. "Primum Non Tacere: An Ethics of Speaking Up."
Hastings Center Report Jan-Feb 1994; 24 (1): 13-18.
One oft quoted maxim of medicine is "First do now harm". The author
proposes another- the Socratic maxim: "Primum non tacere. First do not
be silent" particularly to students. As an clinical clerk, a student may
feel intimidated into not asking questions or pointing out things
relevant to patient care. The author argues that this is not acceptable
to either the student or the patient. The benefit to the patient of a
student speaking up is obvious and the benefit of speaking up to the
student is no less important. "It is the work of medical students to
acquire the knowledge, skills, and habits that good physicians need. To
acquire these skills and habits, and even this knowledge, it is not
enough for students passively to observe medical practice and to note
what they will do when they are full-fledged physicians....Habits of
reflection, character, and intervention need to be developed and
exercised if they are to be ready-at-hand in the future." The author
cautions that medical students are not the only ones that need to speak
up. "Speaking up is a problem for everyone in medicine, and those with
more power and authority have a greater obligation to confront the
problem." He concludes, "I guess I am really suggesting that the
practice of medicine needs to become more Socratic. Perhaps medicine
could not function if everyone acted like Socrates- perhaps there would
be too much discussion and too little patient care. Yet I believe that
medicine could function quite well if everyone were a little more
Socratic, a little more willing to raise questions about what is right
and good."
Feudtner, Chris, and Dimitri A. Christakis. "Making The Rounds:
The Ethical Development of Medical Students in the Context of Clinical
Rotations." Hastings Center Report Jan-Feb 1994; 24 (1):
6-12.
There are special ethical dilemmas that students confront when they
enter the hospital as clinical clerks. The authors had a good look at
what these dilemmas are and how they affect the personal ethics of
students as they functioned as fourth-year preceptors of an ethics
mini-course that all students took during their first clinical rotation
in internal medicine. Pressed from above by superiors and an hierarchal
social structure, and from inside from a desire to learn and from
outside by the needs of patients, a student must balance his own place
on the medical team with feelings of inadequacy and fear added to the
personal beliefs and ideals brought to the hospital setting. This, the
authors found out, is what shapes medical student ethics to be uniquely
its own. With in-depth discussions of clinical vignettes, this article
is a well written first hand look into the world of the medical student.
In conclusion the authors point out the lack of adequate ethics training
and "the need to move beyond static conceptions of 'core
values'...Essentially we are arguing that medical ethics education must
consider the meandering and arduous journey that students make on their
way to becoming ethical physicians- that the nature of this odyssey will
shape the kind of doctors they will become. Too much discussion
currently focuses on issues relevant to the destination; more is needed
on the challenges posed by the trip itself. By attending to the
experiences, high and low, that make up the daily rounds of clinical
clerks, and by caring as much about their ethical as their intellectual
development, perhaps medical education could help students to complete
the journey with their humanity and compassion intact."
Fuedtner, Chris, Dimitri A. Christakis, and Nicholas A.
Christakis. "Do Clinical Clerks Suffer Ethical Erosion? Students'
Perceptions of Their Ethical Environment and Personal Development."
Academic Medicine Aug 1994; 69 (8): 670-79.
During clinical clerkships, students may be exposed to situations in
which either they feel an obligation to participate in a believed
unethical act or they observe an unethical act performed by superiors.
The authors undertook to study how "clinical students perceive their
ethical environment, their feelings about their dilemmas, and whether
these dilemmas erode students' ethical principles" by mailing surveys to
third and fourth year students in Pennsylvania. Over half of the
students who responded (58%) reported having done something they
believed was unethical with 62% believing "that at least some of their
ethical principles had been eroded or lost." Also, "students who
witnessed an episode of unethical behavior were more likely to have
acted improperly themselves for fear of poor evaluation." These students
were twice as likely to report ethical erosion. The authors conclude,
"The ethical dilemmas that medical students perceive as affecting them
while serving as clinical clerks are apparently common and often
detrimental, and warrant the attention of physicians, educators, and
ethicists."
Council on Ethical and Judicial Affairs, American Medical
Association. "Disputes Between Medical Supervisors and Trainees." JAMA
21 Dec, 1994; 272 (23): 1861-65.
The quality of medical education is largely dependent upon the
relationships between medical students, residents and their supervisors.
Thus, open and honest communication is necessary in fostering an
environment conducive to learning. "Many of the sources of conflict
between supervisors and medical students, resident physicians, and other
staff can be avoided through open, ongoing communication....Addressing
the concerns that cause disputes between trainees and supervisors,
through adequate communication and the promotion of clear standards of
ethical conduct, will avoid situations in which minor concerns develop
into serious problems." This article, put out by the Council on Ethical
and Judicial Affairs from the American Medical Association, discusses
two issues- "handling disputes between medical supervisors and trainees
through grievance and disciplinary committee proceedings," and "disputes
that cannot wait for resolution through traditional committee
procedures." It ends with guidelines for dealing with disputes.
Sanders, Michael. "The Forgotten Curriculum: An Argument for
Medical Ethics Education." JAMA 6 Sep, 1995; 274 (9):
768-9.
The author, a student at the time of this writing, attending Mount Sinai
School of Medicine, submitted this essay in response to the John Conley
Foundation essay contest entitled "How can medical students best develop
ethical thinking and behavior?" In this paper he calls for medical
schools to take a rigorous approach towards teaching medical ethics and
integrating it into the pre-clinical and clinical years. Specifically,
he proposes two initiatives: (1) putting ethics on the Boards; (2)
establish an ethics department at every medical school. "The first step
would make medical schools want to teach ethics. The second would give
them the necessary means to do so."
Iglesias, Teresa. "Hippocratic Medicine and the Teaching of
Medical Ethics." Ethics and Medicine 1996; 12 (1): 4-9.
There are many diverse bodies of opinion regarding medical ethics. Some
think of medical ethics as a "morally-neutral activity", in which
medicine is regarded like science and where the ethics of individual
practitioners count. However, the author argues that medicine is
inherently ethical and "in this understanding of medicine medical ethics
is regarded as a medically based ethic." Today's legal environment has
created "two strands of medicine, a conscience governed medicine, and a
law governed medicine, whereby the truly ethical self-governed medicine
has disintegrated." In view of this, the author has proposed teaching
medical ethics in the Hippocratic tradition. She focuses in particular
on the third paragraph which, in her words, "reveals to us in a
nutshell, the core of medicine, and so, the core of the Hippocratic
ethics." After analyzing its core points, she concludes, "The Oath, by
upholding and invoking justice, recognizes and upholds an unconditional
respect for the sick and for the physicians' professional and moral
integrity....Here, in my view, we could find the seed of that
non-discriminatory and universal concern for the sick and injured that
medicine upholds."
Green, Michael J., Gary Mitchell, Carol B. Stocking, Christine
K. Cassel, and Mark Siegler. "Do Actions Reported by Physicians in
Training Conflict With Consensus Guidelines on Ethics?" Archives of
Internal Medicine 12 Feb, 1996; 156 (3): 298-304.
Various medical organizations have put out ethical guidelines, including
the American College of Physicians (ACP) in its ACP Ethics Manuel, and
the authors of this study attempted to determine whether its members
were aware of the guidelines and if they followed them. Surveys were
mailed to a random sample of 1000 associates of the ACP (mostly internal
medicine residents) and 40% completed the questionnaire. Only 17% were
aware of the guidelines on ethics and "on average, associates responded
yes to 16% of questions where a yes response indicated they have acted
outside guidelines on ethics one or more times." The authors conclude,
"Few responding ACP associates indicated awareness of the ACP guidelines
on ethics. Physicians in training nevertheless reported acting according
to the presented guidelines most of the time...Physicians in training
need to know more about ethical standards that apply to their own
practice and should be aware when their actions deviated from ethical
norms. Before acing outside guidelines on ethics, trainees should
discuss their conflicts with others, such as attending physicians,
clinical ethicists, or hospital ethics committees."
Swenson, Sara L. and Julie A. Rothstein. "Navigating the Wards:
Teaching Medical Students to Use Their Moral Compass." Academic Medicine
Jun 1996; 71 (6): 591-94.
"The upsurge in formal medical ethics training stems from the desire for
more compassionate, less 'dehumanized' physicians who can competently
face the ethical dilemmas posed by technologic advances and resource
constraints. How best to encourage ethical thinking and behavior among
medical students remains an open question. However, the authors argue
that medical ethics education suffers from an overreliance on strategies
that target ethical thinking, with relative inattention to students as
ethical actors in specific clinical contexts. In order to produce
ethically competent physicians, medical educators must not only teach
students to understand and learn from the dilemmas that shape their
moral world but also train them to respond to those dilemmas
appropriately. The authors discus current practices in ethics education
and how traditional approaches may not equip students with the types of
moral 'navigating skills' they need to become ethical physicians. They
illustrate how medical students can and do learn norms of ethical
behavior on the wards and argue why medical education ought to focus
more explicitly this aspect of clinical training. They conclude by
recommending ways medical educators can encourage ethical thinking and
behavior throughout the entire course of medical training."
Testerman, John K., Kelly R. Morton, Lawrence K. Loo, Joanna
S. Worthley and Henry H. Lamberton. "The Natural History of Cynicism in
Physicians." Academic Medicine Oct Supplement 1996; 71 (10):
S43-45.
The medical school experience often leads a student to develop an
attitude more cynical than when one started. Termed "traumatic
deidealization" this cynicism has been documented. However, "no previous
studies reporting cynicism in medical students have employed an
empirically validated instrument that measures cynicism specifically in
the medical domain." The authors developed the Cynicism in Medicine
Questionnaire and gave it to medical students, residents and faculty to
fill out. Using the results, they compared two different previously
proposed models on how cynicism develops in students. They found that
medical students were the most cynical, with a decline through residency
to the lowest levels found among faculty physicians. They conclude, "The
data support our proposed 'professional identity' model, which
attributes cynicism among medical students to their struggle to develop
coping skills while trying to survive the complex challenges of the
medical education environment. Medical students begin their training
with altruistic motives and idealized concepts of health care. As
inexperienced and powerless members of the health care team, however,
students may develop cynicism as a means to manage their
environment….As physicians-in-training develop greater confidence
and skills and achieve greater status in the health care team, they
become more adept at tolerating ambiguity, synthesizing information, and
analyzing ethical situations. In achieving this balance, they become
less cynical and more optimistic in their professional identities."
Erde, Edmund L. "The Inadequacy of Role Models for Educating
Students in Ethics With Some Reflections on Virtue Theory." Theoretical
Medicine Mar-Jun 1997; 18 (1-2): 31-45.
"Persons concerned with medical education sometimes argued that medical
students need no formal education in ethics. They contended that if
admissions were restricted to persons of good character and those
students were exposed to good role models, the ethics of medicine would
take care of itself. However, no one seems to give much philosophic
attention to the ideas of model or role model. In this essay, I
undertake such an analysis and add an analysis of role. I show the
weakness in relying on role models exclusively and draw implications
from these for appeals to virtue theory. Furthermore, I indicate some of
the problems about how virtue theory is invoked as the ethical theory
that would most closely be associated to the role model rhetoric and
consider some of the problems with virtue theory. Although Socrates was
interested in the character of the (young) persons with whom he spoke,
Socratic education is much more than what role modeling and virtue
theory endorse. It -that is, philosophy- is invaluable for ethics
education."
Dawson, Drew, and Kathryn Reid. "Fatigue, Alcohol and
Performance Impairment." Nature 17 Jul, 1997; 388 (6639):
235.
How much does lack of sleep really affect one's cognitive skills? In
this study, the authors set out to compare the effects of lack of sleep
against the effects of alcohol, a known and measurable quantity. They
found that after 17 hours of sustained wakefulness "cognitive
psychomotor performance decreased to a level equivalent to the
performance impairment observed at a blood alcohol concentration of
0.05%" and after 24 hours of sustained wakefulness "cognitive
psychomotor performance decreased to a level equivalent to the
performance deficit observed at a blood alcohol concentration of roughly
0.10%." The authors conclude, "Our results underscore the fact that
relatively moderate levels of fatigue impair performance to an extent
equivalent to or greater than is currently acceptable for alcohol
intoxication."
Orr, Robert D., Norman Pang, Edmund D. Pellegrino, and Mark
Siegler. "Use of the Hippocratic Oath: A Review of Twentieth Century
Practice and a Content Analysis of Oaths Administered in Medical Schools
in the US and Canada in 1993." The Journal of Clinical Ethics Winter
1997; 8 (4): 377-88.
Although the origins of the Hippocratic Oath is disputed, few would
contradict the fact that it has been a major force in shaping the
ethical nature of medicine. With the rise of ethics as a discipline,
debate now centers on "whether the Hippocratic Oath or newer
alternatives oaths are preferable statements of the ethical basis of
modern medicine." Research by these authors show that while the
tradition of administering an oath to graduating medical students "has
steadily increased during this century", the content of the various
oaths administered differ both from one to another and from then to now.
In order to study how the contents of oaths administered differ, the
authors mailed surveys to all the schools in the U.S. and Canada in
1993. Out of the 150 schools that responded, only one still used the
classical version of the Hippocratic Oath, while 68 other schools (46%)
used some other form of it. Excepting for three schools (2%) that didn't
administer oaths, the rest of the schools used an alternative oath. In
analyzing the content of the different oaths, the authors found that
"When compared to the contents of the classical Hippocratic Oath,
currently used oaths are less likely to agree to be accountable, invoke
a deity, or foreswear euthanasia, abortion, or sexual contact with
patients." They concluded, "We document with some concern this dilution
of the core values of Hippocratic medicine."
Coles, Robert. "The Moral Education of Medical Students."
Academic Medicine Jan 1998; 73 (1): 55-58.
"The author begins his essay by discussing George Elliot's novel
Middlemarch, in which a doctor, early in his career, wanders from his
idealistic commitment to serving the poor. Although he establishes a
prominent practice, he considers himself a failure because 'he had not
done what he once meant to do.' The essay explores how many of us
(physicians included) forsake certain ideals of principles- not in one
grand gesture, but in moment-to-moment decisions, in day-to-day
rationalizations and self-deceptions, until we find ourselves caught in
lives whose implications we have long ago stopped examining, never mind
judging. Medical education barrages students with information, fosters
sometimes ruthless competition, and perpetuates rote memorization and an
obsession with test scores- all of which stifle moral reflection. Apart
from radically rethinking medical education (doing away with the MCAT,
for example, as Lewis Thomas proposed), how can we teach students to
consider what it means to be a good doctor? Calling upon the work of
Eliot, Walker Percy, and others, the author discusses how the study of
literature can broaden and deepen the inner lives of medical students
and encourage moral reflectiveness."
Daugherty, Steven R., C. Baldwin DeWitt, and Beverley D. Rowley.
"Learning, Satisfaction, and Mistreatment During Medical Internship: A
National Survey of Working Conditions." JAMA 15 Apr, 1998; 279 (15):
1194-99.
Many studies have been done regarding the first year of residency or
internship in terms of income and long hours, but these have "shed
little light on how residents view their training experience." The
authors undertook to randomly survey 10% of all second-year residents
listed in the American Medical Association's medical research and
information database on six criteria in order to learn more about the
internship experience. They conclude, "Residents report significant
problems during their internship experience. Satisfaction with
internship is enhanced by positive learning experiences and lack of
mistreatment."
Marracino, Richelle K. and Robert D. Orr. "Entitling the Student
Doctor: Defining the Student's Role in Patient Care." Journal of General
Internal Medicine April 1998; 13 (4): 266-70.
As medical students approach their clinical years, there is
often a temptation to misrepresent oneself as "Doctor". A serious
ethical dilemma for students, this article analyzes the assumptions that
could lead a student to rationalize deception, identifies the underlying
problem and then proposes appropriate solutions. The authors conclude,
"The goals of adequately informing the patient and receiving adequate
medical training are not mutually exclusive; quite the contrary,
adequately informing and communicating honestly with the patient provide
the integral foundation on which clinical training, patient interaction,
and ethical awareness are built."
Bibliography
Asch, David A., Ruth M. Parker, Timothy B. McCall, Norman G.
Levinsky, and Robert M. Glickman. "The Libby Zion Case." The New England
Journal of Medicine 24 Mar, 1988; 318 (12): 771-82.
The Libby Zion case unleashed a storm of fury and
fault-finding, two of the targets being residents' work hours and
adequate supervision of house officers. In its Sounding Board section,
the NEJM published four articles from five doctors analyzing and
proposing solutions to the problems that conceivably led to this
tragedy.
Crevier, Bill. "Medical Education and Medically Neglected". CMDS
Journal Winter 1990; XXI (4):19-21.
In this article the author points out the shortage of
physicians in rural and inner city areas and blames medical education
and residency training for discouraging "physicians from becoming
seriously involved with health care for the poor." He concludes by
outlining remedies for overcoming the common obstacles posed to
students, residents and doctors who want to practice in an underserved
area.
Biebel, David B. "Good Mentors Make Good Doctors" Today's
Christian Doctor Spring 2000; XXXI (1):12-16.
Using Loma Linda University's mentoring program as an example, David
Beibel describes the need for Christian physician mentors. He goes on to
outline the underlying principles of an explicitly Christian mentoring
program, stressing one not need be part of an established program to
make a difference in a medical student's life.
