Bioethics Discussion Blog: Your Job as Experienced Patient is to Teach Medical Students Ethics and Ethical Behavior

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Friday, July 20, 2007

Your Job as Experienced Patient is to Teach Medical Students Ethics and Ethical Behavior

Pretend that you have been given the responsibility to prepare and teach an ethics course for medical students. Your duty would be to provide the students who are learning how to become doctors with the key ethical issues that they may face as they go out into practice. You must also provide them with the knowledge and tools which they need to make fair ethical decisions and be, themselves, ethical. The goal is for all the medical students under your wing to end up as moral, ethical physicians who are free from misbehavior and who are looked upon with trust by their patients and by their medical colleagues. We are all calling for doctors who are good, do good and are honest and trustworthy to care for us and our families. Now, here is your chance, based on your own experiences, to set down in writing what you are going to instruct them and how they will be able to develop the behavior benchmarks that you are setting for them.


You might say to me, "It's hopeless. Students are either ethical or they are not when they come to medical school. Education is not going to help the one's who are not." Really?
You might say to me, “I am not a physician, philosopher or a teacher..I am only a patient!” Don’t give up on this challenge. The approaches suggested by experienced patients to teaching medical students ethics and ethical behavior may be more constructive and realistic then what is coming from our current medical school teachers. Give it a try. Medical school classes for the first and second year students begin in just a month and we have to get an ethics program started now. Even if you respond after classes begin, we can always change course. Remember, setting the students on the right path is more constructive than later just complaining about them as physicians and mumbling “I hate doctors”. ..Maurice.

11 Comments:

At Sunday, July 22, 2007 6:20:00 AM, Blogger MY OWN WOMAN said...

I am in the medical profession, my father is not. He had a primary care doctor who, when I was in the room, talked to me about my father's medical conditions and not to him. All his comments, directions and concerns were directed to me. Every time we would leave the doctor's office, my father would say, "Does the man think I'm an idiot that he can't talk to me? I'm the patient, not you. I hate when he doesn't talk to me."

I spoke with this doctor about this but Dr. "X" told me it was just easier to tell me so I can tell my father in detail later; thus the practice continued. My father changed doctors.

His present doctor talks and listens to my father even if I happen to be in the room. He also asks my father if he understands everything that has been said. Then he will ask BOTH of us if we have any questions.

Please, if you hear just one thing from me, his this: If the patient can understand, talk to him/her. Don't take the easy way out and talk to the patient's family who just happens to be a nurse, or a doctor.... or... I think you get my drift.

 
At Sunday, July 22, 2007 9:40:00 PM, Anonymous Anonymous said...

Dear Maurice,

Thank you for this opportunity.

Rather than learning issue by issue (since a person cannot forsee all possible issues that may arise), I would focus on the "knowledge and tools" that the student needs to prevent unethical behaviour. One of these tools/knowledge would be an awareness of the *process* by which normal people do evil (unethical behaviour).

I have been recently reading: "Extraordinary Evil: a brief history of genocide"
by Barbara Coloroso.

You might ask what this has to do with doctors, but she does a very clear and systematic analysis of how people/groups slide down that slippery slope towards extremes. I don’t wish to equate all doctors with such incredible evil, nor minimize the tragedies of which she writes. However, I would like to argue that doctors are perhaps more vulnerable to what she describes, and the process she describes starts somewhere. Even in these beginnings there are lessons for all of us to learn.

One of the first steps is *contempt*, a feeling we all are guilty of. As I was reading her deconstruction of contempt, I realized it was an accurate word to describe the way I have been treated by some doctors. And it was their contempt that hurt and really made me angry.

Contempt can be very obvious and very subtle. Paraphrasing/quoting Coloroso’s analysis, she defines contempt as a feeling of dislike toward somebody considered to be worthless, inferior, or undeserving of respect. Stereotypes (thoughts), prejudices (feelings), and discrimination (action) are used to validate ones contempt for others. Contempt ranges from disregard to scorn to cold hate. It is the devaluation of another human being to the point of placing them outside the web of moral obligation.

The "apparent" psychological advantages of contempt are:
- a sense of entitlement (privilege and right to control, dominate, subjugate and abuse)
- an intolerance towards differences (different = inferior = not deserving of respect)
- a liberty to exclude (isolate, segrate, ostracize)

She says that it is an "apparent" advantage because these advantages are built on the false assumption that some humans are more human than others (superiority). Doctors are often accused of being arrogant (feelings of superiority).

Other things along the path that contribute to people behaving badly that are mentioned in the book are membership in a group (comradeship), imbalances of power, and the breakdown of moral inhibition. Paraphrasing again, moral inhibitions are broken down by
- unquestioning obedience to authority that relieves people of personal responsibility
- routinization of cruelty (cruel actions are normalized)
- dehumanization

Everyone of us can follow along this path to various degrees. Not just doctors. We all have to be conscious of the PROCESS of how we become unethical, the internal
and external messages, thoughts and actions that lead ordinary people to do great and little evils. I want to argue that certain characteristics about the medical profession and doctor/patient relationships perhaps make doctors more vulnerable to unethical behaviour of both the mild and extreme forms.

First there is the imbalance of power in the doctor/patient relationship. There is the dehumanization of the patient that occurs overtly or just because of the nature of the health system and its interaction with sick people. There is the sense of entitlement that society gives doctors and doctors learn at medical school I have been told. Also, at medical school and as part of a profession, there is the group think (comradeship), that can contribute to the creation of a certain unhealthy doctor mindset. And, there are probably more parallels I could draw, like the stereotyping, prejudices and discrimination.

So, my recommendation for an ethics class would be a study of contempt, arrogance, stereotyping, prejudices, discrimination, dehumanization, power relationships, group think, group behaviour, etc. in the students’ own experiences and attitudes, in hospitals, waiting rooms and examination rooms. How it happens on small scales and large scales, in mild forms and extreme forms.

 
At Sunday, July 22, 2007 10:42:00 PM, Blogger Maurice Bernstein, M.D. said...

Excellent recommendations by Anonymous from today. Do you think My Own Woman's father was treated by Dr. X with a form of contempt possibly because the patient did not appear as medically sophisticated as the family member or was contempt not the behavior but was done for efficiency, since communication with a more medically sophisticated individual would transmit the message in the least amount of time. Either way, this represented poor professional practice of humanistic medicine. ..Maurice.

 
At Monday, July 23, 2007 7:51:00 AM, Anonymous Anonymous said...

With the doctor shortage, doctors are under time pressures. The first doctor could very well have made a value judgement for himself that time is more important than civility. From my point of view, I don't see this as contempt, or at least the same kind of contempt that I am speaking to above. It does raise another topic for an ethics course: how lack of time and job stress can lead to unethical behaviour and the things doctors can do to take care of their physical, mental and spiritual health to prevent meltdown.

Frankly, the more I learn about doctor's lives and the health care system, I really wonder how many students know what they are getting themselves into. Are they entering this profession with some half-baked notion of what it is to practice medicine? An ethics class could maybe include a reality check. Because when reality doesn't match the new doctor's ideals of a career path in which he/she has invested a great deal of time, effort, money, personal identification, and commitment, I think a potentially very unhealthy situation is created for patients, doctors and their families.

 
At Sunday, July 29, 2007 10:14:00 AM, Anonymous Anonymous said...

Another suggestion:

Many patients and patient behaviours can be frustrating for doctors on a daily and hourly basis. Other doctors have skills for dealing with these frustrating behaviours, while maintaining and showing respect for the same patient. It would be worthwile to learn how this second group of doctors accomplishes this. I wouldn't be surprised if it's in the way they frame or re-frame the situation. Which is partly about adjusting one's attitude(s) about the patient and about the patient's behaviour.

Would it be possible to find doctors from this second group, talk to them about this, figure out what these skills are and teach them to new medical students? Such an exercise might involve bringing such model doctors into the classroom, or doing role playing of patient/doctor encounters.

 
At Sunday, July 29, 2007 12:53:00 PM, Blogger Maurice Bernstein, M.D. said...

As I may have noted somewhere on my blog, the ethicist, Dr. Robert Veatch, has shown the way toward the best doctor-patient relationship would be for the patient to discover a physician for themselves who bear similar religious and moral beliefs, culture, general goals and temperament as the patient. I am not sure how practical this matching of patient to doctor is in these days of medical care. Nevertheless, through trying out different doctors, eventually some matching may occur.

Therefore, Anonymous from today, do you think that doctors from the second group you identified, are simply just better matched to their patients and really do not bear some special skills compared with the first group? ..Maurice.

 
At Monday, July 30, 2007 8:56:00 AM, Anonymous Anonymous said...

"do you think that doctors from the second group you identified, are simply just better matched to their patients and really do not bear some special skills compared with the first group?"

No, not at all.

Lots of people work in occupations where they have to deal with all
kinds of personalities and behaviours. One way to approach difficult encounters is to tackle the problem, and not make the other person into the problem.

A very minor example to explain this: I went to a new doctor. I brought 3 pages of my history and symptoms because I was getting tired of repeating myself and trying to remember it all. I bring out the pages and the doctor immediately responds with a mild insulting comment. I just met this guy one minute ago, he just met me. I ignore the comment, but I'm wasn't expecting this, so I have nothing prepared to turn this appointment around from this negative beginning.

This doctor has brought what is -his- problem into our meeting. My actions triggered negative thoughts in his head. I couldn't have known that. And instead of dealing with -his- problem, he puts me down verbally.

Some of the discussions these days are about teaching doctors to think about how they are thinking. The reviews I've read of Dr. Groopman's book for example, talk about this for preventing diagnostic error.

It would also help doctors to be aware of the prejudices and
stereotypes and assumptions they are using, how their tone of voice or choice of words reveal their prejudices. If the patient is irritating you as a doctor, be aware of this, figure out why, and develop more constructive ways to deal with it. It is the doctor's problem, and yet too many times, the doctor deals with it by attacking the patient, rather than the patient's behaviour or the limitations of the health system that both doctor and patient have to work within.

In the example I gave above, this doctor could have responded in many better ways. But of course, he's got to be sincere about it. This involves reframing the problem: the sheets of papers and the doctor's anxieties are the problem, not the patient.

"Please forgive me, but I get ______ when a patient brings out sheets of paper." (acknowledges that it is -his- problem, not the patient's)

"I appreciate the time and effort you took to prepare this"

"I'm sorry, I don't have time to read and discuss this in the appointment time today. What is the most important concern today for you that we could discuss in the time we have?"

"This is great to have this information organized. What would be even better is if you could in the future, send me this before the appointment so I have time to read it"

"May I keep it and look at it? Then, if you don't mind scheduling another appointment, we could spend more time on it".

Patients are not going to stop bringing in pieces of paper to their appointments. If doing so continually causes negative responses in the doctor, well, that doctor has a problem. He needs to figure out why it bothers him, and come up with constructive ways of dealing with it. This involves being aware of his thoughts and feelings.

I think this kind of thing can be modelled and taught. These aren't special or unusual skills only to be used in a doctor's office. I think this could be classified as Psychology 101 stuff. And I've seen doctors and non-doctors who are exceptional at it. But we can all learn to some degree. It involves seeing the patient as another human being, not as an annoying problem.

 
At Monday, July 30, 2007 10:21:00 AM, Blogger Maurice Bernstein, M.D. said...

Anonymous, I think your example of a physician's response represents a problem of control. Medical students are taught that the consultation with a patient is all about the one on one interview. When a physician starts to interview a patient, it is the physician who expects to ask the open-ended first question, listen to the response and then ask more direct questions to gain further details. The physician would like to organize and control the question asking process. When a patient starts off by handing the physician a bunch of papers with the narrative of the history or just notes, it shows that the patient wants to control the inititation of the doctor-patient communication. To many busy physicians, this unexpected denial of their own control may be unacceptable to them and that is the basis for the negative response. One of the problems in reading a bunch of papers is trying to parse out the significant parts of the story. It is easier when the patient is verbally telling the story to have the patient stop and explain something the physician doesn't understand. Finding for the patient's inspection and pointing out the confusing portion of a written document is more difficult and more time consuming.

The issue of who controls the beginning of the relationship should be anticipated by both the physician and patient. The nominal control of the process of the visit, by virtue of the fact that the patient has initiated a consultation by the physician, usually would be by the consultant. However, as the consultation progresses and the two become more familiar with each others needs, how the process of interview and examination continues will be modified with the physician accepting more control by the patient. But it is hard to believe that the doctor will give up control when the patient first walks into the office.I agree that how the physician responds to the patient regarding this unexpected and undesired beginning to the relationship is very important and if improperly done can lead to termination of the relationship. Your suggestion for response are all appropriate.

I also agree that it might be useful to have the written history provided the doctor well in advance of the appointment so hopefully the doctor will read this introduction and be more prepared to grasp what the patient will be telling the doctor verbally.

Anonymous, you know..today you have brought up a very important aspect of doctor-patient relationship (issues of control in the initiation of the visit) that we really have not brought out in the teaching of clinical medicine to the first and second year students when discussing beginning the interview. Thanks for the heads up. ..Maurice.

 
At Sunday, August 05, 2007 8:27:00 AM, Anonymous Anonymous said...

"Anonymous, I think your example of a physician's response represents a problem of control."

I would agree with that. And perhaps a lot of physician/patient problems are about power and control. I think that doctors focussing on control could be creating more problems than helping. I hear doctors complaining about patients who don't follow doctor's orders. If doctors expect this, they are really naive, and don't understand human behaviour. They are always going to be frustrated and angry if they don't come to terms with such issues.

In the example I cited, if the doctor felt I had taken control at the start and if this was of critical importance to him, he had plenty of opportunity to change that as I noted in my previous post. Your dissection of the process seems to be justifying the doctor's poor response. If such a small thing (i.e. showing him 3 pieces of paper) throws him off balance, I can't imagine what he would be like in serious situations where the patient might be belligerent or drug-seeking or mentally incompetent.

As a patient I have experienced all kinds of styles of initial doctor-patient communication and taking of history and symptoms. There's no consistency, but I am co-operative and accommodating if I know what is being expected of me.
I say it half seriously, but doctors ought to issue their patients instruction manuals if they don't like what the patient does. Patients don't know what's going to upset the doctor. How does the patient know it's not what they are wearing or how they look or talk, or the doctor's prejudices that have set him off.

I read somewhere that patients try to prevent three things inherent in the healthcare system: depersonalization, loss of control and lack of knowledge. I would consider it normal and healthy for a patient to try to prevent these things from happening to them. But the behaviours they use to prevent this go against how a "good" patient is supposed to behave.

I think it is absurd to expect patients to be passive blobs who only speak when asked a question. To pretend that they have never used the internet or read a medical journal or formed an opinion about what they think their health problem is, or how it might be treated.

 
At Sunday, August 05, 2007 7:41:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous brought up the issue of a "good patient". I thought that was so important that I have created a new thread on just that subject. Let's go there to discuss what makes up a "good patient" both from the viewpoint of patients and from the viewpoint of healthcare providers. Perhaps we can discuss there in more detail how to eliminate the conflicts in definition if possible. Let's continue here on any additional tools to teach medical students about ethics and ethical behavior. ..Maurice.

 
At Tuesday, August 07, 2007 6:22:00 PM, Blogger LisaMarie said...

There's no such thing as a right to exert power and control over other people (unless, perhaps, they happen to be your children). Therefore, it's not something you earn just because your educational attainment is high. It may all be true that you spent years in school, you owe a lot of debt, you feel like you get no respect, insurance reimbursements are too low, your practice doesn't make any money, your malpractice premiums are through the roof, you just got sued, etc. These things suck, but power and control in the doctor-patient relationship is not some kind of reward that you get for putting up with it. The fact that some doctors think it is might explain why patients complain so much about doctor-patient relationships. Ethical education for students might include exploring how their own beliefs and issues about power and control can play out in a therapeutic relationship, and how to handle that appropriately.

 

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