Here is a summary of seven opportunities I have been privileged to experience over the past 25+ years within the medical education/practice sphere. I continue to draw deeply from these ‘on the field’ ways to participate in the promotion of respectful, humane, and socially sensitive patient care as I seek a very healthy center by/through which to ‘see from below’.
1. Residency Education/Training
Tom Elkins, MD, (1949-98) recruited fourteen fulltime medical faculty members to join him in rebuilding the LSU Obstetrics and Gynecology Department’s residency program and establishing its social conscience. I was brought on board first as an adjunct faculty member (1992-94) and then as a fulltime faculty member (1994-97) with the following responsibilities as the department’s residency program coordinator and as an imbedded ethics educator.
Ethics education. I was brought on board with the specific assignment to create an ethics program that would clarify and enhance his vision for the department. With the assistance of numerous medical faculty members and residents in the department, we created and field-tested a survey instrument that was administered at the beginning, the mid-point, and the end of the four-year residency program. The data gathered using the survey instrument assisted in resident evaluations as well as provided discussion points for didactic sessions. We integrated a series of ethics seminars into each year’s teaching schedule. We concentrated on the professional maturation of the younger medical faculty members since they spent more time than others with the residents in patient encounters.
Resident rotations. My responsibilities included (but were not limited to) (1) reviewing/revising the four-year rotation templates to the three teaching sites to insure uniformity, (2) assigning residents (with the necessary written and oral communications) to the appropriate rotations, (3) arranging for transitions at each three-month rotation shift for 2nd and 3rd year residents (with orientation meetings for all incoming residents), (4) updating the weekly schedule (clinic assignments, conference times, operating assignments, labor/delivery coverage), (5) monitoring/revising intern rotations to meet the RRC primary care requirement, (6) updating the clinic staff re the residents assigned to New Orleans, (7) gathering/reviewing evaluations of off-service and elective rotations, (8) adjusting all schedules when rotation assignments were changed, (9) writing communications to chairpersons/program directors of departments with which our residents had off-service rotations.
Clinics. My responsibilities included (but were not limited to) (1) meeting at least every other week with the supervising medical faculty, the chief residents, and the clinic’s head nurse to trouble-shoot clinic needs, (2) maintaining (with regular revisions) the schedule of faculty assignments to clinic coverage, (3) preparing reports on faculty attendance assigned to the clinics in order to comply with the required 1:4 faculty-resident ratio, (4) answering staff and resident inquiries about faculty coverage assignments, (5) arranging for replacements when emergencies or oversights kept assigned faculty members from being in clinic, (6) creating/circulating continuity-of-care clinic dates for each resident projected over six month periods, (7) keeping updated lists of the residents’ panel of continuity-of-care clinic patients, (8) preparing communications for and conducting meetings with residents to insure their understanding of the continuity-of-care clinic format and process, (9) supervising the clinic worker who had as part of her work responding to the on-site needs of the continuity-of-care clinics.
New interns. My responsibilities included (but were not limited to) (1) contacting faculty members and residents about their availability to interview applicants, (2) forming interview teams for each interviewing session, (3) making sure preparations had been made for each interviewing session (e.g., rooms, food, handouts, folders for interviewers, hospital/clinic tours), (4) preparing schedules for each interviewing session, (5) writing letters to applicants, (6) conducting each interviewing session, (7) participating in the interviewing of applicants, (8) updating the handout circulated to applicants, (9) organizing the three-day orientation schedule for incoming interns (including at least two hours of my own meetings with the new interns), (10) preparing explanatory handouts for incoming interns, (11) arranging for mentors for incoming interns.
Statistics. My responsibilities included (but were not limited to) (1) (re)educating residents on the proper interpretation of statistical categories and on the importance of accurate/complete documentation, (2) revising the obstetrics and gynecology statistics forms used in all teaching sites, (3) making sure adequate supplies of these statistics forms were available in all teaching sites, (4) making sure primary care cards were being filled out, collected, and tabulated for all residents, (5) supervising the collection and computer-entry of all obstetrics and gynecology statistics forms, (6) updating tabulations quarterly on each resident’s obstetrics and gynecology procedure statistics, (7) circulating updated tabulations to each class of residents for their review and correction, (8) arranging for the updating of the computer software designed for data entry of obstetrics and gynecology statistics information, (9) making sure the obstetrics and gynecology statistics reports for the monthly department conferences were prepared, copied, and circulated, (10) preparing statistics reports on each resident for program director and Education Committee review.
Resident evaluation. My responsibilities included (but were not limited to) (1) scheduling and conducting the monthly meeting of the Resident Evaluation Committee, (2) preparing a detailed summary of each meeting for the program director (including extensive commentary on residents about whom the committee had significant concern), (3) reviewing this summary with the program director and devising remedial plans for the residents so identified by the committee, (4) participating in the remedial plans for some residents and insuring that all remedial plans were completed, (5) supervising the transfer of student evaluation scores into resident evaluation folders, (6) reviewing at least twice yearly each resident’s evaluation material and meeting with residents whose evaluations were of concern, (7) observing residents in clinic, on labor/delivery, in the operating room, (8) visiting residents in Baton Rouge and Lafayette, (9) collecting evaluations on residents assigned to Baton Rouge and Lafayette, (10) preparing various analyses of CREOG scores for assessment of strengths/weaknesses in fund-of-knowledge among the total residents, among residents by level, and for each individual resident.
Faculty evaluation. My responsibilities included (but were not limited to) (1) revising evaluation forms, (2) scheduling regular resident evaluations of each medical faculty member, (3) supervising the transfer of resident and student evaluation scores into faculty evaluation folders, (4) reviewing at least twice yearly with the chairperson and program director each faculty member’s evaluations, (5) forming and implementing recommendations for remediation as indicated by the evaluations, (6) implementing strategies for faculty enrichment (e.g., teaching methods, professionalism, ethics/humanities).
Didactics. My responsibilities included (but were not limited to) (1) meeting with members of the Education Committee in order to schedule the Monday afternoon teaching conferences for the academic year, (2) scheduling Grand Rounds for the academic year, (3) making sure preparation was complete (including assigned faculty to conduct the conferences) for the monthly obstetrics and gynecology statistics and morbidity/mortality conferences, (4) making sure preparation was complete for the monthly gynecologic pathology conference, (5) juggling the weekly schedule of presentations as/when unexpected conflicts kept speakers from fulfilling their assignments, (6) keeping attendance records for residents and faculty, (7) evaluating conference presentations, (8) monitoring the quality of instruction -- faculty to resident and resident to student -- in the work settings at all three teaching sites, (9) upgrading the library resources available to residents, (10) arranging for the selection of residents to attend various professional meetings, (11) scheduling special didactic series (e.g., fetal monitoring sessions for the interns and 2nd year residents).
Department research. My responsibilities included (but were not limited to) (1) arranging for meetings of the Research Committee, (2) participating in the Research Committee’s meetings and related activities, (3) keeping each resident on the established time line -- from internship to Resident Research Day presentation -- for the program’s research requirement (e.g., regular meetings with the Research Committee, 3rd year resident presentations in the Monday afternoon conference schedule, 4th year resident presentations at Grand Rounds).
2. Miami Intervention Project re Cocaine-abusing Mothers
I worked closely with Emmalee Bandstra, MD, a neonatologist with the University of Miami, during the first five-year funding cycle when she was the principal investigator for two projects involving in combination 300+ cocaine-abusing mothers who had delivered cocaine-exposed babies. Those women and their children lived in Overtown and Liberty City, two of the most poverty-stricken and violent sections of Miami. My responsibilities included (1993-97) guiding the evaluation process, (re)interpreting the vision and hypotheses, refreshing the overly stressed staff, framing ethical issues, and writing the mothers’ life-narratives. The target population –
Individual Factors. These women and their children were at serious risk to undervalue education, to see women treated as inferior to men, to absorb the language and assumptions of racial prejudice, to underutilize primary health care services, to lack proper nourishment, to thirst for genuine attention, to cease to dream. Childlike resiliency, concreteness, and a sense of humor insulated them somewhat from the full impact of their circumstances.
Family Factors. These women and their children were at serious risk to bear parenting responsibilities for younger siblings, to suffer physical and/or psychological abuse, to witness/experience domestic violence, to not know one or both parents, to lack family support for educational achievement, to never have celebrated a birthday, to feel betrayed, to regard adolescent pregnancy as normal. The incidence of adolescent pregnancy could, ironically, be reinforced by family members (whose behavior toward the pregnant girl often became dramatically more gentle and affirming) and by the expanded availability of societal resources. Many of these women desperately wanted to retain parental responsibility for their children. Few, if any, wanted their children to experience their way of life. Extended family members (esp., grandmothers) often shielded their children from at least the most severe disadvantages and conveyed to them that they were loved and wanted.
Education Factors. These women and their children were at serious risk to have attended school irregularly, to have been taught by demoralized teachers, to have attended improperly equipped schools, to have formed poor study habits, to have had discipline problems, to have lost their intellectual curiosity.
Peer Factors. These women and their children were at serious risk to form relationships based on ‘macho’, to link self-image to strength, to resort quickly to violence when in conflicts, to be taunted toward destructive misbehavior, to be suspicious of others, to find street-gangs attractive. Community-based athletic programs, religious organizations, substance-abuse support groups (e.g., TRUST Groups), and community-based social organizations (e.g., Big Brother/Sister, YMCA/YWCA, Boys/Girls Club) made constructive peer relationships at least a possibility.
Neighborhood Factors. These women and their children were at serious risk to lack a sense of pride in their community, to live in deteriorated housing, to change residence frequently, to regard violence as normal, to have a street name, to ‘work’ on a lower rung of the drug-world ladder, to have a family member and/or neighbor who had died a violent death or who had AIDS, to regard the police as the enemy. Their neighborhoods did vary in the degree of risk they posed. Even in the most hostile neighborhoods, local groups -- some formally established, others ‘street-organized’ -- could be found working to insure a measure of safety and encouragement for these women and their children.
Society/Media Factors. These women and their children were at serious risk to have no sense of membership in the larger society, to have never visited other parts of the city, to have learned by watching closely the adults around them how to ‘work the system’, to have a surreal worldview shaped by television, to be influenced by militant music, to place no value on newspapers or news magazines. Harsh predispositions against them, widespread in the larger society, made interactions across social lines predictably adversarial. Sustained efforts to introduce resources and options (e.g., businesses, vocational institutes, and community colleges) could be found attempting to create fresh start opportunities.
Shortly after the proposal was funded, two medical school collaborators abruptly abandoned Dr. Bandstra’s leadership team, pulling critical legs out from under the project. Then Hurricane Andrew slammed through Miami, leaving the city in utter chaos. Six months later, signs of recovery in the city were still scant. With the cocaine-abusing mothers scattered by the storm and difficult to locate, Dr. Bandstra’s turf battles with other researchers intensified. And her case management staff had completely turned over.
My first task was to help Dr. Bandstra and her staff regroup. We went back to basics. Could they answer the five questions of a mission statement – i.e., Who/what are we? What do we do? For whom? To what end? By what values? – with wording that had centripetal force? Only then could we determine what (if any) goals were still feasible.
We proposed to rebuild the intervention project around writing life narratives with/about the mothers. Each mother’s story was badly broken. But it was her story. And we were convinced there was more to each mother than her cocaine-addiction. Each narrative developed around the same set of questions. Who is this mother? What does she value? How does she make sense of her experiences? In what social context does she live? How does she view parenting? What aspirations does she have for herself? for her child/ren? How does she define key words (e.g., hope, joy, success, power, freedom, fear)? How does she view her involvement with drugs (e.g., a fact, a recreation, a coping mechanism, a threat to well-being)? Does she want to be drug-free? Does she want her child/ren to be drug-free? What barriers does she face? Why does she try or not try to benefit from available resources? Why do her attempts succeed or fail? How does she define success or failure?
3. Neonatal Intensive Care
Sheldon Korones, MD, a pioneer in the formation of the neonatal subspecialty, is founder and 1968-2005 director of the University of Tennessee Memphis neonatal ICU. He was my closest friend during the last two and most difficult years of my first wife’s fight against multiple sclerosis (d. 1987). Our collaborative relationship began during a 1985-86 sabbatical I spent with Dr. Korones and his NICU staff. The many hours in the unit allowed me to learn much from and about the nurses as well as from Dr. Korones and his physician colleagues. Dr. Korones and I have worked together on various ethical issues peculiar to neonatal medicine. However, our primary work together continues to be writing his professional biography. We have given particular attention to his experience beginning with his Yiddish grandfather’s immigration in 1901 from Czarist Russia to New York’s Lower East Side and ending with his 1967 decision to leave a lucrative private pediatric practice in Memphis in order to devote his career to the socially disadvantaged babies in inner-city Memphis dying two-to-three times the rate of socially advantaged babies in the Memphis suburbs (a decision he traces to his childhood impressions from his grandfather’s stories of Czarist oppression against the Jews). The research related to this project deepened my appreciation for Jewish history/culture and continues to anchor my search for an approach to ethics and spirituality that recognizes/supports every professional’s integrity.
4. Primary Care for Rural and Uninsured Families
David McRay, MD, leads three community health clinics located in counties along the eastern Kentucky-Tennessee state line. These clinics exist to extend health care -- without regard to ability to pay -- to families whose geographic and cultural isolation leaves them far removed from standard medical care. In both part-time (1994-97) and full-time (1997-2007) affiliations with Dr. McRay and the health center he leads, my responsibilities have centered on refining the organization’s vision and hypotheses, prompting the physicians’ professional motivations, framing the ethical issues they face, coordinating resident and student rotations, extending the health center’s involvement with public health issues, and writing narratives about the clinics’ patients.
I had first visited this East Tennessee/Kentucky Appalachia health center a few months before our move from Vermont to New Orleans. I had been invited to return every six weeks or so to spend long weekends with the medical staff members and their families as they attempted to embrace the experience of living among and practicing with disproportionate attention to poor/uninsured Appalachia families. They recognized the need for a simple yet potent statement of mission that would center/steer the health center’s direction, decisions, actions by answering five questions – (1) What are we? (2) What do we do? (3) For whom do we do what we do? (4) To what end do we do what we do? (5) By what values do we do what we do? After reviewing stacks of health center material and interviewing numerous representatives, I deduced a first draft. On each of my visits over the next eighteen months, I listened carefully as the participants in the process of crafting a statement with ‘pause effect’ pressed every word in the latest draft. Between visits I would circulate yet another revised draft. Here is the adopted mission statement --
5. Field Research re Dutch End-of-life Care (Including Euthanasia)
I made annual research trips to Holland 1992-2004 to track the professional experience of a cross-section of Dutch physicians with end-of-life care (including euthanasia). This research began in 1991 as an extension of an ethics project I had facilitated for the University of Michigan Department of Obstetrics and Gynecology (where I had been an adjunct researcher since 1985). My responsibility with the department was to facilitate research/writing projects with various medical faculty members in the department who were interested in addressing the clinical and surgical situations they were facing from an ethics/values perspective. I continued to work with the department through 1997. The anchoring project studied end-of-life decision-making from the perspective and experience of 108 gynecologic cancer patients who were receiving care from the department’s gynecologic oncology division. The subject of assisted suicide became a central issue in Michigan shortly after the data gathering for this study had been completed. Needing to expand the project to incorporate this subject, I began in 1992 to make what became annual research trips to Holland. The University of Leiden Department for General Practice served as host for the initial visit, made its faculty as well as residents accessible to me, and remained helpful for many years in the coordination of research efforts. A steadily expanding network of Dutch professionals -- including twenty-four physicians -- formed. This research network included (1) five general practitioners of varying persuasions regarding euthanasia; (2) a former chair of and now emeritus professor with the University of Leiden Department for General Practice who contributed significantly to the formation of a consensus by the early 1980s regarding euthanasia for competent patients experiencing unbearable suffering; (3) a senior neonatologist with the Amsterdam Medical Center who chaired the Dutch Pediatrics Association ethics committee for addressing neonatal decision-making in light of euthanasia guidelines; (4) a senior professor of medical ethics at the University of Leiden who was a past-president of the Voluntary Euthanasia Society and now serves in the Dutch Parliament; (5) three junior members of the research team at Erasmus University doing follow-up studies to the Remmelink Commission’s 1991 national study of end-of-life decision-making in Holland; (6) a psychiatrist whose assisted-dying case was the first such case considered by Holland’s Supreme Court.
6. Social Justice and Health Care Policy/Delivery in Israel and the Occupied Palestinian Territories (OPT)
David McRay, MD, (introduced above) and I began making annual trips to Israel and the OPT in 2004 for four purposes – (1) to establish professional ties with physicians and support staff members in both settings who are resolved to address health care disparities with a keen sense of social justice, (2) to examine the medical education and post-graduate training methods in both settings for reinforcing the social conscience of health care professionals, (3) to identify onsite ways for us to encourage/assist the educators, policymakers, and clinicians in the OPT, (4) to explore the possibility of creating educational rotations in both settings for medical students and residents in the United States who are interested in international medical relief efforts.
7. Barnes-Jewish Hospital Ethicist
In September 2006 Barnes-Jewish Hospital (the teaching hospital for Washington University School of Medicine) created a fulltime ethicist position. As an imbedded ethics educator in this position, I (1) round on services throughout the hospital, (2) attend (often on the agenda for 10-15 minute ethics education ‘pauses’) faculty or staff meetings, (3) provide resources/guidance for resident ethics education, (4) participate with the hospital’s Cultural Diversity and Inclusiveness initiative, (5) serve on the IRB, (6) participate in ethics training for the hospital’s nursing staff. In each setting, I draw attention to and strengthen the understanding of “the ethical dimensions of care” (found on the BJH Basics poster hanging throughout the hospital).
My aim is to maximize the fluency of the hospital’s ethics committee members with the language and literature of medical ethics (with particular attention to the promotion of a respectful, gentle, fair, and socially responsible delivery of healthcare services) and to facilitate with/through them a proactive and comprehensive ethics program (1) that raises awareness and a sense of accountability re ‘the ethical dimensions of care’ throughout the hospital, (2) that qualitatively alters decisions and actions throughout the hospital, (3) that provides an effective educational environment re medical ethics for caregivers (in training), and (4) that positions the hospital as a leading voice in regional and national deliberations re ethics and medicine.
1. Residency Education/Training
Tom Elkins, MD, (1949-98) recruited fourteen fulltime medical faculty members to join him in rebuilding the LSU Obstetrics and Gynecology Department’s residency program and establishing its social conscience. I was brought on board first as an adjunct faculty member (1992-94) and then as a fulltime faculty member (1994-97) with the following responsibilities as the department’s residency program coordinator and as an imbedded ethics educator.
Ethics education. I was brought on board with the specific assignment to create an ethics program that would clarify and enhance his vision for the department. With the assistance of numerous medical faculty members and residents in the department, we created and field-tested a survey instrument that was administered at the beginning, the mid-point, and the end of the four-year residency program. The data gathered using the survey instrument assisted in resident evaluations as well as provided discussion points for didactic sessions. We integrated a series of ethics seminars into each year’s teaching schedule. We concentrated on the professional maturation of the younger medical faculty members since they spent more time than others with the residents in patient encounters.
Resident rotations. My responsibilities included (but were not limited to) (1) reviewing/revising the four-year rotation templates to the three teaching sites to insure uniformity, (2) assigning residents (with the necessary written and oral communications) to the appropriate rotations, (3) arranging for transitions at each three-month rotation shift for 2nd and 3rd year residents (with orientation meetings for all incoming residents), (4) updating the weekly schedule (clinic assignments, conference times, operating assignments, labor/delivery coverage), (5) monitoring/revising intern rotations to meet the RRC primary care requirement, (6) updating the clinic staff re the residents assigned to New Orleans, (7) gathering/reviewing evaluations of off-service and elective rotations, (8) adjusting all schedules when rotation assignments were changed, (9) writing communications to chairpersons/program directors of departments with which our residents had off-service rotations.
Clinics. My responsibilities included (but were not limited to) (1) meeting at least every other week with the supervising medical faculty, the chief residents, and the clinic’s head nurse to trouble-shoot clinic needs, (2) maintaining (with regular revisions) the schedule of faculty assignments to clinic coverage, (3) preparing reports on faculty attendance assigned to the clinics in order to comply with the required 1:4 faculty-resident ratio, (4) answering staff and resident inquiries about faculty coverage assignments, (5) arranging for replacements when emergencies or oversights kept assigned faculty members from being in clinic, (6) creating/circulating continuity-of-care clinic dates for each resident projected over six month periods, (7) keeping updated lists of the residents’ panel of continuity-of-care clinic patients, (8) preparing communications for and conducting meetings with residents to insure their understanding of the continuity-of-care clinic format and process, (9) supervising the clinic worker who had as part of her work responding to the on-site needs of the continuity-of-care clinics.
New interns. My responsibilities included (but were not limited to) (1) contacting faculty members and residents about their availability to interview applicants, (2) forming interview teams for each interviewing session, (3) making sure preparations had been made for each interviewing session (e.g., rooms, food, handouts, folders for interviewers, hospital/clinic tours), (4) preparing schedules for each interviewing session, (5) writing letters to applicants, (6) conducting each interviewing session, (7) participating in the interviewing of applicants, (8) updating the handout circulated to applicants, (9) organizing the three-day orientation schedule for incoming interns (including at least two hours of my own meetings with the new interns), (10) preparing explanatory handouts for incoming interns, (11) arranging for mentors for incoming interns.
Statistics. My responsibilities included (but were not limited to) (1) (re)educating residents on the proper interpretation of statistical categories and on the importance of accurate/complete documentation, (2) revising the obstetrics and gynecology statistics forms used in all teaching sites, (3) making sure adequate supplies of these statistics forms were available in all teaching sites, (4) making sure primary care cards were being filled out, collected, and tabulated for all residents, (5) supervising the collection and computer-entry of all obstetrics and gynecology statistics forms, (6) updating tabulations quarterly on each resident’s obstetrics and gynecology procedure statistics, (7) circulating updated tabulations to each class of residents for their review and correction, (8) arranging for the updating of the computer software designed for data entry of obstetrics and gynecology statistics information, (9) making sure the obstetrics and gynecology statistics reports for the monthly department conferences were prepared, copied, and circulated, (10) preparing statistics reports on each resident for program director and Education Committee review.
Resident evaluation. My responsibilities included (but were not limited to) (1) scheduling and conducting the monthly meeting of the Resident Evaluation Committee, (2) preparing a detailed summary of each meeting for the program director (including extensive commentary on residents about whom the committee had significant concern), (3) reviewing this summary with the program director and devising remedial plans for the residents so identified by the committee, (4) participating in the remedial plans for some residents and insuring that all remedial plans were completed, (5) supervising the transfer of student evaluation scores into resident evaluation folders, (6) reviewing at least twice yearly each resident’s evaluation material and meeting with residents whose evaluations were of concern, (7) observing residents in clinic, on labor/delivery, in the operating room, (8) visiting residents in Baton Rouge and Lafayette, (9) collecting evaluations on residents assigned to Baton Rouge and Lafayette, (10) preparing various analyses of CREOG scores for assessment of strengths/weaknesses in fund-of-knowledge among the total residents, among residents by level, and for each individual resident.
Faculty evaluation. My responsibilities included (but were not limited to) (1) revising evaluation forms, (2) scheduling regular resident evaluations of each medical faculty member, (3) supervising the transfer of resident and student evaluation scores into faculty evaluation folders, (4) reviewing at least twice yearly with the chairperson and program director each faculty member’s evaluations, (5) forming and implementing recommendations for remediation as indicated by the evaluations, (6) implementing strategies for faculty enrichment (e.g., teaching methods, professionalism, ethics/humanities).
Didactics. My responsibilities included (but were not limited to) (1) meeting with members of the Education Committee in order to schedule the Monday afternoon teaching conferences for the academic year, (2) scheduling Grand Rounds for the academic year, (3) making sure preparation was complete (including assigned faculty to conduct the conferences) for the monthly obstetrics and gynecology statistics and morbidity/mortality conferences, (4) making sure preparation was complete for the monthly gynecologic pathology conference, (5) juggling the weekly schedule of presentations as/when unexpected conflicts kept speakers from fulfilling their assignments, (6) keeping attendance records for residents and faculty, (7) evaluating conference presentations, (8) monitoring the quality of instruction -- faculty to resident and resident to student -- in the work settings at all three teaching sites, (9) upgrading the library resources available to residents, (10) arranging for the selection of residents to attend various professional meetings, (11) scheduling special didactic series (e.g., fetal monitoring sessions for the interns and 2nd year residents).
Department research. My responsibilities included (but were not limited to) (1) arranging for meetings of the Research Committee, (2) participating in the Research Committee’s meetings and related activities, (3) keeping each resident on the established time line -- from internship to Resident Research Day presentation -- for the program’s research requirement (e.g., regular meetings with the Research Committee, 3rd year resident presentations in the Monday afternoon conference schedule, 4th year resident presentations at Grand Rounds).
2. Miami Intervention Project re Cocaine-abusing Mothers
I worked closely with Emmalee Bandstra, MD, a neonatologist with the University of Miami, during the first five-year funding cycle when she was the principal investigator for two projects involving in combination 300+ cocaine-abusing mothers who had delivered cocaine-exposed babies. Those women and their children lived in Overtown and Liberty City, two of the most poverty-stricken and violent sections of Miami. My responsibilities included (1993-97) guiding the evaluation process, (re)interpreting the vision and hypotheses, refreshing the overly stressed staff, framing ethical issues, and writing the mothers’ life-narratives. The target population –
Individual Factors. These women and their children were at serious risk to undervalue education, to see women treated as inferior to men, to absorb the language and assumptions of racial prejudice, to underutilize primary health care services, to lack proper nourishment, to thirst for genuine attention, to cease to dream. Childlike resiliency, concreteness, and a sense of humor insulated them somewhat from the full impact of their circumstances.
Family Factors. These women and their children were at serious risk to bear parenting responsibilities for younger siblings, to suffer physical and/or psychological abuse, to witness/experience domestic violence, to not know one or both parents, to lack family support for educational achievement, to never have celebrated a birthday, to feel betrayed, to regard adolescent pregnancy as normal. The incidence of adolescent pregnancy could, ironically, be reinforced by family members (whose behavior toward the pregnant girl often became dramatically more gentle and affirming) and by the expanded availability of societal resources. Many of these women desperately wanted to retain parental responsibility for their children. Few, if any, wanted their children to experience their way of life. Extended family members (esp., grandmothers) often shielded their children from at least the most severe disadvantages and conveyed to them that they were loved and wanted.
Education Factors. These women and their children were at serious risk to have attended school irregularly, to have been taught by demoralized teachers, to have attended improperly equipped schools, to have formed poor study habits, to have had discipline problems, to have lost their intellectual curiosity.
Peer Factors. These women and their children were at serious risk to form relationships based on ‘macho’, to link self-image to strength, to resort quickly to violence when in conflicts, to be taunted toward destructive misbehavior, to be suspicious of others, to find street-gangs attractive. Community-based athletic programs, religious organizations, substance-abuse support groups (e.g., TRUST Groups), and community-based social organizations (e.g., Big Brother/Sister, YMCA/YWCA, Boys/Girls Club) made constructive peer relationships at least a possibility.
Neighborhood Factors. These women and their children were at serious risk to lack a sense of pride in their community, to live in deteriorated housing, to change residence frequently, to regard violence as normal, to have a street name, to ‘work’ on a lower rung of the drug-world ladder, to have a family member and/or neighbor who had died a violent death or who had AIDS, to regard the police as the enemy. Their neighborhoods did vary in the degree of risk they posed. Even in the most hostile neighborhoods, local groups -- some formally established, others ‘street-organized’ -- could be found working to insure a measure of safety and encouragement for these women and their children.
Society/Media Factors. These women and their children were at serious risk to have no sense of membership in the larger society, to have never visited other parts of the city, to have learned by watching closely the adults around them how to ‘work the system’, to have a surreal worldview shaped by television, to be influenced by militant music, to place no value on newspapers or news magazines. Harsh predispositions against them, widespread in the larger society, made interactions across social lines predictably adversarial. Sustained efforts to introduce resources and options (e.g., businesses, vocational institutes, and community colleges) could be found attempting to create fresh start opportunities.
Shortly after the proposal was funded, two medical school collaborators abruptly abandoned Dr. Bandstra’s leadership team, pulling critical legs out from under the project. Then Hurricane Andrew slammed through Miami, leaving the city in utter chaos. Six months later, signs of recovery in the city were still scant. With the cocaine-abusing mothers scattered by the storm and difficult to locate, Dr. Bandstra’s turf battles with other researchers intensified. And her case management staff had completely turned over.
My first task was to help Dr. Bandstra and her staff regroup. We went back to basics. Could they answer the five questions of a mission statement – i.e., Who/what are we? What do we do? For whom? To what end? By what values? – with wording that had centripetal force? Only then could we determine what (if any) goals were still feasible.
We proposed to rebuild the intervention project around writing life narratives with/about the mothers. Each mother’s story was badly broken. But it was her story. And we were convinced there was more to each mother than her cocaine-addiction. Each narrative developed around the same set of questions. Who is this mother? What does she value? How does she make sense of her experiences? In what social context does she live? How does she view parenting? What aspirations does she have for herself? for her child/ren? How does she define key words (e.g., hope, joy, success, power, freedom, fear)? How does she view her involvement with drugs (e.g., a fact, a recreation, a coping mechanism, a threat to well-being)? Does she want to be drug-free? Does she want her child/ren to be drug-free? What barriers does she face? Why does she try or not try to benefit from available resources? Why do her attempts succeed or fail? How does she define success or failure?
3. Neonatal Intensive Care
Sheldon Korones, MD, a pioneer in the formation of the neonatal subspecialty, is founder and 1968-2005 director of the University of Tennessee Memphis neonatal ICU. He was my closest friend during the last two and most difficult years of my first wife’s fight against multiple sclerosis (d. 1987). Our collaborative relationship began during a 1985-86 sabbatical I spent with Dr. Korones and his NICU staff. The many hours in the unit allowed me to learn much from and about the nurses as well as from Dr. Korones and his physician colleagues. Dr. Korones and I have worked together on various ethical issues peculiar to neonatal medicine. However, our primary work together continues to be writing his professional biography. We have given particular attention to his experience beginning with his Yiddish grandfather’s immigration in 1901 from Czarist Russia to New York’s Lower East Side and ending with his 1967 decision to leave a lucrative private pediatric practice in Memphis in order to devote his career to the socially disadvantaged babies in inner-city Memphis dying two-to-three times the rate of socially advantaged babies in the Memphis suburbs (a decision he traces to his childhood impressions from his grandfather’s stories of Czarist oppression against the Jews). The research related to this project deepened my appreciation for Jewish history/culture and continues to anchor my search for an approach to ethics and spirituality that recognizes/supports every professional’s integrity.
4. Primary Care for Rural and Uninsured Families
David McRay, MD, leads three community health clinics located in counties along the eastern Kentucky-Tennessee state line. These clinics exist to extend health care -- without regard to ability to pay -- to families whose geographic and cultural isolation leaves them far removed from standard medical care. In both part-time (1994-97) and full-time (1997-2007) affiliations with Dr. McRay and the health center he leads, my responsibilities have centered on refining the organization’s vision and hypotheses, prompting the physicians’ professional motivations, framing the ethical issues they face, coordinating resident and student rotations, extending the health center’s involvement with public health issues, and writing narratives about the clinics’ patients.
I had first visited this East Tennessee/Kentucky Appalachia health center a few months before our move from Vermont to New Orleans. I had been invited to return every six weeks or so to spend long weekends with the medical staff members and their families as they attempted to embrace the experience of living among and practicing with disproportionate attention to poor/uninsured Appalachia families. They recognized the need for a simple yet potent statement of mission that would center/steer the health center’s direction, decisions, actions by answering five questions – (1) What are we? (2) What do we do? (3) For whom do we do what we do? (4) To what end do we do what we do? (5) By what values do we do what we do? After reviewing stacks of health center material and interviewing numerous representatives, I deduced a first draft. On each of my visits over the next eighteen months, I listened carefully as the participants in the process of crafting a statement with ‘pause effect’ pressed every word in the latest draft. Between visits I would circulate yet another revised draft. Here is the adopted mission statement --
Dayspring Family Health Center is a not-for-profit community health center founded on the conviction that everyone should have access to affordable quality healthcare. We are committed to providing our patients comprehensive medical care in a fair and gentle manner. A healthy community is one in which all of its members begin life with hope, experience life with joy, and end life with dignity. We are convinced that many health problems have community causes and community solutions. Therefore, our ultimate purpose is to promote the full health – physical, spiritual, mental, and economic – of the communities we serve.
5. Field Research re Dutch End-of-life Care (Including Euthanasia)
I made annual research trips to Holland 1992-2004 to track the professional experience of a cross-section of Dutch physicians with end-of-life care (including euthanasia). This research began in 1991 as an extension of an ethics project I had facilitated for the University of Michigan Department of Obstetrics and Gynecology (where I had been an adjunct researcher since 1985). My responsibility with the department was to facilitate research/writing projects with various medical faculty members in the department who were interested in addressing the clinical and surgical situations they were facing from an ethics/values perspective. I continued to work with the department through 1997. The anchoring project studied end-of-life decision-making from the perspective and experience of 108 gynecologic cancer patients who were receiving care from the department’s gynecologic oncology division. The subject of assisted suicide became a central issue in Michigan shortly after the data gathering for this study had been completed. Needing to expand the project to incorporate this subject, I began in 1992 to make what became annual research trips to Holland. The University of Leiden Department for General Practice served as host for the initial visit, made its faculty as well as residents accessible to me, and remained helpful for many years in the coordination of research efforts. A steadily expanding network of Dutch professionals -- including twenty-four physicians -- formed. This research network included (1) five general practitioners of varying persuasions regarding euthanasia; (2) a former chair of and now emeritus professor with the University of Leiden Department for General Practice who contributed significantly to the formation of a consensus by the early 1980s regarding euthanasia for competent patients experiencing unbearable suffering; (3) a senior neonatologist with the Amsterdam Medical Center who chaired the Dutch Pediatrics Association ethics committee for addressing neonatal decision-making in light of euthanasia guidelines; (4) a senior professor of medical ethics at the University of Leiden who was a past-president of the Voluntary Euthanasia Society and now serves in the Dutch Parliament; (5) three junior members of the research team at Erasmus University doing follow-up studies to the Remmelink Commission’s 1991 national study of end-of-life decision-making in Holland; (6) a psychiatrist whose assisted-dying case was the first such case considered by Holland’s Supreme Court.
6. Social Justice and Health Care Policy/Delivery in Israel and the Occupied Palestinian Territories (OPT)
David McRay, MD, (introduced above) and I began making annual trips to Israel and the OPT in 2004 for four purposes – (1) to establish professional ties with physicians and support staff members in both settings who are resolved to address health care disparities with a keen sense of social justice, (2) to examine the medical education and post-graduate training methods in both settings for reinforcing the social conscience of health care professionals, (3) to identify onsite ways for us to encourage/assist the educators, policymakers, and clinicians in the OPT, (4) to explore the possibility of creating educational rotations in both settings for medical students and residents in the United States who are interested in international medical relief efforts.
7. Barnes-Jewish Hospital Ethicist
In September 2006 Barnes-Jewish Hospital (the teaching hospital for Washington University School of Medicine) created a fulltime ethicist position. As an imbedded ethics educator in this position, I (1) round on services throughout the hospital, (2) attend (often on the agenda for 10-15 minute ethics education ‘pauses’) faculty or staff meetings, (3) provide resources/guidance for resident ethics education, (4) participate with the hospital’s Cultural Diversity and Inclusiveness initiative, (5) serve on the IRB, (6) participate in ethics training for the hospital’s nursing staff. In each setting, I draw attention to and strengthen the understanding of “the ethical dimensions of care” (found on the BJH Basics poster hanging throughout the hospital).
My aim is to maximize the fluency of the hospital’s ethics committee members with the language and literature of medical ethics (with particular attention to the promotion of a respectful, gentle, fair, and socially responsible delivery of healthcare services) and to facilitate with/through them a proactive and comprehensive ethics program (1) that raises awareness and a sense of accountability re ‘the ethical dimensions of care’ throughout the hospital, (2) that qualitatively alters decisions and actions throughout the hospital, (3) that provides an effective educational environment re medical ethics for caregivers (in training), and (4) that positions the hospital as a leading voice in regional and national deliberations re ethics and medicine.
