[Sent -- 14 June 2018 to the 170+ surgeons et al of our Surgical Ethics (Education) Consortium]
Greetings. For the ‘Surgical Ethics Education Resources’ #2 communication, I am sharing with you one component of a professionalism/ethics curriculum design I created and introduced in the 2013-14 academic year for our surgery clerkship students. I began managing our 12-week surgery clerkship in November 2011 and immediately started attending all of the dozen or so clinical/operative lectures delivered by various surgery faculty members during each clerkship, both to make sure any logistical/technical snags were quickly resolved and also to consider the educational effectiveness of the faculty lectures. As I listened to the faculty lectures, I quickly decided to keep a log of the professionalism/ethics concerns they revealed in passing – i.e., 15-20 second asides, often expressed with noticeable frustration – during their lectures. After several clerkship cycles, I organized my list of the faculty members’ numerous professionalism/ethics concerns into themes/categories and began sending the resulting template (with direct quotes from the faculty lectures) to the clerkship students mid-way through their surgery clerkship with a request that they prioritize (‘high’, ‘medium’, ‘low’) each of the listed faculty members’ professionalism/ethics concerns. I have inserted below an example of the template plus the clerkship students’ prioritization that was sent to the faculty members recruited to facilitate an hour session of small group discussions with one set of clerkship students in Week 9 of their surgery clerkship. The ‘high priority’ percentages varied from clerkship to clerkship, as you would expect.
This adaptation of qualitative research methods was very well received by our clerkship students as well as by our faculty members. The format proved to be substantive and relevant but not disproportionately time consuming, two linked ‘head scratching’ challenges for integrating meaningful professionalism/ethics education into a clerkship student curriculum. A very encouraging secondary result was the discovery/identification of a rather sizable pool of faculty members who welcomed the opportunity to speak with the clerkship students about these professionalism/ethics concerns.
I suspect your faculty colleagues have/express similar professionalism/ethics concerns in settings not designed for extended deliberation and careful analysis. I encourage you to consider experimenting with some variation on this curriculum design with your clerkship students and/or residents.
Doug
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Subject/Concern – Failing to be
cost-conscious or follow EBM thinking
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% Students ‘High Priority’
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“A MRI for a 80 y/o with
arthritis is a waste of healthcare dollars” . . . “Fight the urge to do a CT
scan for every pt” . . . “In the ED – ‘ABC’ is Airway, Breathing, CT Scan”.
|
50%
|
|
“Patients rarely see the costs
they incur and so want many unnecessary tests done and are not satisfied
until they are. Conversely, they often do not do what would help make
their health care effective.”
|
50%
|
|
Re colloids cost range compared
to crystalloids – “The data do not justify expensive colloids which are nonetheless
heavily used” . . . “Who care?” . . . “Your generation will be more cost
conscious”.
|
40%
|
|
“Do we over-prep or under-prep
pts for surgery?”
|
25%
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|
“I have missed many diagnoses
because I wasn’t thinking”.
|
15%
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|
“You have an ethical obligation
to look at/to check every item of every test you order”.
|
10%
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•
Subject/Concern
– Attitudes about and perceptions of patients
|
% Students ‘High Priority’
|
|
“Should students be
instructed/permitted to perform rectal exams on sedated patients in the OR?”
|
50%
|
|
“I just cut off this pt’s leg
and all he can think about is getting out to smoke” and other discouraging
comments re patients failing to make changes in risky behaviors.
|
35%
|
|
“Patients harm themselves to
manipulate the system–e.g., prisoners who swallow safety pins.”
|
25%
|
|
Surgeons making disparaging
remarks about patients while the patients are under general anesthesia.
|
25%
|
|
•
Subject/Concern
– Impact of time constraints on patient care
|
% Students ‘High Priority’
|
|
“Do busy surgeons have time to
discuss the diagnosis and keep the patient informed prior to surgery?
If not, whose job is it?”
|
45%
|
|
“The trust patients place in
surgeons is staggering.”
|
30%
|
|
“You can’t do a proper history
in fifteen minutes”.
|
30%
|
|
“You can be caught up in the moment
and fail to establish trust”.
|
25%
|
|
“You often have to decide/act
before test results are back”.
|
20%
|
|
•
Subject/Concern
– Attitudes about and perceptions of other physicians/fields
|
% Students ‘High Priority’
|
|
“I wish primary docs would pay
more attention in medical school” and “If all you have is a hammer,
everything looks like a nail” – re how physicians in one area of medicine
perceive (often negatively) physicians in other areas of medicine.
|
45%
|
|
“The surgeon is ultimately
responsible for a patient in pulmonary failure, not the
anesthesiologist. The surgeon is the pilot; the anesthesiologist, the
co-pilot.”
|
30%
|
|
•
Subject/Concern
– Financial incentives/motives
|
% Students ‘High Priority’
|
|
“It’s all about money” . . .
“The unscrupulous orthopod who drives a Lamborghini who scopes a knee w/o
clinical justification”.
|
35%
|
|
“Pay for performance is your
future” . . . “At BJH we are penalized when the infection rate makes us an
outlier–e.g., 5% penalty” . . . “Linking infection rate to compensation gets
one’s attention”.
|
25%
|
|
“West Co gallbladders go to Dr.
_____ and the important guys, not to me”.
|
20%
|
|
“What drives your
decision-making?”
|
15%
|
|
•
Subject/Concern
– Research, Surgical innovations
|
% Students ‘High Priority’
|
|
“Drug companies are not
investing in antibiotics because they can’t make money doing so” . . . “We
face a serious risk of reverting to pre-antibiotic medicine”.
|
30%
|
|
“What are we missing now that
is analogous to female MIs that were missed in the 60s-80s?”
|
25%
|
|
“Unfortunately, this device is
not yet approved in the US” . . . “This device was approved just a year ago”
. . . “The US is behind” . . . “Even though we do these procedures” – re how
devices and procedures are approved in the US.
|
25%
|
|
“Back in the day when you could
study/test something w/o the IRB” . . . “An experiment design that
would not get you in the Post-Dispatch” – re research ethics.
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20%
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