[Sent – 30 September 2018 to the 170+ surgeons et al of our Surgical Ethics (Education) Consortium]
Greetings. For my ‘Surgical Ethics Education Resources’ #7 communication, I have inserted below the set of cases we used several years ago in one of the first professionalism/ethics small group discussion sessions we organized/conducted with our surgery clerkship students. The slide inserted below (a nearly exact quotation from some WashU 3rd-year students with whom I was having a conversation a few years ago) indicates the ethics education problem we are attempting to address --
Re background -- I joined the WashU Surgery Department in 2011. My primary responsibility has been to manage our department’s 12-week surgery clerkship (under the supervision of the Vice-Chair for Surgical Education and the Surgery Clerkship Director). Thus embedded, I have additionally served as an ethics educator and qualitative researcher for our department. Near the beginning of my work within the department, I prepared and began to circulate seven brief professionalism/ethics promptings for/to our surgery clerkship students, distributing one prompting every couple of weeks during the clerkship. We soon began experimenting with several ways to provide the surgery clerkship students a meaningful professionalism/ethics didactic session timed so as not to be near the beginning or the end of the clerkship and structured so as not to be too time-demanding. A few years ago, we settled on the following format –
• All surgery clerkship students are required to submit one disturbing case (template for case presentation provided) from their surgery clerkship, ideally by Week 8 of the clerkship. (Dr. Klingensmith approved this surgery clerkship requirement beginning with the 2014-15 AY.)
• I select 5-6 cases from the submitted cases and edit/organize them (with input from Jennifer Yu, now a PGY4 in our residency program) into a set of cases for small group discussion. (Cases submitted too late to be considered are rolled forward into the next surgery clerkship.)
• We routinely have enough faculty members and residents to have two facilitators per small group. (More than twenty faculty members and several residents have participated regularly as small group discussion facilitators.)
• I begin the session with a brief ‘ethics 101’ reminder/refresher presentation after which the facilitators and clerkship students are separated into small groups for an hour discussion of the selected cases.
We have been very pleased with the encouraging feedback from the surgery clerkship students and also from our faculty and residents. We now have collected more than 300 cases from surgery clerkship students and are planning in the near future to analyze these cases for presentation and/or publication. We are also looking into the possibility of introducing this format to other 3rd-year clerkships here at WashU.
I welcome your questions and observations. You are free to use the above information and the cases as you think might be helpful in your surgical ethics education efforts.
Doug
Case
#1
A
patient presents with small bowel obstruction, likely a sequelae of prior
cholecystecomy. The case is further complicated by sepsis. The patient was
found unresponsive and was subsequently intubated. She needs bronchoalveolar
lavage (BAL) to rule out pneumonia. After BAL is completed, medical students
and residents involved in the patient’s care are allowed to practice
bronchoscopy, causing the patient’s oxygen saturation to dip into the 70s.
Case
#2
A
patient presents for a scheduled cholecystectomy for biliary colic. The
attending, intern, and medical student enter the pre-op room to consent the
patient for the procedure. Before signing her name, the patient asks, "Who
will be doing the surgery?" The attending replies, "I will do the surgery
with some help from the resident." The patient then asks the medical
student what she will be doing. The attending responds, "Just
watching." In the OR, the intern performs the majority of the case with
help from a senior resident who did not speak with the patient before surgery.
The medical student drives the camera. The attending checks in on the case from
time to time (including confirming the critical view) but never scrubs in.
Case
#3
A
patient well known to the service presents in clinic with a chief complaint of
chronic pain in her joints that has been ongoing for years without effective
therapy for symptom resolution. Before entering the room, the medical
assistants tell the medical student -- "Nothing is wrong with this
patient. She just has fibro and is a little crazy." The medical student
does not talk to the attending about the patient’s history before entering the
room, but later learns that he has a similar view of the patient. The attending
gives the patient what the medical student considers to be a sub-optimal
physical exam before bargaining with the patient regarding if/how many pain
medications she would receive.
Case
#4
A
patient presents in spine clinic with a longstanding complaint of shooting pain
down his left arm. The pain began as an acute injury a year earlier during the
patient’s work. His clinical exam at that time was consistent with C8
radiculopathy. EMG/nerve conduction studies showed C8 pathology, but imaging
was negative. He received an anterior cervical disc fusion which did not help
his pain. Since this operation, the patient has been to several different pain
management physicians for help managing his pain. Each one eventually decided
not to treat him further. Before seeing the patient in clinic, the medical
student is handed the chart and told the patient is “one of those patients”
(i.e., “weird/crazy patients”). The medical student enters the room with this
preconception but concludes the patient seems genuinely frustrated that no one
has answers for his pain (i.e., “they shrug their shoulders at me”). The
attending appears appropriately attentive and detailed in answering the
patient’s questions. However, outside the exam room, the attending, fellow, and
medical assistant are all skeptical, agreeing the patient is clearly
drug-seeking and questioning his motives/character.
Case
#5
The
patient presents with unilateral thyroid nodules that were recently biopsied to
be papillary carcinoma. The patient comes to clinic to discuss her surgical
options. The surgeon recommends surgical excision. However, the patient is very
reluctant to have the surgery due to the Internet research she had done. The
surgeon spends half an hour explaining the procedure and eventually manages to
convince the patient to have the surgery.
Case
#6
The
call resident is informed about a patient with testicular torsion who is being
transported from an outside hospital. The outside hospital is known to be
equipped to handle testicular torsion. The resident tells the medical student
that the physician at the outside hospital most likely refused to perform the
procedure because the patient’s insurance would not pay enough. He notes that
similar situations occur routinely – i.e., situations in which patients are
“punted” because of insurance issues. The delay due to the transfer risked the
loss of the testicle.
Case
#7
A patient with
follicular thyroid carcinoma presents for a scheduled completion right
thyroidectomy. The patient speaks very limited English. The patient tolerates
the procedure well and is admitted to the floor for observation. She stays an
extra day because her total calcium down-trended. The calcium values eventually
stabilize. The patient is discharged. Throughout the patient's stay on the
floor, the assistance of an interpreter (by phone) is sought only once -- a few
hours before the patient is discharged in order to answer questions and explain
signs of hypocalcemia. The team otherwise relies on family members (including
teenagers) for assistance with communication. The medical student is the only
member of the primary team present the one time an interpreter is used (the
phone call is conducted by the resident on call, with the medical student
prompting the resident with points the medical student remembers from seeing
the patient on rounds). The phone is never given to the patient and is not
placed on speaker phone.
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