ARTICLE
Auteur(s) :, Peter R
McCombs*
University of Pennsylvania School of Medicine, Division of
Vascular Surgery, Philadelphia, PA. USA
accepté le 20 Février 2004
Education prolongs adolescence. This rubric has particular
relevance in the conventional training of physicians. Because the
process is long and arduous, the majority of residents proceed like
marathon runners with single-minded dedication and without
interruption. Years of focused study through undergraduate school,
medical school and residency effectively prepare young physicians
to acquire the certification and credentials they need to advance
their careers, but may expose some to the risk of being
shortchanged in other critical skill sets.Among the essential
skills all young doctors need in order to succeed in today’s
challenging climate are abilities to maintain perspective and
emotional equilibrium, to synthesize data from an array of sources,
to make decisions often without perfect information, and to
communicate across individual and social divides. They also need
the courage of their convictions. As program directors and
committed clinician educators, we have an obligation to insure that
our trainees are equipped with these tools [1, 2]. In order to
prepare residents to enter an uncertain world, humanistic values,
historical and socio-political trends, and encouragement to think
creatively and critically must be incorporated into the curriculum,
integrated with basic and clinical science [3]. More than ever,
physicians need to be active participants in their own education
and career development. They must have the capacity to deal with
changing expectations, administrative requirements and
socioeconomic realities.Intensively competitive forces,
instability, and rapid change characterize the world our graduates
will enter. Indeed, many believe that our profession as a whole is
currently in a transition similar to the one experienced by the
manufacturing sector of the economy in the mid-twentieth century,
at the dawn of the information age. It is difficult to imagine what
the practice of medicine will be like in a generation, but what is
clear is that without enlightened and courageous physician
leadership, autonomy may erode and the entrepreneurial spirit may
fade.It is therefore not sufficient to train our graduates for a
static career. Many educational leaders have emphasized that
residents must have a solid knowledge base enhanced by clear and
assertive communication skills, and an awareness of themselves as
part of a community. They must learn to balance their innate
yearning for independence with an understanding of the dynamics
that rule the environment [1, 4]. Their dedication must be enhanced
by vision and self-confidence, but balanced by humility. At the
same time, the code of professional conduct mandates that they
maintain their traditional devotion to patient welfare and to
public accountability in spite of emerging market forces,
restrictions on autonomy, limited resident work hours, and
conflicts between the availability and the economics of costly,
complex and risky therapies [5].
Entering an uncertain world
In pre-Christian times, a river known as the Rubicon flowed west
from the Apennines in Tuscany to the Tyrrhenian Sea. Julius Caesar
crossed it with his army as he set forth to build an empire, in
violation of orders from the leaders in Rome. A civil war followed,
after which Caesar emerged as ruler of Rome. Caesar is supposed to
have said, “the die is cast” (referring to a roll of the dice) as
he crossed the river. The expression “crossing the Rubicon” has
become a metaphor for the moment in a mission when one passes the
point of no return after leaving a safe harbor.
All of us cross our personal Rubicon when we leave residency and
enter the uncertain world of practice. As educators, we owe it to
our graduates to give them not only the benefit of our experience
but the perspective and capacity to adapt to change, perhaps even
to lead it.
The traditional curriculum forms the backbone for postgraduate
education. Residents must ultimately pass their specialty Board
certifying examinations. We as program directors and clinician
educators are held accountable if any pattern of failure is
detectable. We expect that students at this level are capable of
educating themselves through adjunctive reading, pursuit of primary
source material, and from new information presented at meetings, in
the published literature, and in the electronic media. We also know
that they learn a great deal from each other through the
traditional hierarchy. Nevertheless, the choices they are required
to make, the allocation of limited resources (particularly as
imposed by managed care), and the application of accurate
risk-to-benefit analysis can be mind-boggling, even to experienced
and intuitive clinicians. These choices can be overwhelming to some
residents [6].
Introducing a new dimension
Most university-based and independent programs include teaching
conferences organized on a periodic schedule. These are usually
structured around basic surgical science and clinical application,
using case presentations as a point of departure. Over the duration
of the program, most of the core material is covered. What is not
typically covered, however, is an array of topics and controversies
that may create unique conflicts and begin to impact young
physicians and surgeons the moment they leave the sanctuary of
residency. The challenge is to enable them to view these conflicts
as opportunities rather than as threats.
Our independent program, following the lead of several others
[7, 8], has embarked on a course of action to address this issue.
We have protected one hour per month for a program of interactive
discussion of an assortment of humanistic and socio-political
topics outside of the standard curriculum. Residents look forward
to these conferences and find them provocative. As much as
possible, we have attempted to avoid the didactic monologue format
as a way of stimulating spontaneous group discussion. We have had
many provocative moments. Representative topics are shown in
Table I( Table I )( Table II ).
There will be others as we go forward. Feedback from residents
has been positive, for a variety of reasons. Little preparation is
required, in distinction to our didactic conferences, which are
oriented to organ systems and focus on mechanisms of disease and
surgical decision-making. Residents may sleep longer or play harder
on the night prior to these sessions. On the other hand, the real
appeal appears to be the opportunity to be challenged and to open
their minds in a new way. They do not learn the topic or receive
any materials until the session begins. They almost always have a
working familiarity with the subject, but their depth of
understanding and their confidence to enter into discussion may be
limited. As the dialogue proceeds and they realize that there are
no experts in the room, no right or wrong answers and a low
probability of intimidation or embarrassment, the exchange
invariably becomes more animated. Many have eventually ventured
courageous or poignant points of view, often derived from family
hardship or personal experience. Some have found themselves
passionately defending arguments on behalf of social issues outside
the realm of daily surgical care, which previously they had not
thought through and perhaps had not even contemplated. At one time
or another, all have expressed that they have been encouraged to
think creatively and to communicate precisely and assertively. The
Chairman selects the subject matter, prepares the agenda and the
appropriate printed or audiovisual materials, and functions more as
a referee or catalyst than as a critic.
Table I Representative topics
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• Negotiating your first employment agreement: what residents
should know about the opportunities and pitfalls.
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• Palliative care in the intensive care unit: combining objective
decision-making with compassion.
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• Professionalism: making the right decision in clinical,
interpersonal and professional dilemmas.
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• Role models: how they have shaped our decisions and career
choices.
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• Mock depositions: how to conduct yourself and give accurate and
consistent testimony.
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• The vital importance of accurate documentation: if it is not
documented in the medical record, it didn’t happen.
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• History in our midst: a review of landmark colonial events and
heroic personalities that shaped our nation.
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• Private surgical practice in a rural setting: how the realities
may diverge from your expectations.
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• “The Road Not Taken”: dissecting Robert Frost’s modern
masterpiece about the consequences of the choices we make.
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• Racial and religious discrimination in the hospital: responding
when bigotry penetrates the work environment and threatens patient
care.
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• Medical ethics: how these are affected by interpretations of
patient rights, concepts of justice, allocation of resources and
areas of potential conflict.
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• Burnout: recognizing the signs in each other and intervening
before a crisis develops.
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• Responding to an act of terrorism: rearranging hospital resources
to facilitate triage and treatment of multiple casualties exposed
to a blast and biologic attack inflicted by weapons of mass
destruction.
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• Individual rights versus the common good: how the First Amendment
of the United States Constitution may affect attitudes and effect
social change.
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Table II Clinical Scenarios with Ethical
Implications
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Confidentiality A 74-year-old male has obstructive jaundice
due to an unresectable cancer of the head of the pancreas.
Palliative surgery could relieve the biliary obstruction. The
patient is fairly lucid but does not know his diagnosis. His wife,
who insists that he must be told only that his condition is benign
and that the operation will be curative, offers to provide informed
consent.
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As the medical attending, what are your obligations to the
patient?
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How would you communicate your position to the wife?
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Futility A 78-year-old male has multisystem organ failure
due to a necrotizing vasculitis. He is anuric, ventilator-dependent
and septic due to ischemia of the sigmoid colon. His family
requests comfort measures, in accordance with his stated
intentions. Before these are instituted, however, the patient’s
estranged daughter arrives and insists that he be placed on
dialysis and undergo resection of the colon.
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How would you promote a dialogue between the daughter and the other
family members?
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Do you have a moral fiduciary responsibility to the patient? To the
family?
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Learning Curve A 64-year-old woman with a severe exfoliative
dermatitis requires central venous access. You ask your PGY
2 resident to insert the catheter. It is the second one she
has done. The line is placed successfully under the supervision of
a more senior resident. However, a chest x ray, taken
45 minutes after the procedure, reveals a 50% pneumothorax and
the patient is short of breath. A surgeon inserts a chest tube,
reexpanding the lung. The patient’s son is angry and confronts the
resident, asking, “By the way, Doctor, how many lines have you
done?”
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As the medical attending, what are your obligations to the patient?
To the resident? To the son?
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What, if anything, would you write in the medical record?
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One representative topic
The challenge posed was to consider the concept of the common good
vs. the case for individual rights. As a point of departure, I
selected the U.S. Supreme Court’s decision in Lawrence v. Texas to
strike down that state’s law prohibiting certain forms of intimate
behavior (sodomy), thereby initiating momentum across the country
to legitimize homosexual conduct.
I framed the discussion with a brief presentation of the facts
of the case and a summary of the arguments made before the Court. I
asked the residents to consider whether men and women in committed
same-sex relationships should have as valid a right before society
and the law as heterosexual couples to enter into legal contracts,
be designated as beneficiaries, be entrusted with privileged
medical information, and so on. The residents quickly identified
the issue as one in which demands for personal liberty directly
confront traditions and values that constitute important components
of social order. I quoted Justice Kennedy’s statement in the
majority opinion: “Liberty presumes an autonomy of self that
includes freedom of thought, belief, and expression, and certain
intimate contact” [9]. I asked the residents whether in today’s
context “family” and “homosexual union” were mutually exclusive,
and whether the future of the family was in fact threatened by this
decision. Finally, I asked the residents if they believed that our
Constitution, as well as our social values, gave more weight to a
liberal interpretation of individual autonomy or to the concept of
the common good.
The residents tended to feel that the Bill of Rights of the US
Constitution emphasizes individual rights more clearly and
powerfully than the common good. Some pointed out that when
individual rights and freedoms are defended, the common good
usually benefits, although the price for producing social change
may be high. The fight for school desegregation, initiated by the
decision in Brown v. Board of Education, served as an example.
Others saw the Lawrence decision as an attempt by the highest
judiciary body in the land to effectively “legislate” a form of
morality, essentially exercising inappropriate judicial
authority.
What followed was a polarized discussion. Some saw the decision
as an expression of justice that was long overdue. Several saw
personal privacy as an essential and inalienable civil right. A few
felt equally strongly that such basic institutions as marriage were
threatened by this decision, and that in the wake of the implied
sanctioning of homosexual unions, the future of marriage itself
might be no marriage at all, an opinion that has also been
expressed in the media [10]. The majority did not agree with this
bleak conclusion. Most residents reported that they left the
session with the feeling that liberal interpretations of individual
rights were sometimes difficult to reconcile within the concept of
the common good. Ultimately, however, they agreed that aggressive
protection of individual rights is the engine that drives social
change and the evolution of social justice in our culture.
The impact on professionalism
The purpose of these exercises is to encourage residents to
understand that their patients bring individual and cultural
imperatives to the encounter. But how do conferences like this one
impact on the training of physicians? The effect is incremental and
nearly impossible to measure. The residents themselves invariably
provide strong feedback about these sessions and about the program.
They appreciate the uniqueness of the exercise in the course of the
daily curriculum. They like to delve into liberal discussions, to
debate fundamental truths and controversies, and ultimately to
express themselves in a manner beyond the customary recitation. But
they are forced to consider the validity of other points of view
and to formulate rebuttals that are derived as much from opinion as
from fact. They get the chance to think in a different way and to
stand by their conclusions.
There are no grades and no one is declared a winner. Discussion
is rarely truncated by the end of the conference. It frequently
extends into the hospital cafeteria and finds its way into dialogue
on rounds and in the operating room. Some residents seek me out to
continue a point of discussion or to try to resolve an unsettled
matter days or even weeks later. It is clear that many residents
continue to turn the issues over in their minds long after the
conference has ended.
We have not developed a tool to measure the impact of these
experiences objectively, nor do I believe that we need one. The
Accreditation Council for Graduate Medical Education (ACGME) does
not require instruction in humanism or social justice [11]. Board
certification does not require candidates to be facile with such
issues. The program has worked its way into our Departmental Goals
and Objectives, and while there is always room for improvement, we
are satisfied with its effectiveness. Patients and faculty from
other departments frequently comment on our residents’ maturity and
code of professional conduct.
Residents are increasingly aware that they are held to differing
and ever-rising standards by the media and by public opinion. They
are beginning to realize the great importance of social
consciousness and of having familiarity and sensitivity with both
sides of interpersonal and societal conflicts. They are finding
themselves cast in the role of mediator of family conflicts on the
wards and in critical care units, as acuity rises and decision
making with respect to interventional procedures, riskier therapies
and end of life issues become more prevalent and complex.
Summary
At its core, our program serves to remind residents that they are
treating not only diseases, but human beings carrying with them
high expectations, hopes, biases and an increasing array of
information. Gone is the era when the physician’s word is beyond
challenge. In today’s environment, communication skill is as vital
as technical skill. Whether in obtaining informed consent for a
procedure, explaining an unexpected outcome, determining whether to
withdraw care, or simply monitoring our patients’ daily progress,
the nature of the dialogue may be as important as the conclusion.
As physicians, we must have the ability to understand as well as to
prescribe.
References
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5 American College of Surgeons Task Force on Professionalism.
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