Home > Medical School, Medical/Health Commentary > Think not, want not

Think not, want not

September 22, 2010 Leave a comment Go to comments

There’s a central intellectual tension to be navigated during the first few months of medical school.  On the one hand, there’s the desire to critically engage with the material, to think about it, and in some cases to challenge what we’re learning.  On the other hand, there are some things you just have to know.  All sorts of estimates abound as to the number of new terms to be learned in the first year of medical school — I’ve heard numbers in the thousands — and there comes a point where it doesn’t matter “why,” or “what more,” or “what if”… there are some things you just have to know.

This tension has so far manifested itself most clearly in the “soft” courses:  the ones that try to teach ethics, professionalism, policy, “cultural competency,” “humanism,” and so on.  SUMS has structured its ethics and professionalism courses quite interestingly.  Small “discussion” groups get together to consider scenarios and watch media clips — some chosen from mass media, some from actual clinical practice — designed to prompt “discussion.”  Invariably, these clips have been trite, facile, and chosen to allow only one “correct” answer:  be nice to nurses; care about the patient; the patient is more than a disease; you need to see the patient to learn from the patient; don’t get in the attending’s way during a tricky surgery; etc.

If you’ve never been told these sorts of things before, it’s important to hear them, intuitive though they should be.  Given the abundance of rhetoric from SUMS administrators about the importance of “reflection” in medical education, it’s a shame that no such opportunities are provided when considering the maxims of professionalism handed down from on high.  After all, it’s the exceptions that prove* rules, and it’s the exceptions that give rise to the hardest questions, deepest thought, and ultimately the best engagement with and internalization of these norms.

Take, for instance, one of the many clips from medical shows depicting an arrogant young intern ignoring and/or being rude to nurses and other support staff.  Obviously, one should not ignore or be rude to nurses or support staff.  But what happens when there’s a legitimate difference of opinion?  Who’s ultimately accountable for the patient’s care, and how should the decision-making and teamwork process go from there?  What if someone is advocating for something that is just plain wrong?  These things happen.  Hiding behind a series of feel-good maxims about professionalism doesn’t prepare anyone for the tradeoffs they will encounter in the real world.

The reason I started thinking about this again was because of some remarks made by a SUMS assistant dean at our latest class meeting.  As I’ve written before, at SUMS the threshold for “official professionalism incident reports” to be placed in the files that get sent to residencies can potentially be pretty low; even minor lateness to class or with administrative deadlines could potentially be punished this way.

At this meeting, the dean provided, sua sponte, an attempted justification for the breadth of this policy, and the school’s apparent willingness to make use of it (fortunately, this isn’t known to me firsthand).  According to him, studies have found correlations between medical school disciplinary action and state medical board action; the biggest predictors of subsequent license sanctions for medical students are apparently” irresponsibility” and “diminished ability to improve or take criticism.”

These are bad things, and it’s not surprising that these traits in medical students would be correlated with subsequent disciplinary action as physicians.  Nonetheless, part of me still wonders if this correlation might not suggest causation.

When ethics and professionalism are treated as Platonic Maxims to be taken as dictated from the Faculty Above, with no room for thought, discussion, criticism, or engagement, might not a medical student facing sanction for unprofessional conduct — particularly if that conduct is a minor instance of tardiness — become disengaged from the entire set of ideals that professionalism is supposed to represent, thereby becoming more prone to major breaches later in life?

When ethics and professionalism, instead of representing the ideals of meaningful commitment to patients, come to be associated with arbitrary-seeming exercises of power by medical school administrators or as ways of stifling legitimate discussion about the role and behaviours of physicians, might not a student learn to distrust these concepts later in life?

When students are threatened with inflated artificial sanctions in lieu of facing the actual consequences of their actions, what does it teach them about autonomy?

I usually don’t display these sorts of blatantly anti-authoritarian leanings, and I’m not asking these questions to cause a ruckus or make a point of any sort.  I’m legitimately curious, and mildly concerned, about the implications of this approach to the teaching of ethics and professionalism to medical students.

These are the sorts of questions I would have loved to have asked him.  I might have even started a conversation that would have been so informative as to alleviate my concerns entirely, or maybe raise them in his mind.  Such potentially valuable exchanges of ideas, however, will have to wait until I’m actually permitted to initiate them.

***

* – I use “prove” here in the sense of “demonstrating the existence of the rule” but also in the sense of “testing the boundaries, applicability, and viability of the rule.”

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