NYT op-ed on ethical training in medical school

[CitrusPeel]

I wanted to share this piece by Carl Elliot in the New York Times because it struck a chord with me. He argues that many doctors don’t oppose ethics violations because the culture of medical training teaches them to doubt their own moral instincts. There have absolutely been times when, while working in hospitals or in medical research, I’ve felt that something about a study or the way a patient was treated was “off.” When I was an RA, I was able to advocate for what I thought was right because our process was deliberative and, frankly, I had job security. However, in more clinical settings, I was working under people who had way more training than me and whose good intentions I trusted, and I often put my concerns down to inexperience.

We’ll still be the least-qualified people in the room when we get to medical school, but someday the buck will stop with us. So my question is: how do we hold on to our moral instincts in training and teach ourselves to stand up for what we think is right, when there’s so much implicit pressure not to?

*to add my 2 cents: the way our medical system works causes us to lose touch with our sense of justice, because we’d — well, I’ll speak for myself — I’d just be outraged all the time. I don’t think a profit incentive in healthcare is compatible with the interests of patients, and on a more immediate level, injustice is so normalized I started to be inured to it. You have to be, or how would you get patient care done? But if we keep going like this, how will the system ever change?

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[Mr.Smile12]

Fantastic points. Moral distress is fueling the healthcare burnout epidemic. Is it ever appropriate to speak out? Where you are working or who you work for determines how you push the brakes on something you intend to do. This is how "medical experiments" are justified by those conducting them.

In our SJT presentations, I present scenarios that can introduce the concept of moral distress: the conflict between what you are supposed/expected to do versus what you would actually do. For example (from the workshop/presentation):

You sit down for a one-on-one interview at a health professional program (Y) a week after you interviewed at your top-choice program (X). The faculty interviewer at Y asks you about other schools where you have interviewed or will interview.

Rank your response from "most effective" to "least effective" among these choices:
You respond by saying:
1: “I interviewed at X last week.”
2: “No other schools have interviewed me.”
3: “I have other interviews, but school Y is my top choice.”

Having run this a few times, most attendees put 1 first (123 or 132). But is that what you would do? I let that sink in.

 

[gyngyn]

Fantastic points. Moral distress is fueling the healthcare burnout epidemic. Is it ever appropriate to speak out? Where you are working or who you work for determines how you push the brakes on something you intend to do. This is how "medical experiments" are justified by those conducting them.

In our SJT presentations, I present scenarios that can introduce the concept of moral distress: the conflict between what you are supposed/expected to do versus what you would actually do. For example (from the workshop/presentation):

You sit down for a one-on-one interview at a health professional program (Y) a week after you interviewed at your top-choice program (X). The faculty interviewer at Y asks you about other schools where you have interviewed or will interview.

Rank your response from "most effective" to "least effective" among these choices:
You respond by saying:
1: “I interviewed at X last week.”
2: “No other schools have interviewed me.”
3: “I have other interviews, but school Y is my top choice.”

Having run this a few times, most attendees put 1 first (123 or 132). But is that what you would do? I let that sink in.

The faculty interviewer has no business being this intrusive.

 

[LizzyM]

Do you have the guts to call out a superior who you feel is doing something wrong or asking you to be complicit in that behavior. I'm thinking of a student who was horrified by the way a woman in labor was addressed by the attending physician and the demeaning things he said to her. The student felt powerless to speak up in the moment and wondered if there was any point in reporting the physician and to whom.

How do you hold on to your moral instincts when the person training you is calling an uncooperative patient a "cow" and asking if she wants to die?

 

[zakimran23]

This is my anecdotal experience as a student, but this issue starts much earlier than as a doctor. In my cohort, I know many premeds and medical students who cheat on their exams, lie about hours, etc. When asked whether they should be reported, more often than not the overwhelming response by other students is "just let it go." They justify it by saying that it will impact the rest of the class or that the person who is cheating will not be able to do so on standardized exams such as the MCAT or STEP. Medical schools have implemented situational judgment tests such as CASPER and Preview. However, they can be studied for just like any other exam, which IMO renders them ineffective. Getting into college, medical school, residency,etc, is difficult; however, if you can't be trusted to follow the most basic rules, such as not cheating or treating patients well, then how can you trusted as a physician with their health?

 

[eteshoe]

Fantastic points. Moral distress is fueling the healthcare burnout epidemic. Is it ever appropriate to speak out? Where you are working or who you work for determines how you push the brakes on something you intend to do. This is how "medical experiments" are justified by those conducting them.

In our SJT presentations, I present scenarios that can introduce the concept of moral distress: the conflict between what you are supposed/expected to do versus what you would actually do. For example (from the workshop/presentation):

You sit down for a one-on-one interview at a health professional program (Y) a week after you interviewed at your top-choice program (X). The faculty interviewer at Y asks you about other schools where you have interviewed or will interview.

Rank your response from "most effective" to "least effective" among these choices:
You respond by saying:
1: “I interviewed at X last week.”
2: “No other schools have interviewed me.”
3: “I have other interviews, but school Y is my top choice.”

Having run this a few times, most attendees put 1 first (123 or 132). But is that what you would do? I let that sink in.

Option 4. "I've interviewed at other programs and I'm excited to learn more about Y".

Of course being a non-trad applicant made me feel less pressure to box myself in or divulge information that I thought wasn't pertinent to the discussion at hand.

 

[Mr.Smile12]

Option 4. "I've interviewed at other programs and I'm excited to learn more about Y".

Of course being a non-trad applicant made me feel less pressure to box myself in or divulge information that I thought wasn't pertinent to the discussion at hand.

I agree, but when restricted to these three, how would you rank them relative to one another. That's the point of the exercise because injecting your own solution is not always available. This is about the tests and not directly your own moral compass.

 

[chssoccer7]

I agree, but when restricted to these three, how would you rank them relative to one another. That's the point of the exercise because injecting your own solution is not always available. This is about the tests and not directly your own moral compass.

Is this part of a training exercise or a medical school interview? As part of a training exercise where answers are discussed, I can see some value. As part of a medical school interview, I would be baffled and annoyed that I am spending money for something this extraneous to the mission at hand.

 

[Mr.Smile12]

Is this part of a training exercise or a medical school interview? As part of a training exercise where answers are discussed, I can see some value. As part of a medical school interview, I would be baffled and annoyed that I am spending money for something this extraneous to the mission at hand.

I do it as a workshop to prepare for SJTs where you don't get a chance to discuss your answers on PREview but you might on CASPER or other interviews. In person workshops allow for discussion while online ones don't.

 

[LizzyM]

I do it as a workshop to prepare for SJTs where you don't get a chance to discuss your answers on PREview but you might on CASPER or other interviews. In person workshops allow for discussion while online ones don't.

I think that this kind of exercise is Bu115hit. I get what it is getting at but when a person has free will to respond in any one of a variety of ways, to limit it to 3 possible responses is not of the real world. I'd really take the results of these sorts of test with a gram of salt.

 

[Mr.Smile12]

I think that this kind of exercise is Bu115hit. I get what it is getting at but when a person has free will to respond in any one of a variety of ways, to limit it to 3 possible responses is not of the real world. I'd really take the results of these sorts of test with a gram of salt.

I just point out in PREview, you are given 7-9 responses that test-takers must assess their "effectiveness" (most effective to most ineffective). The answer key is derived from consensus opinions from subject matter experts in academic medicine (student affairs, diversity affairs, admissions, academic affairs, clinical education). It takes less time for me to write up 9 options on a Powerpoint slide and discuss them all. Ideally, we'd go over both PREview sample tests and go through the answer key to each of the 186 (x2) responses possible.

What makes the PREview exam tough that I cannot address directly is distinguishing between "most effective" vs. "effective" vs. "not effective" vs. "most ineffective." Presumably a candidate can get partial credit if they are "close" to the consensus answer. Talk about bul... the answer key doesn't show me how partial credit is awarded.

The UCAT SJT ranking questions only involves 4 response options to weigh, and the exam is standardized so that plausible outcomes are more likely to be ranked. They also use fewer scenarios compared to PREview or Casper.

I leave it up to adcoms to determine how much they are willing to take PREview results into consideration, but 30+ schools are doing "research" with scores to see if there is validity/predicatbility to overcome any thoughts that the test is a load of bunk. AAMC Admissions Initiative took 10 years worth of research to build this test this way with a fair amount of pilot testing. A recently published study suggests that results correlate with faculty ratings of interview candidates (noting the faculty mostly are "research-only" in the study FWIW).

 

[Mr.Smile12]

Letters to the editor

Opinion | Ethical Lapses in the Medical Profession

Readers discuss a guest essay by a doctor calling for changes in the medical culture. Also: Columbia donors; a Florida bookstore; a balloon release ban.

www.nytimes.com

 

[CitrusPeel]

Came back from a vacation to find all these thoughtful, nice responses. Thank you all!

In our SJT presentations, I present scenarios that can introduce the concept of moral distress: the conflict between what you are supposed/expected to do versus what you would actually do. For example (from the workshop/presentation):

Oh man, PREView flashbacks. But I don’t understand what this question is getting at, since (like with PREView) you’ve presented the candidate with several non-ideal choices and not a lot of room for creativity. What is their response going to tell you, other than that they can pick the answer that breaks the fewest rules? Are you looking for them to articulate the moral dilemma?

Do you have the guts to call out a superior who you feel is doing something wrong or asking you to be complicit in that behavior. I'm thinking of a student who was horrified by the way a woman in labor was addressed by the attending physician and the demeaning things he said to her. The student felt powerless to speak up in the moment and wondered if there was any point in reporting the physician and to whom.

How do you hold on to your moral instincts when the person training you is calling an uncooperative patient a "cow" and asking if she wants to die?

This is what I was thinking about. Or even, in less extreme situations, not knowing how to voice genuine questions that come off as critical: is this patient being “punished” or discriminated against, or is there a medical reason for the care they’re getting that I don’t know yet?

I don’t know a good solution, other than us as students making a point to support one another and committing to encouraging our own future students to do the same. A physician mentor let me sit in on her Balint group once and it really made an impression on me. I had never heard medical professionals be so open about their difficulties with patients and the moral grey areas in healthcare. Maybe, among ourselves, we should be building more autonomous spaces for free expression.

 

[Mr.Smile12]

But I don’t understand what this question is getting at, since (like with PREView) you’ve presented the candidate with several non-ideal choices and not a lot of room for creativity. What is their response going to tell you, other than that they can pick the answer that breaks the fewest rules? Are you looking for them to articulate the moral dilemma?

What's hard about PREview specifically is the distinction between Most effective and effective (or similarly for ineffective). Given my experience with interviewing, you give people an open form response, 70% of all respondents will pick "the most effective" or most conservative answer. That's great, but it's when you are faced with a situation where you are left with bad options that things can get interesting. In real practice this can happen as individuals become non-responsive to known standard treatments, and all you are left with is a lot of questionable or bad options, moral distress included. I agree that's more for a safe discussion rather than a licensure exam or interview, but discerning to take action among poorer quality options is part of your job.

It also would help to know how "partial credit" is awarded if you are "close" to the consensus answer, but that's a different discussion.