Welcome to Professional Formation Front Page, designed to keep readers up to date on health care professionalism education, assessment, literature, conferences, and grants, as well as interviews with leaders in our field. We hope this newsletter will be the foundation for a strong professionalism community, where educators, students, and practitioners can share, learn, and lead.

The Academy for Professionalism in Health Care (APHC) and Professionalism Formation, which produces this newsletter team, have a vision: A global community of practice that advances conversations and perspectives about the practice, education, and research of clinical professionalism as it evolves. Your input and feedback is welcome. Shall we through our online newsletter and APHC conferences and events, and as a global community of health providers, educators, and researchers in professionalism ‘foster inclusive, trustworthy relationships’ as we explore professionalism in its many facets? That is, how do we foster professionalism in our institutions and units, professional identity formation for various health professions and support sustained commitment to professional intents, actions, and words? This may include a focus on ethics, humanities, education, and remediation. We would like to hear about your innovations, ideas, workshops, and conferences with the aim of fostering professionalism to ultimately support excellent patient and family care and health research.

Professional Formation and APHC launched a podcast, Healthcare Professionalism: Education, Research & Resources.

Released every other Saturday morning, recent episodes include: Dr. Andrea Leep discusses What Does the Reality of Pluralism Mean for Professionalism, Dr. Christine Sullivan talks about Remediation of Professionalism, Dr. Rebecca Volpe shares insights on Professionalization for Students Who Don’t Fit the Stereotype, and Dr. Tom LaVeist discusses The Role of Physicians in Addressing Health Disparities.

Don't miss Dr. Adina Kalet's two podcast episodes including Remediation in Medical Education: A Midcourse Correction and Kern Institute for the Transformation of Medical Education.

You can access the podcast episodes on your favorite platform or at:
https://bit.ly/PF-APHC-Podcast

Everyone will conjure an image in their head when they hear the word “librarian.” Bespectacled, bookish, perhaps wearing a festive cardigan. As a librarian myself, I can say this description is incredibly accurate. Accurate, but not complete.

As a librarian, I am also a medical educator.

As someone without a medical degree or clinical background, it took time for me to identify as a medical educator. Although I was involved in the teaching of medical students, I frequently worked under the assumption that I was less-than a clinician educator. Further, despite holding faculty status at my institution, I considered myself a lowercase faculty member, or faculty with an asterisk; self-induced demotions I gave myself because I didn’t have clinical qualifications.

One article I read on the topic described my feelings in terms of capital: “Non-clinicians lack the symbolic capital accrued through a clinician’s status in the medical school.”1 In other words, in a realm where patient care is sacrosanct, possession of clinical credentials is the ultimate status symbol. Non-clinicians, as a result, often maneuver the educational space on the margins, to the point of feeling or being excluded.

These feelings and experiences of marginalization can have a drastic impact on professionalism for the non-clinician. When someone feels less-than, they often behave less-than, and their commitment to the medical education enterprise can take a nosedive.

It is for this reason that I wish to point to the AMEE guide (No. 132) on supporting teacher identity, especially their advice to “establish formal or encourage informal teacher networks and communities.”2 It is through these networks and communities that professional identity - and the outward expression of professionalism - is supported and enriched.

My understanding of myself as a medical educator really formed when I was welcomed into a community of medical educators from diverse backgrounds, clinical and otherwise. Instead of existing only in the library space, I was drawn in, both proactively and through the championing of others, to discussions and action around mission and vision at my institution.

To be the medical educator I wish to be, I’ve had to get up from the reference desk and meet my users where they are - not only in the classroom, but also where important decisions about the medical curriculum are taking place. But I also couldn’t do it alone. To both feel and be seen as a medical educator also required supporters, across and upwards within my institution, who recognized the value of my involvement.

For example, at my previous institution, senior leadership actively engaged me in decisions about the longitudinal Evidence Based Medicine (EBM) curriculum, a cornerstone of Health Systems Science at the school. Two years later, at the beginning of the COVID-19 pandemic, that experience of belonging gave me the confidence to create and teach a bioethics elective with my colleague, Dr. Bryan Pilkington, on medical crowdfunding. From these experiences, numerous other professional projects and collaborations have developed, even beyond institutional boundaries - all of which have made me the educator I am today.

Am I still sometimes referred to as “the librarian” in conversations with my colleagues? Absolutely. But now - through the professionalism I demonstrate as a medical educator - I know my understanding of myself, and others’ impressions of who I am, encompasses far more than just the stereotypical image of my profession.

Allison Piazza, MHA, MLIS, AHIP is a Clinical Medical Librarian at Weill Cornell Medicine.

References:
1. Hu, W. C., Thistlethwaite, J. E., Weller, J., Gallego, G., Monteith, J., & McColl, G. J. (2015). ‘It was serendipity’: a qualitative study of academic careers in medical education. Medical Education, 49(11), 1124-1136.
2. van Lankveld, T., Thampy, H., Cantillon, P., Horsburgh, J., & Kluijtmans, M. (2021). Supporting a teacher identity in health professions education: AMEE Guide No. 132. Medical teacher, 43(2), 124-136.

Equity in patient care is essential for the ethical practice of medicine. Barriers to the ideal equitable patient experience typically involve prejudice of some sort. In the past 15 years, global migration rates have been steadily rising, a prominent reason for this being conflict in home countries. We have seen, in particular, large numbers of immigrants leaving Muslim-majority countries to seek safety in Western countries (Mohamed, 2018). In the past few decades, Islam, and those associated with it, has been treated as a foreign, unknown, and antagonistic concept. That treatment has spilled into the world of medicine, harming Muslim women, particularly those who wear the hijab. The hijab is a traditional headscarf worn by Muslim women as an expression of faith. It holds significant cultural, religious, and personal meaning. Behind the plethora of reasons behind the practice, Muslim women mainly wear the hijab to identify themselves as members of the Muslim community. Every woman who wears the hijab wears it differently, with each setting different standards, requirements, and personal tastes that make it a very colorful form of faithful expression. Without getting into extensive detail of rulings, the hijab requires that when a woman is in public, or in the company of non-familial men, her body should be covered from head to toe, excluding the face, hands, and sometimes the feet (Alkiek, 2021). Typically, looser-fitting clothing accompanies these coverage requirements. There are many instances of prejudices surrounding the hijab that arise in areas where the Muslim faith is not well understood or not often seen, particularly through ignorance, indifference, and the epidemic of Islamophobia. In the presence of these biases, or sometimes a simple lack of awareness, violation of dignity in women who wear hijab occurs more often than realized. These violations should not go unnoticed but demand education about cultural competency, as their presence highlights a lapse in professionalism for health care systems and providers.

It is not a supplement in care that these violations be addressed but a necessity to protect the patient's dignity. Human dignity is the intrinsic value people possess by the simple virtue of being human. No matter the constituents of a person’s identity - their status, health condition, or experiences - there is an inherent equal worth that is not earned and inversely is never diminished. It is owed to the species, to groups, and the individual. This realization of humans’ inherent worth consequently compels us to behave accordingly to respect each person’s value and ensure it is not forgotten (Andorno, 2014). As physicians pledge against maleficence towards patients and depriving patient dignity, they must concurrently protect their patients' dignity in an equitable fashion, especially regarding care to marginalized peoples who have been systemically diminished (Parsa-Parsi, 2017).

Professionalism in medicine is a foundational aspect that encompasses the behaviors, attitudes, and values that are expected from medical practitioners (Kirk, 2007). It involves a commitment to ethical principles, respect for patients and colleagues, and the continuous pursuit of excellence in clinical practice. The act of ignoring a patient’s values, whether or not one is aware of them, is incredibly unprofessional and reflects poorly on the cultural competency of the physician and the health care field as a whole.

To combat this health care epidemic of the breach of dignity for these patients, which presents an incredibly unprofessional view of the field, the topic begs for education and awareness. Health care providers need to be educated on different patient populations and their boundaries. Women in hijab are no exception to this. Health care providers should learn what the hijab is, the guidelines of hijab, and the accommodations necessary to adhere to said guidelines. These accommodations should be presented to the patient, as it is much easier to be asked if you need accommodations than to ask for accommodations in health care scenarios. Furthermore, awareness of predetermined bias, particularly Islamophobic biases perpetrated by the mass media, should be at the forefront of fighting the violation of dignity in patients who wear the hijab. Professionalism in this case should entail treating each patient as a single individual, taking into account their personal values and not the values that they are perceived to have. Our dignity-based claims in support of our call for greater cultural competence are rooted in an understanding of that concept, which prohibits the humiliating treatment of persons who are possessors of dignity. It is an ethical obligation, we argue, that medical providers preserve dignity by avoiding placing patients in humiliating situations and without greater education about diverse cultural practices, this obligation cannot be satisfied.

Jenna Mustafa is a student at the Hackensack Meridian School of Medicine.
Mirit Girgis is a student at the Hackensack Meridian School of Medicine.

References
1. Alkiek T. Is hijab religious or cultural? how Islamic rulings are formed. Yaqeen Institute for Islamic Research. Accessed June 18, 2024. https://yaqeeninstitute.org/read/paper/is-hijab-religious-or-cultural-how-islamic-rulings-are-formed.
2. Andorno , R. (2014). Human Dignity and Human Rights. In H. ten Have & B. Gordijn (Eds.), Handbook of Global Bioethics. essay, Springer Reference .
3. Kirk LM. Professionalism in medicine: definitions and considerations for teaching. Proc (Bayl Univ Med Cent). 2007;20(1):13-16. doi:10.1080/08998280.2007.11928225
4. Mohamed B. New estimates show U.S. Muslim population continues to grow. Pew Research Center. January 3, 2018. Accessed June 18, 2024. https://www.pewresearch.org/short-reads/2018/01/03/new-estimates-show-u-s-muslim-population-continues-to-grow/.
5. Parsa-Parsi RW. The Revised Declaration of Geneva: A Modern-Day Physician’s Pledge. JAMA. 2017;318(20):1971–1972. doi:10.1001/jama.2017.16230

The holiness approach varies among people; its perception and integration into life value differentiate people, making them connected at variance, following differing disputes with consequences on human life.

Static and dynamic life forms are perpetually transient on the planet and put in front of humans the creation problem: Who, why, what, and to whom necessitate all that is deciphered partially, much of it remaining a mystery. God could never be understood since the divine’s magnified and bright work blinds all when they come to explore its interrelated nuances. Humans can control various life forms on earth but cannot comprehend or control divinity.

Faith can provide us with stability and wealth when we follow the rules given to us by the teachings of God and his chosen disciples. Living in a clean environment and being fair, respectful, trustworthy, and honest can lead to a prosperous and fulfilling life. When we maintain our wholesome nature, we become closer to divine energy, which can significantly and positively influence our existence. Being mindful in our work and caring for ourselves and others reward us with better inner workings; its energy can align with the Universe’s positive energy and resonate with it, improving well-being. We must strive to create positive outcomes in all our endeavors.

Individuals must emphasize the benefits of reasonable work and a healthy lifestyle in a suitable environment to maintain and improve their welfare. When feeling unwell, taking the time to reflect on past actions and attitudes in daily interactions with others can help identify any harm caused and allow steps to be taken to rectify the situation. This can be a small step towards restoring the body’s functioning, as mental health is essential in governing all bodily functions.

God invites us not to make more mistakes. Errors cause harm to both the receiver and the person who created the error. The negative energy of the thoughts and emotions associated with these errors can also disturb the contributor’s mental and energetic state, leading to more or less clinically expressive disorders.

Healing human disorders means dealing with darkness and restoring light to the affected area; to do that, we need assistance with thought power. Considering divinity as an indefinite spring, our thinking expects support in troubled times; to receive this help, we must be diligent in our daily lives and struggle to align ourselves with the Universe’s positive energy. By doing so, we can refine our microcosm and achieve overall welfare.

People aspire to perfection but must have an appropriate configuration to achieve it. With dirty life arrangements, you can never be bright. By cleaning up our surroundings, purifying our thoughts, and engaging in proper work, we can attain a peaceful inner life that interrelates with divine energy.

Human hearts are changeable over time, and they want another one - a stable adoration that can support them through life’s ups and downs. God continuously sustains and reinforces them when they follow Its principles.

In today’s digital age, it has become increasingly important to have a basic understanding of different religions across the globe due to the rising movement of people. When managing medical disorders, it is necessary to approach discussions with patients regarding their religious beliefs appropriately. Medical teams must honor people's opinions on divine creation and human life. Furthermore, their relationship with the patients and their families should facilitate patients’ involvement in decision-making concerning their viewpoints and practices relating to the existing divine.

Sofica Bistriceanu, MD, PhD, is a Family Physician and the representative of Academic Medical Unit- CMI in Romania.

A group of blind men encounter an elephant for the first time. Each person touches a different part of the elephant—its side, tusk, trunk, knee, ear, and tail—and makes assumptions about the shape, size, and appearance of the whole elephant based on their individual experience. Perhaps unsurprisingly, the group's descriptions of the elephant differ significantly from one another.

This parable (Majumder, 2017) can act as an analogy for the ways in which ableist ideals are perpetuated within discussions of medical professionalism. Just as the blind people in the parable address only one part of the elephant and make assumptions about the whole, medical students and educators often develop similarly fragmented understandings of disability based on individual, limited interactions with patients and learners. This is problematic in that holistic understandings of disability, and disabled learners’ needs, are critical in ensuring that the education and practice of medicine, including education and practice relating to professionalism, are inclusive by design (Persson et al., 2015).

This narrow perspective is often reinforced by the hidden curriculum. The hidden curriculum is “a set of influences that function at the level of organisational structure and culture,” or “the unintended, unofficial learning” students engage in whilst present within educational environments (Brown, Hafferty, and Finn, 2020, p.1). The hidden curriculum is powerful, and its influence means that many students come to understand that certain abilities and attributes are implicitly valued over others. This leads to the development of a specific, normative ideal of what it means to be a “professional” physician (Brown et al., 2020).

Normative ideals of professionalism within medical education emphasise physical and cognitive traits that align with ableist standards. By ableist standards we mean expectations that discriminate against disabled people (Peña-Guzmán and Reynolds, 2019), e.g., prioritising speed of cognitive processing in decision-making (Croskerry et al., 2014) and valuing the ability to work in busy, noisy environments without accommodation (Shaw, Doherty, and Anderson, 2023).

It can be difficult to identify the ableist norms shaping our conceptualisations of professionalism within medical education. The hidden curriculum is, by definition, hidden – as Martin (1994, p.158) muses “[it] is not something one just finds; one must go hunting for it.” Literature on the sources of hidden curriculum can signpost us to possible ways in which ableist norms act to shape our understanding of professionalism – or, where in plain sight, they are hiding. Finn and Brown (2023) categorise sources of the hidden curriculum into: Environmental sources (e.g., the physical layout of a space); behavioural sources (e.g., the attitudes and role modelling of faculty); resource sources (e.g., case studies and textbooks); and sources within oral culture (e.g. how things are said, and stereotyping). Of course, how ableist norms relating to professionalism manifest will differ between contexts, e.g., between institutions, between international contexts. Identifying and addressing sources of the hidden curriculum contributing to the propagation of ableist norms within local contexts requires concerted effort from educators and leaders within the medical education community. Here, we consider the hidden curriculum of ableist norms relating to professionalism within medical education scholarship to offer an example of how this can be approached, and the potential strategies for enhancing inclusivity within professionalism education.

In 2020, we conducted a focus-group qualitative study with 39 medical students from one medical school, and 14 faculty (Brown et al., 2020). What we found surprised us. We set out to inductively explore what the “hidden curriculum” meant to students, and how they would apply this concept to their own experiences of medical school. We expected to hear wide-ranging stories regarding the hidden curriculum, but most groups chose to discuss professionalism. The students saw professionalism negatively: “Professionalism… is the things we shouldn’t do” and perceived the hidden curriculum as a vehicle to communicate the views and standards of those at the top of medical and educational hierarchies.

In wider literature, we see this play out in relation to ableism – those at the top of hierarchies, after all, are usually White, abled men (Legha and Martinek, 2022). The discourse of professionalism in medical education has traditionally involved emphasis on traits such as resilience (Wald, 2015), independence (Birden et al., 2013), and selflessness (Hafferty, 2008). Though perspectives are beginning to shift, with debates regarding the impact of promoting values such as altruism (Burks and Kobus, 2012), and resilience (Yuan, Reimer and Minkley, 2023), radical change is yet to occur, and our conceptualisations of professionalism continue to be to the determinant of many learners. Where disabled people are expected and pressured to conform to ableist standards, there are associated negative impacts on mental health, wellbeing, and attainment (Lindsay et al., 2023). Conceptualisations of professionalism defined using ableist ideals and communicated through the hidden curriculum imply that professional physicians must adhere to able-bodied norms, marginalising those who, for whatever reason, cannot.

Alongside drawing attention to the presence of ableism and the role of the hidden curriculum in discussions of professionalism within medical education, it is important we consider how medical education can challenge these hidden and entrenched norms. Exploring sources of the hidden curriculum within local context is a positive first step, but we must move beyond naming ableism, to actively dismantling it. We can consider “universal design” (Jain, 2020) as a way of doing this. Universal design involves the creation of learning environments accessible to all students. Rather than taking an individualistic approach to supporting single learners to overcome barriers, universal design advocates for the creation of environments free of barriers (Jain and Scott, 2023). This means creating curricula, assessments, and educational environments that cater to a wide range of student needs. For professionalism, a universal design approach may involve redefining professional competencies – ideally this would be done in conjunction with learners themselves but may involve, for example, prioritising collaborative working, over individual resilience. Approaches to teaching and learning may also shift – offering multiple ways to learn about, and demonstrate professionalism enables participation from a wide range of learners, whilst ensuring visible representation of disability within faculty role models and curricula content is important in promoting a holistic understanding of disability. The application of universal design in teaching professionalism also means fostering a culture that enables learners and faculty to actively challenge ableism, racism, sexism, and other forms of discrimination.

Ableism influences our ideas of what it means to be a “professional” physician, and this works within the hidden curriculum to subtly enforce a set of narrow standards that marginalise disabled learners. To dismantle these entrenched ideals, medical education must consciously adopt inclusive practices, such as universal design. Only through such intentional and systematic reform can we ensure that our future physicians are equipped to serve and represent the diverse populations they will encounter.

Megan E.L. Brown, PhD, is a Senior Research Associate at the School of Medicine, Newcastle University, Newcastle, UK.
Gabrielle M. Finn, PFHEA, NTF, FAS, FRSB, is Vice Dean for Teaching, Learning and Students at the University of Manchester, Manchester, UK.

References
Birden, H., Glass, N., Wilson, I., Harrison, M., Usherwood, T. and Nass, D., 2014. Defining professionalism in medical education: a systematic review. Medical teacher, 36(1), pp.47-61.
Brown, M.E., Coker, O., Heybourne, A. and Finn, G.M., 2020. Exploring the hidden curriculum’s impact on medical students: professionalism, identity formation and the need for transparency. Medical Science Educator, 30, pp.1107-1121.
Brown, M.E., Hafferty, F.W. and Finn, G.M., 2020. The hidden curriculum and its marginalisation of Longitudinal Integrated Clerkships. Education for Primary Care, 31(6), pp.337-340.
Burks, D.J. and Kobus, A.M., 2012. The legacy of altruism in health care: the promotion of empathy, prosociality and humanism. Medical education, 46(3), pp.317-325.
Croskerry, P., Petrie, D.A., Reilly, J.B. and Tait, G., 2014. Deciding about fast and slow decisions. Academic Medicine, 89(2), pp.197-200.
Hafferty, F.W., 2008. Professionalism and the socialization of medical students. Teaching medical professionalism, pp.53-70.
Jain, N.R., 2020. Frameworks for inclusion: toward a transformative approach. Disability as diversity: A guidebook for inclusion in medicine, nursing, and the health professions, pp.1-13.
Jain, N.R. and Scott, I., 2023. When I say… removing barriers. Medical Education.
Legha, R.K. and Martinek, N.N., 2022. White supremacy culture and the assimilation trauma of medical training: ungaslighting the physician burnout discourse. Medical Humanities.
Lindsay, S., Fuentes, K., Ragunathan, S., Lamaj, L. and Dyson, J., 2023. Ableism within health care professions: a systematic review of the experiences and impact of discrimination against health care providers with disabilities. Disability and Rehabilitation, 45(17), pp.2715-2731.
Majumder, M., 2017. The blind men, the elephant and the well: A parable for complexity and contingency. Water Diplomacy in Action: Contingent Approaches to Managing Complex Water Problems. London: Anthem Press, xiii–xvii.
Martin, J. R. (1994). What should we do with a hidden curriculum when we find one? In Changing the educational landscape: Philosophy, women and curriculum (pp. 154–169). New York, NY: Routledge. Metcalfe, J., Wilson, S., & Levecque, K. (2018). Peña-Guzmán, D.M. and Reynolds, J.M., 2019. The harm of ableism: Medical error and epistemic injustice. Kennedy Institute of Ethics Journal, 29(3), pp.205-242.
Persson, H., Åhman, H., Yngling, A.A. and Gulliksen, J., 2015. Universal design, inclusive design, accessible design, design for all: different concepts—one goal? On the concept of accessibility—historical, methodological and philosophical aspects. Universal Access in the Information Society, 14, pp.505-526.
Shaw, S.C., Doherty, M. and Anderson, J.L., 2023. The experiences of autistic medical students: A phenomenological study. Medical Education.
Wald, H.S., 2015. Professional identity (trans) formation in medical education: reflection, relationship, resilience. Academic Medicine, 90(6), pp.701-706.
Yuan, J.H., Reimer, R. and Minkley, M., 2023. Beyond resiliency: shifting the narrative of medical student wellness. Canadian Medical Education Journal.

In the digital era, people’s lives have changed; virtual interaction is preferred to traditional in-person cooperation since it is more comfortable, saving time and travel expenses. Individual online data, including verbal and non-verbal communication, provide a picture of their value, and further collaborators can make an informed decision when selecting them for their business expansion.
Life balance plays a crucial role in maintaining equilibrium for individuals.
Increased mental and physical activities can lead to tiredness; excessive fatigue causes inappropriate control of bodily functions, and errors in work appear.

In the health care industry, inaccuracies in practice can adversely affect human life quality and expectancy. Mistakes can result in poor clinical outcomes, customer dissatisfaction, and low adherence to the therapy plans. This, in turn, affects the provider’s reputation, decreases investment return, and leads to business instability and discontinuity. Usually, a patient’s negative experience predicts their disloyalty to the provider. For the next episode of care, the patient and their families may search for a new provider from the offerings. These frustrations can hurt the patient’s emotional well-being, leading to various disorders such as depression, heart disease, or metabolic abnormalities. The patient’s suffering can also extend to their loved ones who resonate with them, affecting their health.

Therefore, provider burnout must be considered a critical factor affecting a practice’s standing by determining the customer’s negative experiences.
Gaps in instruction or mental disabilities in handling data in daily work also lead to errors in practice. And so, expertise in the domain prepared for is mandatory. Work impairment, determined by various medical conditions, must be identified and managed accordingly. If deficiencies in instruction are combined with work impairment, unskilled interaction with the patient, and tiredness, then summative adverse effects on the end users are accounted for, which can be disastrous for a medical professional’s social and professional life.

A health care expert who accumulates fatigue often makes errors in practice. Quality work, not workload volume, ensures a good reputation, personal satisfaction, positive patient experience, and loyalty, predicting a positive trajectory in business evolution.

Medical data is now available online, which can assist individuals in instruction. That can stand in for a medical professional informing people how to prevent and manage disorders. Transferring this task to virtual assistants, with connected informative programs, makes their work easier and less time-consuming, preventing burnout.

Telemedicine, on-site clinics, and remote work positively impact health care professionals’ lives and reduce burnout. Advancement of technologies facilitates instant communication, following better decisions in clinical practice with good results.

Environmental characteristics adjusted to the personal data for proper work, skills of interaction with others, avoidance of rude chat, food intake value adapted to the individual needs, a well-calibrated sleep program, and working and recreational activities in balance lead to a healthy personal life.
Burnout represents a deficiency in maintaining human equilibrium and attaining a satisfactory societal existence. When combined with other errors in calibrating life value, we can assist in terrible consequences at the individual and collective levels.

The ability of an individual to choose a suitable workplace, have loyal collaborators, work in a friendly environment, and balance distress when it arises with recreational activities envisions a successful way of life for themselves and others in a constantly evolving world.

Sofica Bistriceanu, MD, PhD, is a Family Physician and the representative of Academic Medical Unit- CMI in Romania.

As a follow-up to the November 2023 APHC virtual conference “Reimagining Professionalism: Using Cultural and Generational Lenses,” here is a review of a front-runner book on what we can expect from Generation Z (b. 1995-2010) in our teaching/learning and mentoring of beginning health professionals. Steve Robertson, spending three decades in talent acquisition for camps and enrichment programs for youth ages five to 18 from almost all states and many countries, gives us “raw knowledge” and wisdom on “how to deal with” the Aliens Among Us.

Robertson gracefully and passionately warns parents, employers, and educators not to roll their eyes and cling to a new adage, “Don’t trust anyone under 30.” He is optimistic that “the kids are all right.” He structures the book around Ten Surprising Truths about Gen Z, with each chapter giving detailed and vivid symptoms of these peculiar creatures, the root causes (especially the pace of technology), and how to “treat” them by leveraging their unique assets.

A founding premise that cannot be overstated, given we all know something about the changes in generations, he makes a compelling case that this generation and its consequent affects are unique given this generation:
o is completely a digital native—more so than Millennials (b. 1980-1995);
o is “wired differently;”
o will not assimilate, as with the smooth transition as other generational changes;
o is the first generation mentored primarily by their peers; and
o will change us in significant ways.

Robertson gives robust examples to the gestation of this new generation. He explains the consummation as a Perfect Storm given Gen Z kids were exposed to a) rapid advances in technology, b) pervasive onslaught of news and messages, c) rewriting of their brains through social media, and d) lack of parenting and leadership at this moment. The latter is significant in the important role we play in academic and professional formation.

While the word “paradox” does not appear in his book, I found as I worked through the chapters this descriptor came to mind. For example, while they are growing up faster than other generations, they are slower to mature. They consider themselves their own CEO but need a “Guide Positioned at their Side” in more times than they realize. On the one hand, they have an entrepreneurial and gig economy spirit but are not risk tolerant like the Boomers (b. 1950-1965).

Robertson walks us through a range of characteristics of Gen Z from some that are endearing, to the quirky, to some even concerning, without making normative comments. As he writes after each one: “This [change] is not good or bad—it just is. We must adapt and learn to deal with these new realities.”

So, what do they need us for (Boomers, Xers, and even Millennials)? And what does knowing all this have to do with professional formation? Robertson with his extensive “in the field” experience with Gen Z confidently states that they have four areas underdeveloped: 1) communication, 2) problem solving, 3) perseverance, and 4) gratitude. Now more than ever pre-licensure and continuing education educators and mentors need to be involved in formation of the whole person, not simply “training” knowledgeable, skillful, and compassionate clinicians. Taking on these four underdeveloped areas is a challenge.

Chapters 5 (growing up fast and slow), 7 (first generation mentored primarily by peers), and 9 (They need a Guide by their Side.) are salient readings for the work we do in professionalism formation. Here is key advice he gives to parents, employers, and educators.

First, as you learn more about Gen Z, commit to seeing them through a new lens. Get ready for something completely different. Switch from being a Sage on the Stage to a Guide by their Side. Teach, coach, or parent with hyper intentionality. Find mutually uncommon ground activities. Don’t put away the wisdom you can share; while they have a lot of raw knowledge, your wisdom and legacy knowledge can be useful—get in their way. In getting in their way and establishing relevancy, use a subtle “invisible curriculum.”

As a couple of parting shots on the review, I think it important that as we work with the “communication” shortcoming, we look at this more as getting clear on expectations. Gen Z’s flat affect is not so much that they are ignoring us, but they are not sure of what to do next. The lack of gratitude is a novel area that members of APHC are well suited to address.

Stephen F. Gambescia, PhD, MEd, MBA, MHum, MLS, MCHES, is professor and director of a Doctor of Health Science program at Drexel University and a consummate Baby Boomer.

Aliens Among Us: Ten Surprising Truths about Gen Z. (2022; Battle Ground Creative, 231 pp.).

There are countless examples of lawyers portrayed both on screen and in print. Fans of onscreen legal dramas will recall, Saul Goodman from Breaking Bad and Better Call Saul. The show depicts a man who works as a mailperson in a law firm to put himself through law school. Even as endearing as his character is, he is a con man using the law to his personal advantage in the most unethical ways. In fact, the show is a masterclass on what not to do as a lawyer. From, Atticus Finch to Perry Mason; from shows such as Law & Order to Suits, being a lawyer focuses on going to court, either prosecuting the bad guys or defending the good ones. Scenes are centered on courtroom drama with the adversarial nature of litigation on full display. And almost every finale involves the lawyer triumphing through a protracted courtroom battle (think A Few Good Men).

But this is just a slice of what the law and what lawyers do on a routine basis. Indeed, what lawyers engage in is not much different from bioethicists a point that has perhaps resulted in the proliferation of JD/MBE programs. That is, to provide counsel, support, and reassurances to clients many of whom are in varying amounts of distress. For lawyers, these scenarios can range from the mundane to violent crimes but can also fall squarely in the realm of bioethics in areas such as estate planning.

Lawyers assisting clients in estate planning are often also involved with end-of-life care planning. As a pedagogical matter, estate planning (trusts and wills) is a part of the law school doctrinal curriculum. Unfortunately, and not unlike medical schools, there is no mandatory class on how to develop the skill set necessary to communicate and engage with clients in these conversations. If students wish to develop such skills, some law schools particularly those connected with a medical school, provide elective clinical or experiential learning courses. Yet, estate planning and more specifically, end-of-life care planning is a critical and essential thing to do.

It is advisable that all of us have an estate plan – it need not be completed by a lawyer in some states – but at the very least an articulated plan for what to do with one’s estate and if ever in a life altering situation. When elderly clients seek counsel for estate planning including end-of-life care, they often are accompanied with an adult child, close relative, or friend. This is particularly relevant when there is mild-to-moderate cognitive impairment of the client. In this case, two major ethical issues arise for the lawyer.

The first is when a client seeks counsel; the lawyer must ensure that there is no conflict of interest. This happens when for example, the lawyer represents both spouses in a married couple. Another example is when the adult child brings the elderly parent to complete an estate plan. The recommendation is for the lawyer to remain diligent and follow the client not the suggestions of her child. But this can be problematic in practice. This is particularly the case as a fair amount of time will be spent talking to the caregiver or close friend or relative about logistics (setting appointment times, expectations of the appointment). Further, in many cultures, it is not uncommon for children of elderly parents to be an integral part of their estate planning. Indeed, the client may want to consult and discuss the options with the children before arriving at a conclusion. Intergenerational families often live together and having some cultural humility can enhance the lawyer’s ability to navigate this situation.

Second, in order to proceed with the estate planning process, the lawyer needs to ensure her client has what is called testamentary capacity. Formal definitions of this include, “ the ability of a person to make a valid will; most states have both an age requirement (usually 18 years old) and a mental capacity requirement. To have mental capacity the testator must have the ability to know the nature/extent of property the natural objects of her property; the disposition that her will is making and the ability to connect all of these elements together to form a coherent plan.”[1] Simply stated, it is the ability to be cognitively aware of what is being done in the process of estate planning. Before signing documents, the lawyer must ensure that her client has met the threshold. Having a client with mild to moderate cognitive impairment adds a layer of complexity to what is likely an already fraught process. An ongoing relationship with the client’s physician can help the lawyer feel reassured that her client maintains testamentary capacity. However, with some clients, on occasion, even whilst having done well on a cognitive evaluation with her physician, may present to the lawyer with some evidence of impairment. In other words, the lawyer may feel that the client is not fully cognitively aware even if the physician’s evaluation said so. This usually happens when the physician’s evaluation and the client’s visit with the lawyer are weeks apart. But this can also occur when the appointments were in proximity of each other. What reassurances can the lawyer have that her client has testamentary capacity? How should the lawyer proceed? Should the lawyer be trained in performing a cognitive evaluation during a client meeting?
Coordination with the healthcare provider is key as the knowledge and awareness of the mental capacity should be well established. Any shifts in impairment noted by the provider should then be properly notified to the legal team.

Like bioethicists, lawyers are taught the fundamental principle to provide counsel in the client’s best interest. But often, in practice factors impact how this plays out. Some scholars have recommended using a one-page condensed cognitive evaluation test that the lawyer can easily administer in the client meeting. But this requires training the lawyer in administering and scoring the test. As these issues become increasingly more prevalent and duly attended to, perhaps more definitive and evidence-based recommendations will be established.

Lynette B. Martins, LL.B., PGDip., MBE, LL.M., is a Law and Bioethics Scholar and Former Senior Research Fellow at the Solomon Center for Health Law & Policy at Yale Law School.

[1] Legal Information Institute Cornell Law School (www.law.cornell.edu/wex/testamentary_capacity)

Medical school professors have occasion to remind students that the Latin root of the word for “doctor” means to teach. It might be in a session on the importance of informed consent and the talk back method, in an argument about why pathologists or other trained professionals (as opposed to the patients themselves via their smartphones) should view the results of a lab report, or merely to refocus a class on the lecture at hand. However, are doctoring and teaching – both of which have been considered professions – as close as their etymological origins might suggest, or do the ethical and professional obligations of those occupying each role diverge? What if an individual occupies both roles? Situations in which physicians train future professionals raise interesting and important questions along these lines: If physicians owe something to the greater public and teachers owe something to their students, what do physician teachers owe when potential future professionals do not meet certain expectations?

As academic medicine increasingly attends to student wellness and balance, both of which are important and needed initiatives, what do faculty members owe to patients when academic rigor is redefined? Does this increased emphasis on student well-being and the pressure for students to succeed present a dilemma to the medical educator? These questions are raised in an educational context in which grading systems have been re-examined in recent years – indeed, more than half of U.S. allopathic medical schools using a pass/fail grading system for the pre-clerkship curriculum shift to pass/fail curriculum1, and the results of Step 1 of the United States Medical Licensing Examination (USMLE), which tests the foundational science knowledge that differentiates physicians from other providers, are now reported as pass/fail2.

Changes in favor of student well-being have been made with good intentions but can sometimes allow for less rigorous standards as a byproduct. What happens if this leads to lower quality patient care? Professional teachers are not bound by patient outcomes or the tenets of the Hippocratic Oath, but physicians are. What of physician teachers? There are three main beneficiaries of sound medical education: Students, Patients, and Society as a whole. The stepwise acquisition of medical knowledge and skill to become a competent physician is a daunting process, and academic medicine faculty have a responsibility to both students and to the patients their students will care for. These patients deserve physicians with a deep understanding, among other things, of pathophysiologic mechanisms of disease and knowledge of how to apply it to diagnose and treat disease. Patients also deserve physicians who are experts in the breadth of the literature and well versed in where the evidence for a given intervention is clear, and where it is not. In this era of an abundance of resources and information of varying quality at the fingertips, the medical educator must be steadfast in a commitment to provide the structure to support students in the acquisition of high-quality lifelong learning skills.

The potential conflict that can exist, given these different spheres of morality, is more common in certain areas of medical training. Medical professors working in the pre-clerkship curriculum are generally PhD medical scientists who teach in the foundational sciences. However, pathologists depart from this norm, as they are usually physicians teaching in this environment. The professional identity of these individuals aligns both with the service of patients and of students, and they do so deeply. When students do not pass a pre-clerkship course at the first go, for example, faculty typically experience a great amount of distress. Worries about a student’s progress, financial aid implications, and a student’s well-being abound. In some cases, these concerns may coalesce to result in the decision to offer a pathway to progress – the move the teacher supports - when, in fact, the student should be held back – a move that the physician considering a future colleague supports – in the interest of patient safety. What professional frameworks should be utilized to ensure that a student’s achievement is balanced with patient safety, and how should those reside in these two spheres to effect positive change?

Jennifer Zepf, DO, is an Assistant Professor at the Hackensack Meridian School of Medicine.

References:
1. Grading systems use by US medical schools. Association of American Medical Colleges. Accessed February 6, 2024. https://www.aamc.org/data-reports/curriculum-reports/interactive-data/grading-systems-use-us-medical-schools
2. Change to pass/fail score reporting for Step 1. United States Medical Licensing Examination. Accessed February 6, 2024. https://www.usmle.org/inCus/

Professionalism is a tenet of medical education that undergirds the institution of medicine while also jabbing at those poised on its foundation. As early as day one of orientation, medical students are advised of the many ways in which professionalism presents and is assessed in medical education. Initially, in the pre-clinical year, it is referenced with respect to punctuality, appearance, and manner of communication with peers and faculty. In the clinical year, it makes up a portion of each rotation’s grade; notably without a rubric at some medical institutions, furthering its position as the amorphous catch-all of ‘good behavior.’ Absent a standardization of the professionalism component, students can over-correct to consummate professionals guarding their opinions and refraining from sharing their thoughts in their medical training.

As a cis-gendered woman in medicine, I would be remiss not to mention the protection that professionalism affords me. With sexually inappropriate comments falling decidedly in the category of unprofessionalism, I feel safe in the knowledge that uncomfortable comments made by attendings or peers can be addressed as such. Without trotting out the scarier term of “sexual harassment,” an inappropriate comment can be defanged with the label of unprofessional. It can be communicated with “I” statements such as, “I felt uncomfortable when xyz comment was made about me because it seemed related to my gender.” An instance where the catch-all of professionalism is helpful in softening an assertion that might not have been considered noteworthy, or entertained by reporting structures, even a decade or two prior to today.

There are also times as a woman in medicine where the importance of staying within the bounds of professionalism keeps me quiet. When attendings bemoan the difficulties male applicants to medical schools face today I can’t help but fail to articulate a response other than sympathy for their waitlisted sons and nephews. As someone who navigated the allopathic medical school application cycle three times across four years, I sincerely commiserate with individuals of any gender who have not obtained an acceptance to medical school as they remain steadfast in their commitment to medicine. But I am still at a loss when an attending looks at me as a woman in medicine and tells me men are having a hard time gaining acceptance to medical school. I can’t help but wonder if my seat in medical school is being questioned. I want to remind them that while women have been making up the majority of medical school classes since 2019 – at 50.5% of students that year¹ – the ratio of graduating male physicians to females was 3:1 with 75% men to women’s 25% as recently as 1980². I want to remind them that there was a time, a long time, when the entering medical school class included 0% women students. But I don’t want any such reference to the facts and statistics to be deemed as unprofessional.

Fielding these statements about medical school acceptances and limited seats brings up the element of race as well as gender when I realize these remarks are being directed to me as an Asian American. In the context of the Supreme Court striking down affirmative action in Students for Fair Admissions vs Harvard this past summer, when an Asian American doctor asks me if I feel that students from all backgrounds have equal grades or discloses that they have heard of low GPAs being accepted to medical school, I can only professionally respond that everyone works hard in medical school. I don’t have the words to phrase how affirmative action barely scratched the surface of trying to address, in a very specific circumscribed way, our country’s history of institutional racism. I don’t have the capacity to unpack the ways we both benefit from the model minority myth as Asian Americans in between conversations on patient management or actual medicine. Even when these discussions unfold over lunchtime, I freeze up and think carefully about how to respectfully disagree.

It is reasonable to say that the above instances of refraining from voicing strong opinions are evidence more of my own non-confrontational nature than of the shortcomings of professionalism. None of the above situations made me feel unsafe or even significantly uncomfortable. They did give me pause and cause me to overthink how to respond. They did make me reflect on what limits me from speaking my mind freely to attendings during non-medical conversations. It is professionalism. For even though I voice differing opinions respectfully, I worry that they will be deemed unprofessional. The professional-in-training can be milquetoast at best when skirting meaningful conversations.

Hajrah Hussain is a medical student at Hackensack Meridian School of Medicine

References
1. The Majority of U.S. Medical Students Are Women, New Data Show. AAMC. Published December 9, 2019. https://www.aamc.org/news/press-releases/majority-us-medical-students-are-women-new-data-show
2. Percentage of U.S. medical school graduates by sex, academic years 1980-1981 through 2018-2019. AAMC. https://www.aamc.org/data-reports/workforce/data/figure-12-percentage-us-medical-school-graduates-sex-academic-years-1980-1981-through-2018-2019

Professionalism in health care encompasses a multitude of attributes, with humility standing out as a key element that not only defines the character of health care practitioners but also plays a pivotal role in enhancing the quality of patient care. Humility, often misunderstood as a sign of weakness is, in fact, an indicator of confidence and self-awareness that distinguishes exceptional health care professionals. In the dynamic and complex world of health care, the ability to embrace and practice humility is crucial for fostering a culture of continuous learning, collaboration, and patient-centered, team-based care.

Broadly speaking, key elements of humility include accurate self-assessment, recognition of limitations, low self-focus, appreciation of others, and awareness of being part of a larger system and universe. While practitioners undergo rigorous training and education, the field is vast and ever-evolving. In turn, humble health care practitioners understand that no individual can master every nuance of clinical knowledge and practice and that professionalism involves ongoing learning and development.

A humble practitioner is more likely to seek out new information, accept feedback, listen attentively to their colleagues (of any professional background), stay abreast of the latest research, and engage in continuous education. In a profession where advancements occur rapidly, humility ensures that practitioners remain open-minded, and adaptable.

Humility is a bridge to effective collaboration in the health care setting. In a multidisciplinary interprofessional environment where diverse specialties converge for the benefit of the patient, the ability to work harmoniously with colleagues is paramount. A humble health care professional values the contributions of others, recognizing that each member of the health care team brings unique expertise to the table. Our research indicates that humility fosters an inclusive and respectful atmosphere, a collaborative spirit that cultivates a supportive work environment where professionals can learn from one another and collectively address complex medical challenges in producing better patient outcomes.

At the heart of professionalism is a commitment to patient-centered care and humility is the compass that guides health care providers in achieving this goal. Humble practitioners understand that health care is a shared journey where the expertise of the provider and that of the patient converge. In fact, studies have shown that patients are more likely to trust and engage with health care providers who approach the care relationship with humility. A humble clinician actively listens to patients, respects their autonomy, and involves them in decision-making processes. This approach not only facilitates effective communication but also contributes to improved treatment adherence and overall patient satisfaction.

Humility is also a critical factor in mitigating medical errors and fostering a culture of safety within health care institutions. In a recent study, we found that tenets of humility appear to buffer the potential noxious aspects of uncertainty in clinical decision making. The ability to seek others’ insights, acknowledge limitations, and learn from missteps are hallmarks of humility and essential for mitigating situations of uncertainty. In a profession where the consequences of errors can be profound, a humble health care professional prioritizes patient safety over ego.

We are now investigating if and how humility is taught (formally and informally) in health professions education, as well as examining the possible barriers and facilitators to the cultivation and practice of humility that may be nested within clinical and non-clinical learning environments. Also, given findings from our previous studies and the connections between humility and status, we are exploring the concept of professional humility - the consistent ability and willingness to: a.) evaluate, account for, and respond to the occupational status hierarchy within health professions, and beyond, b.) understand the strengths and limitations of one’s own profession, and c.) accept and acknowledge the qualities, skills, knowledge, and aptitudes of other health professions and health care team members, including patients and caregivers, in decision-making and care delivery processes. We are currently untangling professional humility from other prominent conceptual cousins such as intellectual humility and cultural humility, as well as showcasing explicit connections to professional identity formation and professionalism in general.

In the demanding and ever-evolving field of health care, humility emerges as a key element of professionalism, shaping the character of health care providers and influencing the quality of patient care. The ability to acknowledge one's limitations, embrace continuous learning, facilitate effective collaboration, prioritize patient-centered care, and contribute to a culture of safety are all manifestations of humility in action. As the health care landscape continues to evolve, the integration of humility into the fabric of professionalism will remain essential for the well-being of patients and the advancement of the noble mission of healing.

Barret Michalec, PhD, is an Associate Professor and Director of the Center for Advancing Interprofessional Practice, Education and Research (CAIPER) at the Edson College at Arizona State University.
Frederic W. Hafferty, PhD, is Emeritus Professor at the Mayo Clinic and the University of Minnesota School of Medicine, Adjunct Professor Yale University Medical School, and Senior Fellow Accreditation Council for Graduate Medical Education.

Who comes to mind when you are asked to think of a “humble” physician? Maybe you think of Hippocrates, the Greek healer whose ethical standards medical students utter every year. Perhaps you are reminded of Dr. Anthony Fauci, the infectious disease specialist who was the face of the country’s defense against COVID-19? Or maybe you reach back to the beginning of recorded history to Imhotep, the first person known to have assumed the role of physician. What if I told you that the greatest exemplar of a humble physician never wrote an oath, appeared on national broadcasts, or had their head sculpted into a bust in a museum? What if I also told you that unlike the names I have mentioned, this physician is a woman?

Dr. Elizabeth Blackwell is one of the great unsung heroes in medicine. She is widely known as the first female physician in the United States and a pioneer of feminism, but her story goes much deeper than that. What interests me most, in my reflections on humility, is what drove her to pursue medicine in the first place. Dr. Blackwell had a terminally ill female friend who remarked on her death bed that she felt she would have had a better outcome if she had been taken care of by a woman rather than the team of male physicians that did not understand her ordeal. Hearing these words from her dying friend, Dr. Blackwell chose not to sit idly, but to enter a career path no woman in the history of the country had taken on.

Dr. Blackwell proceeded to apply to medical schools across the country, one of which was Geneva Medical College in New York. The admissions team allowed the all-male student body to vote on whether Dr. Blackwell should be accepted, and many responded yes, though as a joke. The vote passed and Dr. Blackwell was accepted, much to the dismay of the admissions committee and faculty. She was not taken seriously by the school community and was subject to ridicule and mocking by other students, illustrating a complete lack of professionalism and respect for their classmate. Dr. Blackwell, on the other hand, acted as a model professional, by all accounts; prioritizing education and the pursuit of becoming a physician rather than getting caught up in the drama created by her classmates, she embodied the kind of professionalism needed in medicine today.

Despite the tremendous adversity she faced as a student, Dr. Blackwell eventually graduated first in her class. She went on to become the first female to be published in a medical journal and opened her own practice in New York City. There is now a medal named in her honor to commemorate women who make extraordinary strides in medicine. Her career was characterized by strength in the face of discrimination, and she paved the way for future medical professionals as a pioneer of feminism in health care.

There are many lessons we can learn from Dr. Blackwell about how to embody humility as a professional in health care. For those who have or will embark on a journey similar to mine, to any pre-meds, medical students, residents, or even those who are just thinking about becoming a doctor, I share that we know this process is not easy. Getting into college, scoring well on the MCAT, and passing the board exams are all hurdles we must overcome. Yet, I pause and to think about how much harder that process would be if people harassed me because of gender, religious beliefs, or skin color. Dr. Blackwell dealt with discrimination throughout her career and yet her spirit never wavered. She did not join this field for accolades, money, fame, or power. Dr. Blackwell simply wanted to help others; from the moment her friend expressed the need for female physicians at her deathbed to the last patient she treated in her career. That focus encourages me.

To be a humble physician is to remove one’s ego from the relationship with the patient. Physicians have a sense of what is right or wrong -- some call this conscience -- yet where physicians’ consciences guide them is not always what is best for the patient, from the patient’s perspective. Context matters, a dying woman like Dr. Blackwell’s friend might need the familiar and comforting presence of another woman to improve their disease course. Of course, one could only know this if they asked and listened to the patient. Dr. Blackwell had her ears tuned to what the patient needed, and it changed the course of her life and, by paving the way for a more diverse workforce in health care, the lives of many others.

As a first-year medical student, I have started to think about what it means to be a humble professional in medicine. Dr. Blackwell has taught me that being a good listener is the key to demonstrating respect for patients and my future colleagues. As much as I am excited about interjecting my own thoughts on a condition, lab, or symptom, it is so easy to damage these relationships by dominating conversations and leaving no space for the patient. This insight from Dr. Blackwell will be at the back of my mind at all times as I mature into a physician.

Jack Cucchiara, BS, is a First Year Medical Student at Hackensack Meridian School of Medicine.

References:
1. Blackwell, Elizabeth. "Medicine as a Profession for Women." The Atlantic Monthly, vol. 10, no. 59, 1862, pp. 731-737.
2. Flexner, Abraham. "Elizabeth Blackwell: The First Woman in America to Receive a Medical Degree." Science, New Series, vol. 75, no. 1945, 1932, pp. 582-583.
3. Barry, Kathleen. "Elizabeth Blackwell: First Woman in America to Receive a Medical Degree." Journal of the American Medical Women's Association, vol. 58, no. 2, 2003, pp. 109-112.
4. Wexler, Laura. "Elizabeth Blackwell: America's First Female Doctor." Women in Science: An Encyclopedia, edited by Mary Ellen Zuckerman, ABC-CLIO, 2000, pp. 11-12.
5. Skelton, Renée C. "Breaking the Mold: Elizabeth Blackwell and Emily Blackwell." The American Journal of Surgery, vol. 190, no. 6, 2005, pp. 845-848.

Current literature has attempted to define humility as it relates to the practice of medicine1. Acknowledgement of one’s own limitations, as well as the limitations of current collective knowledge and readiness to admit mistakes are commonly cited as important contributors to humility1–3. Medical humility includes recognition of one’s place in a service-oriented profession and the ability to relate to and work with patients2,3. The literature suggests the use of narrative experiences to instill humility in student physicians1. One area primed to encourage these characteristics is the gross anatomy laboratory, which offers an unparalleled experience. Few individuals are fortunate enough to see life from this perspective and take advantage of this unique learning opportunity. For many students this is their first time in close contact with the deceased. In my opinion, this experience is a catalyst for students to redefine their identity and view of the world in four ways: 1) confronting their own mortality, 2) acknowledging the life that was lived in front of them and the generous gift that was bequeathed them, 3) acknowledging human variation, making predictions about their own anatomy and looking at others in a new light, 4) the uncomfortable process of doing something new as a learning experience. This experience leaves a lasting impression on individuals that they later reflect on throughout their lives.

For younger medical students, in particular, who may have just entered adulthood at the age of 224, the thought of their own mortality may have never entered their mind. Increased risk-taking behavior in adolescence lends itself to ignoring negative outcomes, particularly death. Students are faced with examining their futures as both physician and human. They may reflect on what they wish to accomplish in their careers and how they would like to live the rest of their lives.

Students then come to terms with the fact that the donor lying in front of them once lived a life of their own. They had emotions, family, friends, and goals. Students may reflect on what this person may have accomplished during their life or who they left behind. Basic human similarities between the donors and the students can be jarring. When there is a pathology or hardware visible in the donor, students may reflect on the rehabilitation that person underwent or the hardships they had to live with. At the Hackensack Meridian School of Medicine, where I teach, students spend quality time with their donors, making observations and creating inferences based on what is observed. This not only mirrors the initial intakes they will do as practicing physicians, but gives students time to become acquainted with the individual they will be spending hours with over the coming months. Students can begin to practice respect for patients and appreciation for the trust donors have for them as student physicians.

Once students see the inner structures of the human body, it can be difficult to not project that image on the living. Looking in the mirror, a medical student might begin to visualize the bones of the skull and their own overlying muscles. They may start to take time to appreciate the muscles needed to hold their significant other’s hand. Students may reflect on which variations exist within themselves. Gym days begin to hold more meaning for students beyond the benefits of physical activity.

As new dissectors, first year medical students are required to perform a new skill and utilize the time effectively to enhance content learning. Students often feel as though they should not be dissecting until they have a full comprehension of the content and have practiced making incisions. However, this is a time for discovery and exploring to understand the structural relationships that make up the human body. They are responsible for identifying their own limitations in content knowledge and putting in the time and effort as a learner.

There is no experience quite like dissection-based labs. This experience develops not only skills and content knowledge, but a new sense of self and understanding of their place amongst the human population. Many schools, my own included, celebrate the donors with a Gratitude Ceremony, which gives students an opportunity to express their thanks and reflect on this humbling and empowering experience.

Michelle B. Titunick, PhD, is Assistant Professor in the Department of Medical Sciences at the Hackensack Meridian School of Medicine.

References
1. Coulehan J. “A Gentle and Humane Temper”: Humility in Medicine. Perspectives in Biology and Medicine. 2011;54(2):206-216. doi:10.1353/pbm.2011.0017
2. Li JTC. Humility and the Practice of Medicine. Mayo Clinic Proceedings. 1999;74(5):529-530. doi:10.4065/74.5.529
3. Reynolds CW, Shen MR, Englesbe MJ, Kwakye G. Humility: A Revised Definition and Techniques for Integration into Surgical Education. Journal of the American College of Surgeons. 2023;236(6):1261-1264. doi:10.1097/XCS.0000000000000640
4. Cohen AO, Breiner K, Steinberg L, et al. When Is an Adolescent an Adult? Assessing Cognitive Control in Emotional and Nonemotional Contexts. Psychol Sci. 2016;27(4):549-562. doi:10.1177/0956797615627625

An unspoken rule of being a medical student, and being accepted to medical school, is to be sickeningly positive. “Medicine is great—it’ll be hard, but I will enjoy it so much it’s not even funny, and I’m the person for that job.” You arrive with such humility and find value in every difficult patient, every boring procedure, and every ounce of medical knowledge obtained.

With time, medicine ultimately robs even the most hopeful of prospects bursting with positivity…and perhaps it robs them the most. Because being hit with a ton of bricks hurts that much more when expecting to be met with roses, or even just sticks and stones. I was working as a tech one day and a doctor asked if I wanted to be an MD. I said, “Yes I’m applying this year! Do you have any advice?” She said, “My best advice to you? Don’t. Medicine sucks.”

We all find ourselves in our first pair of scrubs or white coats not yet worn enough to wrinkle instead of crease, look at our predecessors, and we say, “I will never be that jaded.” But the odds are, we will all one day find ourselves, somehow, somewhere, in the shoes we swore we’d never fill.

So what do we hold on to? How do we slow the process of inevitably losing our humility and innocence in medicine? I can at best give you my own personal avenue.

As a young tech with such a sense of humility and innocence, I was desperate to connect with my patients. I chatted with them often—especially my older patients. I would often ask, “So you’re x years old, that’s wonderful. Tell me—what’s the secret to a long, happy life?” Here are a few of my favorite responses.

Some were profoundly motivating. An 85-year-old woman said, “Attitude. I survived breast cancer and now this hip. You either accept the forward movement, or you don’t.” Another, 84-years-old, said, “Stubbornness. It has never steered me wrong. I was born during Hitler and I lived with a pig that my parents tried to hide from the Nazis. When I was 14, I said, ‘I’ve gotta get outta here.’ I got my degree and never looked back.”

Some were hilarious. An 84-year-old man once told me, “Drink a lot of funny water…sometimes I mix it with actual water.” Another, 80-years-old, said, “It’s all about playing the odds. Even if I did crazy things as a kid, you have to do crazy things in a smart way. Did I drive 8 hours at 120 miles per hour? I did. But was I drunk? No! It’s all about playing the odds—you have to stack the deck.”

Some made me ache. An 84-year-old gentleman answered, “The secret to a long happy life? I never did find it.” Another, 78, said, “There’s no secret! It’s just whatever the big man upstairs decides to give you.”

Some hit me just right. An 80-year-old woman said, “The capacity to love and to be loved.” Another, 79, turned to his wife and just said, “Her.” An 80-year-old man said, “Well I don’t know—I turned 80 and my body started to fail me. But the secret to living long and happy to 79 is a good relationship. That’s half of it. The other half is finding and doing things you love.” My favorite word of advice was that of an 87-year-old gentleman. He said, “I guess I’d say go out there and get among ‘em. Go crazy. Go dancing on a Saturday night!”

It appears the secret to a long happy life is different for everyone—as will be what keeps one grounded in medicine. I feel the answer, though, lies in the question: “What would they want me to learn from my patients?” And by they I mean that hopeful ingenue showing up to the first day on the job without a clue in the world what she was in for. What’s on this cancer patient’s bucket list? What meal reminds this GI patient of home? My advice to you is to find your question and ask your patients—you might even find the secret to a long, happy life.

Haley Wymbs, MBS, MD Candidate, University of South Carolina School of Medicine—Greenville

Acknowledgments: My wonderful patients and Ann Blair Kennedy, LMT, BCTMB, DrPH

Having spent a good deal of time thinking about ethical issues that arose during, and might have led to, the recent pandemic as well as responses to it, I have often wondered about two things: the relationship between those of us who receive care and those who offer it, and how this relationship might be (or was or is) strained in certain times of peril but not in others. Though not always at the forefront of ethical reflections on health crises, this relationship is especially important and especially interesting for at least three reasons. The first is historical. However, one traces the history of the current state of health care, even a causal stumbling upon the Hippocratic Oath or a code of ethics of a particular health profession suggests the foundational nature of such a relationship. The second is normative. Discussions of proper roles and boundaries, principles to live by, to practice by, or which ought to govern specific locations where care is offered require that something be said about those offering care and those receiving it. The third is linguistic. Even if leaders at health care institutions were tempted to think persons visit “XYZ Hospital” or “St. Caring’s Health System,” when one speaks with patients, albeit anecdotally, one understands that patients have doctors, see nurses, and visit their physical therapist.

If this is right, what might – and needs – to be said about this relationship and how the state of affairs are to be improved such that, especially in times of peril, it is not strained?

Granted, this is a big question that calls for a series of multifaceted responses and will surely not be answered in a single piece of writing. However, one that comes close to answering it is K. Stuart Kinsinger’s Principles of Professionalism in Health Care: A Guide to Building Relationships or Trust. Kinsinger’s exploration of professionalism offers a strong answer to the aforementioned questions. Early on in his text, he highlights the foundational pillars of all professions: “control over a specialized body of knowledge, and a commitment to the use of this expertise for the good of others,” (Kinsinger, 2023, p. 6) which leads to what he understands as professionalism’s “set”: seven key principles which, together, embody that “one is professing to society the promise of being worthy of trust, professing never to use specialized skills for self service and self reward, but always and without exception, to use such expertise for the greater good, benefitting society” (Kinsinger, 2023, p. 7). This framing leads to helpful reflections on the importance of interpersonal skills, appearance, and attitude, culminating in 10 straightforwardly expressed (yet philosophically rich and interesting!) claims that professionals profess.

The first chapter, like all the chapters of the book, concludes with a helpful “You be the judge” case scenario. Following the chapter on what professionals profess, Kinsinger turns to ethics – relating principles and virtues in an interesting way and returning to the “standard” set of four principles of biomedical ethics two additional and sometimes diminished principles: veracity and confidentiality. From there, chapter three engages the ever-important topic of professional boundaries, taking seriously the vulnerability of patients. Chapter four focuses on conflicts of interest, highlighting the importance of integrity – as well as commitment, forthrightness, and steadfastness, the three virtues that comprise it. The fifth chapter engages professional responsibility, including a helpful section on resolving ethical dilemmas and another on leadership – both the keys to demonstrating it and the entities to which it might be demonstrated. The sixth, and final, chapter discusses fit to practice, with especially useful practical discussions of burnout, humility, and vacation.

What makes this text a good answer to the questions posed earlier is that the discussion of professions is offered in light of reflection on the social contract, where Kinsinger highlights that the benefits to professions (and members of professions) and to society (and patients) are reciprocal. His work here follows the work of Professors Richard and Sylvia Cruess, who offer an excellent preface to the text. In that preface, they highlight that this relationship between health care professions and society can have failures on both sides (Kinsinger, 2023, p. XXIV): each must trust the other, but this is not always the case. The Cruess’ foreward to the second edition nicely follows the sociologically informed foreward to the first edition, written by Ian Coulter, which frames the problem that my question touches on in this way: “The challenge therefore is how to return professions back to the process of professionalization…” (Kinsinger, 2023, p. XIX). Coulter’s answer, with which the review concurs, is education, an answer that he writes “might be partly achieved through such efforts as contained in this work” (Kinsinger, 2023, p. XIX).

Penultimately, another positive feature of the text, not only for those interested in the questions discussed or topics listed in this review, but for anyone interested in (but especially members of) health professions, each chapter has an excellent list of references and resources, with classics from the likes of the Cruesses and Hafferty, as well as from the Kinsinger himself.

For all these reasons and for its well-written nature and clear structure, I commend this book to all; it is a joy to read.

Bryan C. Pilkington, PhD, is a Professor at the Hackensack Meridian School of Medicine..

Kinsinger, F.S. (2023). Principles of Professionalism in Health Care: A Guide to Building Relationships of Trust, Stuart Kinsinger.

In the ever-evolving narrative of medicine, there is a new chapter being penned – not with ink, but with code. The long-standing traditions of medical academia, grounded historically in human cadavers, bedside rounds, and stacks of textbooks and histology slides, now finds itself intertwined with the binary world of zeroes and ones. From serving as a study tool for specialty exams to facilitating practice for objective standardized clinical examinations, artificial intelligence has heralded change across medical education (1-3). No longer is it an abstract concept of the future, but it is our present, shaping medicine as we know it.

As medical students standing at the precipice of this technological renaissance, we are in a unique position. Taking our first steps into the vast sea of medicine, we are tasked with one job: to plunge deep and absorb as much medicine as our minds allow. Our perspectives are fresh, unburdened by the baggage of past clinical practices and established routines. Our application is textbook, unaware that the differential diagnosis that we suggested in rounds is a one-in-a-billion possibility. Our education is formed not solely through the enhancement of our clinical insight but also by attuning ourselves to the whispers within hospital wards. There, concerns are voiced about the escalating dependence on AI, the preservation of the originality of work, the existential question of whether AI will ultimately replace our roles.

It is essential to recognize these concerns; not as an antiquated resistance to change, but as genuine reflection in how technology intersects with the human side of medicine. This delicate dance of technology and humanity is an age-old struggle. Doctors have historically grappled with accepting new technologies: from the stethoscope, feared to disrupt the intimacy of the doctor-patient relationship, to robotic surgery, harboring hesitation in navigating human anatomy through the lens of a screen (4). Each development, while initially met with skepticism, eventually found its natural rhythm within existing practices. Thus, the ongoing challenge is how our generation of doctors will choose to reconcile the old with the new.

In the zeitgeist of the AI boom, picture a pediatrician’s office, akin to the one you visit for your child. From the moment you message your pediatrician about his first cold, AI plays a role: a prompt response, sculpted by a chatbot for precision, subsequently reviewed by the physician for empathy and accuracy. You were advised to bring him in for a check-up. AI seamlessly integrates you into her schedule, processes your insurance, and provides estimates on any anticipated upfront costs. Upon arrival, you notice the wait time was reduced to a mere five minutes. You and your child are whisked away to an examination room. The pediatrician steps in and she fully engages with both of you. She dives in, using AI to illustrate the possible progression of your child’s course using real-time data. Concurrently, the information and details of your child’s visit is recorded into their chart, leaving her with more time to address your concerns and questions. As you leave, you are given a personalized summary of next steps and contingency plans. Reflect on your experience: Did you feel rushed? Were your worries adequately addressed? What happened in that exam room to achieve such expediency?

The pediatrician is one of us. Over the course of her medical training, she incorporated AI into the development of her clinical acumen and practice. She deepened her knowledge of medical physiology by interacting with a chatbot, trained on the most up-to-date medical literature. Recognizing the need to explain complex medical phenomena to her young patients, she used AI to cater the content to different comprehension levels. Through simulated patient encounters, she practiced endlessly across different demographics, presentations, and situations. She fine-tuned her bedside manner and constantly sought to improve based on real-time feedback.

Every step of the visit – from initial contact to final prescription – was supplemented by AI. Likewise, the journey of physicians, once primarily charted by intuition and textbooks, is now enhanced by the precision, efficiency, and expansiveness of it. Yet, the human touch, compassion, and ethical judgment remain irreplaceable, anchoring the core of medical practice (5). As medical students move forward, we must not view AI as an adversary but as an ally, one that has the potential to extend our capabilities, minimize errors, and most crucially, improve patient outcomes. In a world often overwhelmed by its own pace, this synergy of technology and humanity offers a promising horizon – a future where medicine is not only more efficient but also more compassionate.

Jamie Chen and Angelo Cadiente are students at the Hackensack Meridian School of Medicine, Nutley, NJ.

References:
1. Mihalache A, Popovic MM, Muni RH. Performance of an Artificial Intelligence Chatbot in Ophthalmic Knowledge Assessment. JAMA Ophthalmol. 2023 Jun 1;141(6):589-597. doi: 10.1001/jamaophthalmol.2023.1144. PMID: 37103928; PMCID: PMC10141269.
2. Suchman K, Garg S, Trindade AJ. Chat Generative Pretrained Transformer Fails the Multiple-Choice American College of Gastroenterology Self-Assessment Test. Am J Gastroenterol. 2023 Jun 9. doi: 10.14309/ajg.0000000000002320. Epub ahead of print. PMID: 37212584.
3. Tsang R. Practical Applications of ChatGPT in Undergraduate Medical Education. J Med Educ Curric Dev. 2023 May 24;10:23821205231178449. doi: 10.1177/23821205231178449. PMID: 37255525; PMCID: PMC10226299.
4. Reinhart RA. The Stethoscope in 19th-Century American Practice: Ideas, Rhetoric, and Eventual Adoption. Can Bull Med Hist. 2020;37(1):50-87. doi: 10.3138/cbmh.317-022019. Epub 2020 Mar 20. PMID: 32208110.
5. Cadiente A, Chen J, Pilkington B. Machine-Made Empathy? Why Medicine Still Needs Humans. JAMA Intern Med. 2023 Sep 11. doi: 10.1001/jamainternmed.2023.4386. Epub ahead of print. PMID: 37695598.

With all the recent uproar around AI, it becomes clearer that our society lives at an impasse: on one hand, there is a strong optimism around the capabilities of artificial intelligence and its potential for providing reliable information, even being able to outperform experts; on the other, multiple declarations by influential figures signal what Luciano Floridi has called the “AI Winter” – a complicated, collective feeling that amalgamates a disappointment towards the capabilities of this new technology with a widespread mistrust of it. Recently deceased De Masi, among others, painted a bright future for labor in which technology would liberate humanity from menial work, the kind that alienates individuals from their existential purposes. However, we have been observing the opposite: the jobs being lost to robots are those related to artistic expression, professional expertise, and ethical reflection. And such is the case with bioethics-related decisions, deeply grounded on the moral agency of those who deliberate about them.

There is this nauseating fear about AI replacing humans in bioethical decision-making. And that seems to be precisely why we should be discussing it. For centuries, doing what is right has been considered a cold virtue, based on the rational reflection of the agent. Likewise, personhood has been attributed to the same type of capacity. If we, in a hypothetical exercise, imagine a type of artificial intelligence capable of reproducing any kind of activity a human brain is capable of (the so-called “artificial general intelligence,” or AGI), why should we be concerned about AI taking our places and preserving us from moral distress?

As a matter of fact, much of the advancement in bioethical thinking has been towards some sort of codification or proceduralization: with frameworks such as the “four topics approach,” bioethics becomes easier to teach, to reproduce, and to be adopted at an institutional level, delegating much of the heavy lifting to the organization itself. As Mary Douglas puts it, institutions make many of the hard decisions, even those that account for life-and-death situations. But acknowledging that much of what is being sought with AI has already been explored with our social technologies does not solve our discomfort. Perhaps because both this concept of moral agency and the role we ascribe to it might be wrong.

Bioethical decisions are complex. Rationality is joined by fear, empathy, luck, faith, and tradition. Many of those seem to somewhat affect moral agency. This has not been ignored by contemporary ethical theory: Ricoeur, for instance, argues that moral agency is concurrent with our narrative identity. It is reflective, manifesting as our capabilities to judge ourselves, to judge others and to be judged by them, while having mutual recognition of our capabilities of taking autonomous moral decisions and being responsible for them. This results from identity itself, as we build character from the succession of our actions while we seek moral congruence by being faithful to our words. This gap is bridged by our storytelling efforts, through which we build our narrative identity by organizing our personal events and experiences in a meaningful plot – what encompasses these emotions and also invites for self-reflection.
Even if we consider that AGI might be able to develop some form of narrative identity, it seems puzzling to disregard how determinants such as social values and biologically conditioned elements play a role in our decision making. These are also part of our sense of moral responsibility. Corporeality, pain, and our group and human identity are some of the elements that seem to limit the reliability of delegating moral choices of these kinds to AI.

However, it does not mean AI should be excluded from bioethical decision-making. The same way we ascribe a partial capacity to our institutions, so should we to artificial intelligence as a tool that might not be independent from us but is still an extension of our cognition that enhances our capabilities. It can help us achieve consistency, by reflecting institutional values in ethical deliberations; it can supply us with invaluable organized data input; and, at last, invite human operators to reflect upon their biases and intrinsic flaws, something that is part of how we build our identity and moral compass. This is also something to be considered by our social structures, such as legal systems, that have been struggling so much to regulate the role of AI. Our experience has always been mediated by some form of technology. So why should AI be different?

Caio Caesar Dib is a master's student at the University of São Paulo, where he also works as a teaching assistant, and a volunteering bioethicist at Hospital de Amor.

On August 13, 1946, President Harry Truman signed the Hill-Burton Act, also known as the Hospital Survey and Construction Act, into law. The Hill-Burton Act provided construction grants and loans to build hospitals in needed areas. Under the Hill-Burton Act, there was a separate-but-equal provision, which stated that racial discrimination was acceptable if there was “equitable provision on the basis of need for facilities and services of like quality for each such group” (1). Concurrently, Dr. Kenneth Clark and Dr. Mamie Clark conducted a series of tests on Black children to examine their psychological experiences during the Jim Crow era of segregation. The test, now famously called “the doll test,” explored black children’s self-perceptions using black and white dolls.

In 1954, the Supreme Court case Brown vs. Board of Education of Topeka, declared that racial segregation of children in public schools was unconstitutional partially because the results of the doll test suggested that black children preferred the white dolls instead of the black dolls due to systemic racism that created a feeling of inferiority and low self-esteem. Due to the children’s societal influence, the white dolls became a default preference among black children who did not prefer a doll that looked more like them. The Supreme Court’s ruling led to the integration of K-12 schools. Ten years later, the precedent set by the Brown vs. Board of Education of Topeka court case made racial segregation in hospitals, known as “Jim Crow medicine,” illegal under Title VI of the Civil Rights Act of 1964, because the “separate-but-equal’ doctrine, as applied to hospitals, violated the Equal Protection Clause.”

The historical precedent set by Brown vs. Board of Education of Topeka and the Civil Rights Act of 1964 benefited communities of color for decades by giving access to all forms of healthcare, regardless of race and location, a legal right for citizens. These legal standings provided communities of color access to better healthcare, improved mortality rates, and set the legal precedent for the National Institutes of Health (NIH) Revitalization Act of 1993 which required, “federally funded clinical trials include women and ethnic minorities as subjects and disaggregate statistics by gender and ethnicity” (2).

These legal victories are standards to build on alleviating racial health disparities, racial underrepresentation, and racial exclusion in medicine. Black and brown bodies, that were not welcomed in historically white medical spaces and clinical trials continue to suffer the consequences of a racist medical history. To alleviate health inequities, it is imperative that we foster the courage to acknowledge uncomfortable racial histories. Furthermore, medical publishers should be intentional in illustrating racial history in medical textbooks for current and future doctors to be competent on the origins that produce the challenges for people of color to access healthcare. Such actions are practical steps in mending the medical transgressions of the past, while strengthening the social determinants of health for people of color in the present and in the future.

Dr. Kirk A. Johnson is an Assistant Professor of Justice Studies and Medical Humanities at Montclair State University. He is a member of the American Society of Bioethics and Humanities and the Atlantic Health Systems Bioethics Committee.

References
1. Largent, Emily A. “Public Health, Racism, and the Lasting Impact of Hospital Segregation.” Public Health Reports (1974-) 133, no. 6 (November 1, 2018): 715.
2. Briggs, Charles L. “Communicability, Racial Discourse, and Disease.” Annual Review of Anthropology. 2005, Vol. 34 Issue 1, 280.

A recent news article quipped that the U.S. healthcare system is “neither healthy, caring nor a system” (1). Those of us in healthcare can relate, and COVID-19 has only intensified this dynamic.

One root of this problem is the false construct that views the interests of clinicians, hospitals, and patients as at odds. When we get it right in healthcare these interests align, and if these interests don’t currently appear to align, then we’ve not yet gotten it right.

This is part of the crisis of care we’re seeing now. A recent study found that “100,000 nurses left the workforce during the pandemic and by 2027, almost 900,000…intend to leave the workforce, threatening the national health care system….” (2). Another study found that “62.8% of physicians had at least one manifestation of burnout in 2021 compared with 38.2% in 2020” (3).

The crisis isn’t limited to physicians and nurses but rather seems to impact all of healthcare and the larger community. A study that included a variety of healthcare workers found the “overall burnout rate was 49.9%” with intent to leave reported at 28.7%, and “perceived work overload” ranging from 37.1 to 47.4%. The study also found, “work overload was significantly associated with burnout…and intent to leave” (4).

The crisis is so bad that some feel the language of moral injury and moral distress is no longer adequate, leading bioethicist Patty Mayer, MD, MS, to advocate the use of the phrase “moral collapse” instead.

The strategy adopted to solve this relies far too heavily on financial incentives – the idea that if we just pay people more, that will fix the problem. And, while workers want their contributions valued appropriately, including financially, I believe the current approach is off the mark, which is why it hasn’t successfully stemmed the rate of turnover, job abandonment, or burnout.

Healthcare has historically viewed the patient-clinician relationship as sacred, the commitment to healthcare as a calling; as something different than the relationship between an accountant and their client; different than a contractual relationship; different than merely meeting the duties outlined in an informed consent form or a statutory or regulatory provision. Historically, the corporate practice of medicine was illegal not just because it violated a particular statutory provision, but for precisely this common law public policy reason – it was believed to so denigrate the practice as to be prohibitively bad for all involved and was therefore legally prohibited (5).

As healthcare has moved toward a more financial centric model of care, I believe many of the crises we’re witnessing are due to the move away from a humanistic model of connection and service and toward a primarily financial and contractual model. One of the main complaints I hear from clinicians considering leaving healthcare is that they went into healthcare because they care and want to make a difference, and they feel demoralized as a widget in the machine being asked to constantly see more patients to generate more income for hospitals.

I propose an evolved model of healthcare that has its foundation in human dignity, relationship, service, respect, and partnership that acknowledges and corrects the false construct of the financial, contractual model, and that generates better healthcare outcomes, higher rates of healthcare worker retention and job satisfaction, and better financial returns for hospitals, because this model creates a tide that will raise all boats, as history has demonstrated.

If we look to the work of researchers like Bob Sutton, Shawn Achor, Barbara Fredrickson, and others, we see a plethora of data supporting the assertion that treating humans with respect and dignity results in better business outcomes (6). In my legal career, I’ve often advised clients along the lines of, ‘If you can’t see your way clear to do the right thing because it’s the right thing to do, let’s talk about why it’s the self-interested thing to do.’ It’s amazing how consistently these things line up.

Healthcare seems to have lost an agreed-upon, shared value system that consistently connects us to the deepest, human-centered reasons people go into and stay in healthcare (7). We’ve surrendered too often to a financial model, seeming to believe that it’s our savior or at least a necessary evil. The rallying cry, “no margin, no mission” fails to recognize at its peril that without a mission no amount of margin will close the gap. This is why we’re losing so many people. This is why we have such severe issues with burnout and retention. This is why we have ongoing issues with just culture. The equation isn’t financial (although money is a component), the equation is human.

References
1. Nicholas Kristof quoting Walter Cronkite in How Do We Fix the Scandal that is American Health Care? N.Y. Times, Aug. 16, 2023.
2. National Council of State Boards of Nursing, April 13 2023 news release (available here: https://www.ncsbn.org/news/ncsbn-research-projects-significant-nursing-workforce-shortages-and-crisis) citing The 2022 National Nursing Workforce Survey, J. of Nursing Regulation, Vol. 14, Issue 1, Supplement 2S1-S90, April 2023, available at: https://www.journalofnursingregulation.com/issue/S2155-8256(23)X0004-0.
3. Shanafelt, T, et al., Changes in Burnout and Satisfaction With Work-Life Integration in Physicians During the First 2 Years of the COVID-19 Pandemic, Mayo Clinic Proceedings, Vol. 97, Issue 12, pp. 2248-2258, Dec. 2022; available at: https://www.mayoclinicproceedings.org/article/S0025-6196(22)00515-8/fulltext#%20.
4. Rotenstein, L., et al., The Association of Work Overload with Burnout and Intent to Leave the Job Across the Healthcare Workforce During COVID 19, J. Gen Intern Med 38(8):1920–7, March 2023, DOI: 10.1007/s11606-023-08153-z.

“Journeys” is Drexel University College of Medicine’s newest, student-run newsletter designed to highlight the experiences of health care providers in training. With this newsletter, we hope to create a platform that represents the unique backgrounds, identities, and perspectives of students. “Journeys” is a space to share stories and sentiments that illustrate both individuality and experience as they contribute to the diversity of health care education and practice.

Focused on diversity, equity, and inclusion (DEI) education, “Journeys” will accept and display submissions of multiple mediums from health care students and trainees. From text to video, or art to music, we want to share your narrative from the classroom, clinic, and community. Edition-specific themes based in DEI will be defined for each edition to inspire and feature related pieces from groups they may represent.

All are welcome and encouraged to submit pieces that represent the reality of their journey best. Submissions may also be anonymized if preferred.

First Edition: Microaggressions and Allyship
Microaggressions can feel like constant pokes or additional mental taxes over time that build up frustration in recipients. In this edition, we will be sharing stories where microaggressions were experienced in a clinical or academic setting. A chance for allyship or bystander behavior may manifest as well. For example: Talk about an incident where you have felt your identity take priority over your role and experienced a level of bias. How did you respond? Did any amount of allyship take place? What have you witnessed as a bystander? An “upstander”? Elaborate.

Please use the following link to submit your work for publication: https://bit.ly/journeys-submissions

Technical Requirements:
Essays, narratives, poems, etc.: Up to 750 words. Please submit as a Word doc.
Image: jpg format
Video/Audio: up to 5 minutes in length

Please submit by Friday, September 1st for consideration. You will be notified of the status of your submission before publication.

By lifting the voices of many to be listened to and learned from, it is our mission to establish, cultivate, and promote a community of inclusion and empowerment with “Journeys.”

Please email any questions or concerns at ducomjourneys@gmail.com

Molly Ruiz, Raven Simmons, and Lauren Wells are third-year medical students at Drexel University's College of Medicine.
Jade Overton is a fourth-year medical student at Drexel University College of Medicine.
Fatima Sawi is a recent graduate of Virginia Commonwealth University's Psychology and Biology programs and a behavioral health counselor.

In 1892, Dr. Andrew Taylor Still founded the first school for osteopathic medicine, in a time when “medical schools were run like barber colleges” (Siegal, 2010). “[Three] of his children [died] from spinal meningitis,” so he resolved there must be a different way to practice medicine. Still’s basic premise was preventive healthcare (AACOM, 2023), and he wanted to study not only illnesses but health as well (PCOM, 2023). Despite the popularity of Still’s schools, osteopathic medicine graduates were not initially considered licensed doctors—they needed to also receive an MD (Matthews, 2022). While MDs championed against the acceptance of DOs as licensed physicians, Governor Josiah Grout approved a bill that allowed DOs to practice like MDs in the state of Vermont in 1896 (Now & Then Museum of Osteopathic Medicine, 2016), lending legal support to a movement that allowed DO schools to proliferate in response to a professional need for a large and diverse physician workforce.

Nearly two decades after the first DO school was established, Abraham Flexner, an educator recruited to the Hopkins Circle to help standardize medical education in the United States, published the Flexner Report in 1910, detailing his pedagogical viewpoint informed by the medical school system in Europe, and primarily Germany (Duffy, 2011). In this report, he claimed many American medical schools were not up to the standard, including all DO programs (Matthews, 2022). In response, the American Osteopathic Association (AOA) sued Flexner and his associates, defending their medical philosophy (Matthews, 2022). While Flexner didn’t push his opposition further, it was still difficult for DOs to receive recognition in the aftermath of his criticism. The Flexner Report’s legacy was incredibly impactful on all American medical education - as one scholar states, “Science […] was the overarching theme, the zeitgeist, in Flexner’s conception of the ideal physician” (Duffy, 2011), as opposed to the more holistic and humanistic focus in osteopathic medicine.

As the only non-MD medical programs left in the country, DO programs struggled to be recognized in medical practice in different areas of America due to their different goals and principles. Finally, in 1947 DO schools began to receive streamlined American medical licensing and Louisiana became the last state to approve the COMLEX-USA (Comprehensive Osteopathic Medical Licensing Examination of the United States) Act in 2001, allowing DOs to take their licensing exam and be practicing physicians in the entire country (AACOM 2023). Despite the mirroring of the curriculum DOs continue to experience hurdles. In the “2022 National Resident Matching Program (NRMP) […] Director Survey revealed […] 29% of the program directors never interview DOs; 49% seldom interview DOs” (Terry et al., 2023). Up to 87% of DO students take two exams: the MD licensing exam (USMLE) and the COMLEX exam to be more competitive for residencies, and MD and DO candidates with equivalent scores are not treated equally by admissions teams (Sandella 2016).

While MD schools and DO schools initially had different intentions in their curricula, in the past century, many changes have brought the two closer together. For example, some schools adopted the PBL (Problem-Based Learning) model popularized by MD schools and reported higher scores on the COMLEX exam as a result (Zaveri, 2019). “[The] Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), and the American Association of Colleges of Osteopathic Medicine (AACOM) all decided to transition to a single accreditation for [Graduate Medical Education] by July 2020,” suggesting that the standards of MD and DO programs are continuing to become increasingly similar (Medhub, 2022). Furthermore, since the merger with the Accreditation Council for Graduate Medical Education in 2015, residencies credited by the AOA have ceased to exist (Terry et al., 2013). Many DO schools want to unify licensing exams entirely and remove the COMLEX so DO students aren’t required to take two rigorous exams on such a close schedule (Ahmed, 2022). Unifying the examinations will further cause DO education to emulate those of MDs. These major changes in the ‘end goal’ of medical education have DOs competing for the same residencies as MD students, as they continue to serve the same societal and workforce need.

Andrew Taylor Still started Doctor of Osteopathy schools with the concept that people and medicine were better served through a focus on health and prevention. DO schools fought against many odds to remain open and compete within a healthcare system that did not support their practice of medicine. In part DO schools were able to survive because of a societal need for more physicians as well as the desire and ability to negotiate and adapt to a modern and changing healthcare system. By accepting the same or similar accreditation criteria and exams Doctors of Osteopathy continue to adapt to the mainstream of American medicine and fill an important need for a clinical workforce. In doing so they potentially forfeit the original visions of their founder; however, they may alternatively be infiltrating a system that can benefit from their more holistic course of medical training. As DOs become more prevalent and continue to adapt and survive within the larger more prevalent allopathic systems of practice, we consider the possibility that the ideals of Andrew Taylor Still and the DO education he developed may influence a healthcare system in need of holistic care.

Prisha C. Jonnalagadda is a senior undergraduate student at Rice University working with Dr. Mary E. Kollmer Horton.
Mary E. Kollmer Horton, MPH, MA, PhD, is Core Faculty within the McGovern Center for Humanities & Ethics, Director of the Medical Student Research Office, and Assistant Professor of Educational Programs at the University of Texas Health Houston McGovern Medical School.

References
AACOM. “Andrew Taylor: History Of Osteopathic Medicine.” Amops.Org, amops.org/history-of-osteopathic-medicine/. Accessed 15 June 2023.
Ahmed, Harris, and J Bryan Carmody. “COMLEX-USA and USMLE for Osteopathic Medical Students: Should We Duplicate, Divide, or Unify?.” Journal of graduate medical education vol. 14,1 (2022): 60-63. doi:10.4300/JGME-D-21-01196.1
Duffy, Thomas P. “The Flexner Report--100 years later.” The Yale Journal of Biology and Medicine vol. 84,3 (2011): 269-76.
Matthews, A. (2022, April 18). 5 stories and artifacts that tell us about the history of osteopathic medicine. The DO. https://thedo.osteopathic.org/2022/04/5-stories-and-artifacts-that-tell-us-about-the-history-of-osteopathic-medicine/
Medhub. (2022, February 2). Solutions for osteopathic education programs. MedHub. https://www.medhub.com/a-committed-advocate-for-osteopathic-institutions/
Now & Then Museum of Osteopathic Medicine. (2016). Now & Then Museum of Osteopathic Medicine: Legalizing Osteopathy: Why Wasn’t Missouri First? Kirksville.
https://www.atsu.edu/museum/pdfs/newsletter/museum_spring_16.pdf
PCOM. “What Is Osteopathic Medicine and How Is It Different?” PCOM, www.pcom.edu/about/what-is-osteopathic-medicine.html#:~:text=The%20osteopathic%20curriculum%20involves%20four,%2Dgynecology%2C%20pediatrics%20and%20surgery. Accessed 15 June 2023.
Sandella, Jeanne M et al. “The Use of COMLEX-USA and USMLE for Residency Applicant Selection.” Journal of graduate medical education vol. 8,3 (2016): 358-63. doi:10.4300/JGME-D-15-00246.1
Siegel, R., & Starr, P. (n.d.). The Flexner Report And Medical Education. Retrieved January 18, 2010, from https://www.npr.org/templates/story/story.php?storyId=122702668.

In this era, the person-centred approach for sustainable practice or corporate efficiency is in the top position. All industries pay attention to it since they are interested in selling or buying goods or services from each other. Doing that means building an honest relationship with collaborators, smoothly flooding information, imports or exports, and offering assistance when necessary.

There are options to navigate factors influencing consumer selection from the goods or services of interest offerings, according to available technology advancement and financial capacity. Factors influencing the people’s preference for collaborators to meet their demands were explored using interviews- open-ended questions for small and representative groups, online surveys, or recorded verbal and nonverbal communication data of interest. These methods reveal that from offerings, the individual choice for a supplier is based on personal reputation, empathy, interaction value, expected outcomes, expenses, provider availability when necessary, and time commitment.

Attaining expertise in the domain selected by the individual, skills in transferring the knowledge in practice, the art of communication with collaborators, promoting respectful, trustful, and merciful relationships with them, compassionate care when required, individual conduct in daily work aligned with social norms were accounted in analysis and decisions by consumers.

Maintaining the connection with the chosen supplier for utility, when necessary, indicates consumer enjoyment. However, if his expectations are unmet, he looks for alternative options from other groups. Therefore, the supplier’s professionalism ensures a successful professional and social life for him and enchanted shoppers. Gaps in performing duties dissatisfy both providers and end-users, affecting practice standing. So, consumer preference for a provider certifies the provider’s professionalism and consumer fulfilment.

Relevant information can quickly spread through the media and impact someone’s social and professional life. Intentional or unintentional misinformation alters a person’s public image affecting his career and emotional well-being. Attentiveness for sharing individual info through mass-media channels is mandatory; the errors must be promptly corrected to diminish adverse effects on the recipient, and those responsible for spreading false information must be punished accordingly in order not to repeat such unwanted communications and to prevent harm to other exposed individuals. To fall in error is common, but its exceeding limits cause detriment to a person’s inner life, contributing to the initiation and advancement of individual disorders and public problems.

For these reasons, professionalism is a core element for practice or corporate performance. It must be taught and implemented across all industries, at the global level, to promote social progress and individual life quality improvement.

In the digital age, consumer experience and preferences are fast identified using Artificial Intelligence supply. Info collected through omnichannel is rapidly analyzed to fulfil people’s expectations, finally increasing purchases and ensuring successful business operations. Traditional models exploring an individual’s reasons for first choice from offerings using interviews or online surveys are quietly flying. AI support provides a quick and accurate tool to explore areas of interest. As technology evolves too fast, its usefulness must be considered and rapidly expended for time-saving in this natural, visible, and audible world where we are endorsed with a limited existence.

Sofica Bistriceanu, MD, PhD, is a Family Physician and the representative of Academic Medical Unit- CMI.

“How can I find a doctor I can trust?” I keep hearing this question—from those feeling confused about a vaccination decision to those looking for an ob/gyn who shares their personal values. There’s unprecedented angst, uncertainty, and mistrust. During two decades as a patient and citizen advocate, I’ve encountered the mistrust that arises when systems that are supposed to protect us cause harm. I’ve learned that trust is an asset our health system cannot do without. It is at the heart of our relationships with our physicians and care teams and an essential foundation for the institution of medicine. Yet as our social fabric continues to fray, even the most trusted relationships come under strain. Our relationships with our physicians feel more fragile when the practice of medicine is politicized, and misinformation compounds our uncertainty and confusion about our health choices.

As an independent volunteer public (non-physician) member of the Board of Directors of ABMS (the American Board of Medical Specialties), a nonprofit organization that oversees the standards for physician certification across 24 medical specialties (the American Osteopathic Association is another), I have a window into what happens inside the network of institutions that oversee the practice of medicine in the United States. The medical profession is dealing with its own trust challenges as it negotiates the tensions between freedom, regulation, and professionalism. In recent months, certifying boards have taken further steps to uphold their accountability by addressing unprofessional behavior and pledging to withdraw or deny certification to physicians who publicly share information that is directly contrary to the prevailing medical evidence.

While some physicians are uniting to defend their ability to take care of their patients and protect those patients’ reproductive freedom and bodily autonomy, others are asserting a questionable freedom to prescribe unproven treatments or disseminate misinformation that leads to medical harm or death. Some physicians are rejecting the institutions that enact and enforce standards of performance and conduct and oversee physicians’ accountability to the public. Efforts by these institutions to overcome mistrust should be welcomed. Self-regulation is a privilege that makes physicians accountable to their peers and importantly, the public. It is grounded in a set of agreed-upon standards and behaviors based on a common set of values and ethical commitments. It represents a social contract between physicians and the community that includes a promise to put the interests of patients first.

But when mistrust in institutions manifests itself as legislative interference in that professional self-regulation, the politicization of the practice of medicine becomes an assault on medicine itself. The assault is already happening in states where state legislatures have told the state boards that license and regulate physicians that they may not take disciplinary action against physicians who disseminate misinformation or disinformation about COVID-19, vaccination, or scientifically valid treatments. The effects are harmful to physicians, nurses, and patients alike. In some states, physicians no longer have the freedom to provide the care they are trained to provide.

As patients, we are left wondering who we can turn to as trusted navigators as we make sense of our medical choices. As medicine becomes politicized, the answer to that initial question “How can I find a doctor I can trust?” is not as simple as reading patient reviews or going to a top-rated hospital. It’s important to know how to recognize a physician who has gone through rigorous and objective assessment of their knowledge, skills, judgment, and competencies.

The 14 years I spent with the nonprofit Consumer Reports taught me to recognize a rigorous testing process and the ways it helps to build trust. That rigor is critical for the process of physician board certification. I’ve been reassured to find it at the American Board of Medical Specialties and its member boards: the research underlying every step, the collaborative process of standard-setting, the scientific methods that inform assessments, the secure examinations, the evaluation of ethics and professionalism, the verification that a physician is clear of any professional wrongdoing, the requirement to contribute to improving health and health care, and the cycles of continuing certification to stay current and maintain competency throughout a physician’s career. As a result, specialty board certification is one of the strongest signals that we can trust our physician. It represents a commitment to both learning and accountability.

Patients choosing a physician for themselves or loved ones would be wise to check online if a physician is currently board-certified. But if we want to help build a culture of trust in medicine, based on facts and not ideology, there are things we need to do as citizens to push back against the assault on the medical profession as well. We can communicate our support to elected representatives and candidates who oppose legislative interference in the practice of medicine and its self-regulation. As civic-minded community members, we can ask to be appointed as “public members” of the state boards that regulate medical practice or join a local hospital board as an advocate for patient safety and physician wellbeing. We can run for school boards where we can participate as champions of science education and children’s health. Civic engagement is as critical for building trust in medicine as it is for strengthening our democracy.

Tara Montgomery is Founder & Principal of Civic Health Partners, an independent coaching and consulting practice that helps leaders reflect on trust and develop public engagement strategies that are worthy of trust. She is a volunteer Public Member of the Board of Directors of the American Board of Medical Specialties.

This essay was originally posted by Civic Health Partners on January 19, 2023, and has been syndicated with permission.

The Josiah Macy Jr. Foundation awarded Dennis Novack and co-principal investigators, Camille Burnett and Leon McCrea, a three-year grant to produce an antiracism module. Over 50 people have been working since July 2020 creating the content, assessment tools, curriculum guides, and a faculty development component. The 20,000-word module with 26 exercises and 38 videos has 16 sections, which include Medicine and Myth of Race; Racial Disparities in Health; The Roots of Racism: A Biopsychosocial Formulation; Critical Race Theory, Intersectionality, Colonialism, and Structural Racism; Clinical Ethics and the Mandate for Antiracism; Ethical Dimensions of Racism; Race Consciousness and Antiracism; Racial Conflict; Confronting Our Biases; Microaggressions; Discrimination; Diversity and Cultural Humility; Advancing Racial Equity; Racial Equity in Research, Policy, Procedures and Practices; Antiracist Approaches to Clinical Care; and Antiracism in Action.

The module is being piloted at 13 collaborating institutions including Albert Einstein College of Medicine, Drexel University Colleges of Medicine and Nursing and Health Professions, Geisinger Commonwealth Medical College, Sidney Kimmel Medical College, Mass General, Ohio State University, Renaissance School of Medicine at Stony Brook, University of Arizona College of Medicine-Phoenix, University of Florida, University of Kentucky Schools of Nursing and Medicine, University of Pennsylvania, Virginia Commonwealth University, and the Wilkes University School of Nursing. Over the next year, the principal investigators and core faculty, Rita Guevara and Kristen Ryczak, will work with the institutions to incorporate the antiracism content in their curricula.

The grant participants selected one of four groups in which to work – module, assessment, curriculum, and faculty development. The module group wrote an article about the process, which has been submitted to a peer-reviewed journal. The curriculum group created nine guides for faculty and students including Introduction to Antiracism in Health Care Education, Critical Race Theory, Intersectionality, Colonialism and Structural Racism Applied to Health Care, Ethics and Antiracism, Race Consciousness and Antiracism, Confronting Our Biases, Cultural Humility, Understanding and Responding to Microaggressions, Skills of Allyship, Advocacy, and Interprofessional Education. The assessment group is finalizing a learning environment survey for institutions to assess their antiracism training and culture. Sections include pre/post-tests to assess the learners’ behavioral and perception changes.

Five students have been working on interviewing 200 randomly selected medical and nursing school personnel about their DEI programs; however, the response has been limited. More recently, the students have turned their attention to creating a newsletter on students’ lived experiences of biases.

Participants have spoken at over 10 national and international conferences about their antiracism work. Dennis, Rita, and Elizabeth Kachur created an allyship OSCE, which has been incorporated into the curriculum at Drexel University since mid-2022.

The module with numerous learning aides will be free to everyone and accessible on a number of platforms in 2024. In the meantime, if you’d like to access the module, click on this link: https://webcampus.med.drexel.edu/PCHC/

Please provide feedback to BLewis@ProfessionalFormation.org. The final version will be released after the collaborating institutions have provided comments. At that time the module will be released with a number of additional features.

More than 20 years ago, I shifted from practice to teaching and “met” Sylvia (and Richard) Cruess via their scholarship. It was like a breath of fresh air to immerse myself in the same areas of interest. A year after hearing them at APHC, I attended a conference in Montreal, first emailing them, wondering if I might swing by their office for a meet-and-greet. Dick replied warmly and on the chosen date, I taxied to this majestic old university building on the campus of McGill.

I already knew they were bona fide “rockstars” in my world and wanted more. My opening salvo was “Tell me how one is able to maintain such a high level of scholarship and creativity in one’s senior senior” years and, we were off, chatting easily and openly. The hour went quickly.

APHC insightfully featured Richard and Sylvia at a few conferences. My understanding of health care as a commodity is based on their illumination of the Social Contract; the deal between the professions and society. It is essential, has never been seriously reconsidered, and works when the parties commit to making it work, for the greater good.

Sylvia and Dick were inseparable at home and at work; an incredible force for good; the reigning king and queen of professionalism academia.

We lost Sylvia last September after she fell and broke her hip while at their summer cottage.

Sylvia was born in Cleveland, did her MD at Columbia U., married Dick while still a student, moved to Montreal in 1963, and began her work as an endocrinologist. Her career in medicine, medical education, and administration is without equal. She and Dick traveled the world sharing their passion for how best to understand and translate professionalism values to learners.
Sylvia, like Dick, was awarded the Order of Canada, the highest civilian honor in the land, for her exemplary work and influence. This was following numerous high-level medical education awards.

I was in touch over these past few years, last seeing them at APHC in New Orleans, where I cheekily grabbed a selfie as we were heading into a session. Dick has a penchant for Mark Twain and enjoys such repartee. I would occasionally send him a new one (for me) and he would reply with another. While this was not the highest level of academic discourse, it gave me a thrill!

Since Sylvia’s passing, I have spoken with Dick a couple of times. After an appropriate pause, he has resumed his current work on communities of practice but admitted he may not have what it takes, so time would tell. He is 93.

There is so much to admire about Sylvia and Dick. Such a lifetime’s influence is without equal. Their work will have currency for generations.

F. Stuart Kinsinger DC, MA, is the author of "Principles of Professionalism in Health Care."

Some people may see quality improvement and working on health equity as separate endeavors, but I see it differently. Improvement methodologies, reliability science, quality improvement methods, and safety sciences are designed to identify where variations occur in systems and then to reduce or eliminate them. Inequities are unjust, unconscionable, very costly variations in systems.

While many disciplines need to play a role in addressing the challenge of health equity, the quality movement can make a special contribution. As we have worked on health equity in systems around the country through our Pursuing Equity initiatives, the Institute for Healthcare Improvement (IHI) has seen the value of the technical tools of improvement as they have been used to reduce or eliminate unwanted, undesired variation. When teams identify inequities and apply quality improvement methods to address them, dramatic effects follow in short order.

We now plan to build on that knowledge to advance equity at scale. IHI has joined with the American Medical Association (AMA), in collaboration with Race Forward and an impressive list of organizations and key funders, to create Rise to Health: A National Coalition for Equity in Health Care. The Rise to Health Coalition will catalyze individuals and organizations committed to health equity and justice to build, change, and transform health care with shared solutions and collective actions.

Building on Momentum
We may not have always realized it, but inequities are present in every corner of our health system, in every part of our communities. And these inequities are not new. Health inequities have existed for centuries, and when we see them in the lives of our patients, our families, and in our communities, we cannot stand idly by and do nothing.

I believe the Rise to Health Coalition is coming together at an important time. More of us are recognizing the opportunities for making a difference not just in isolated parts of the system, but at scale throughout the entire nation. It is especially exciting that many organizations are demonstrating interest in cooperating and collaborating so that we can move the needle on equity in ways none of us could ever do on our own.

With the Rise to Health Coalition, we are shifting our approach and strategy to advancing health equity. Through the formation of a coalition that includes racial justice organizations — such as Race Forward and the Groundwater Institute — we will collectively design and implement solutions that take a more historical and longitudinal perspective for the problems of health inequity in our systems.
These organizations have the knowledge, skills, expertise, and assets to guide and ground this work. They, along with our strategic advisory group, will hold us accountable to ensure meaningful and sustainable impact, not only in numbers, but also in the day-to-day lives of the people and communities that are structurally marginalized.

Working together as organizations with unique strengths and expertise generates new ideas and perspectives and brings more accountability to the work. As part of the Coalition, we will access and use each other’s levers, strengths, and resources. Our goal is to build our capacities and opportunities for action and shared solutions across the health care ecosystem. Together, we can fundamentally change the story of equity in this country. Please join us and commit to taking action.

Kedar Mate, MD, is the CEO of the Institute for Healthcare Improvement.

Editor's note: This piece was originally published by the Institute for Healthcare Improvement on February 1, 2023. It has been reposted here with the authors' permission.

The spring semester at Rocky Vista University is not devoid of excitement, anticipation, and interviews. For our first and second-year students, the spring semester marks new opportunities for leadership and co-curricular involvement. Over the past few years, it has become evident that students would benefit from additional interview training before the leadership openings. Because of this lack, the Career and Professional Development Team decided to try a Mock Interview Week. Mock Interview Week offered an opportunity for students to be evaluated on interview skills, not medical knowledge—taking off the competitive edge of “nailing the knowledge.” Our interview week was designed with all medical professional students in mind and upon completion, interviewees were given rubrics, tip sheets, and valuable resources to use for future interviews.

Format:
Each interview consisted of 8 questions presented in a 20-minute time block, followed by 10 minutes of feedback and reflection. Each student interview block was 30 minutes in total. Using sign-up genius, we create blocks of time for students to sign-up for and then we sent individualized Zoom links to each student to log into for their designated time block.

Training:
The Career and Professional Development team is small, so to accommodate more students, we asked student-facing staff members to volunteer some of their time. To create continuity for the students, all-volunteer staff members were trained using modules to offer mock interview sessions to our COM, PA, and MSBS students, followed by skills-based feedback. To train the interviewers we created PowerPoint and an eight-minute-long training video. We focused on training our interviewers to evaluate interviewing skills and not response content. We also worked to train our interviewers to make the interview a comfortable space. We wanted trainers to be aware of body language and how culture, neurodivergence, and anxiety can all affect those.

Rubric:
Our rubric showed our commitment to interview skills and not response content or knowledge. We tried to include considerations to cultural competencies, diversities, and biases that exist in interview spaces, but we recognized that body language and appearance are still big components of interviews. We tried to balance things that interviewers are looking for alongside our own work on DEI considerations. We recommend using a 4-point scale for the rubric. This can make evaluations easier to complete for interviewers.

After the Interviews:
After the interviews, we wanted students to reflect on why they participated – as well as obtain reflections from those who chose not to participate. We created a survey that was sent to all our residential students (COM I and COM II, PA, and MSBS) that asked the following questions:
Did you find this beneficial?
What's one takeaway you’re going to apply to your interviewing?
If you did not participate why? Too busy, scheduling conflict, confident in skills, nervous
Would you participate again/later on?

A major challenge we experienced was scheduling with different programs across both campuses. Identifying one week that worked well for one program does not mean that it will work for the other programs on campus. Each academic program has different classes, labs, and exam schedules. In the future, we hope to have more advanced advertising and work more directly with the other programs to identify a time that will prove to be beneficial for their students.

Overall, the interview week was a huge success. The main point of contention was scheduling for an already busy medical student schedule. Folks might want to look at alternative times (weekends, mornings/evening) to try and fit things into the med student schedule. Overall, the interview week was a huge success. The main point of contention was scheduling for an already busy medical student schedule. Folks might want to look at alternative times (weekends, mornings/evening) to try and fit things into the med student schedule.

Jeddie Herndon, Career and Professional Development Counselor, Rocky Vista University—UT Campus
Madison Tarleton, Career and Professional Development Counselor, Rocky Vista University—CO Campus

Individual behavior is how one acts or conducts oneself, especially toward others. Human conscious or subconscious response to various internal or external stimuli communicates to us about the person’s approach in different circumstances; it reflects the individual’s genetics, educational and relational development in a specific environment.

Patients’ social behavior toward the medical team mainly supposes appreciation and respect since there is a considerable investment in a medical career: long education period, financial resources, and emotional involvement. In medicine, responsibility is at the highest level; nothing can replace the loss of dear ones, and our mission is to improve and save the life. To achieve these goals, a professional in the health care industry must have specific knowledge, quickly manage info and deliver medical services when and where necessary. The art of communication with patients and community members with different backgrounds helps us to attain the best results in clinical practice. To do that, theoretically, a medical team member must not be distressed, not in their daily program or society. But in their daily routine, they can experience offensive comments or attitudes from persons with reasoning or communication problems.

How much must we tolerate facing daily work adversities from the patients or other individuals?

Genetics, perception abnormalities, info-processing deficiency, reasoning nonconformity, and tolerance groups determine a patient’s social behavior deviance. Medical conditions may affect them at various levels. Misinformation sources must be disapproved, detected, and punished when necessary. Broad-minded groups must be trained for multiple situations that are emerging offensive human actions. Identifying the origin of an individual’s wrong and cruel actions towards others and corrective actions are needed. An ethical, respectful approach to the problem must be considered.

Patients’ intentions may differ from their actions’ end. Good intentions following the worst results reveal judgment impairment or misinformation processing; modeling such gaps helps us improve behavior and joy in redressing individual misconduct in social interaction. Repetitive unpleasant people interactions must be stopped when necessary since improper people collaboration may lead to depression, hypertension, type 2 diabetes, or dyslipidemia in vulnerable persons. So, making the individual aware of the consequences of his unconventional social behavior is mandatory.

The health care professionals offended by the patient may deny the further patient’s requests for health care services [except emergency care]. The patient will be obliged to look after another health care provider, and that technique may initiate the patient’s reflection about their actions, consciousness’ activation and self-awareness for further interactions with professionals. Applying this possible convincing technique adds benefit to problem-solving mastery.

Suppose the patient’s social behavior deviance maintains after initial corrective actions. In that case, interdisciplinary collaboration, a multi-level intervention approach, and a corporate strategy for individual life quality and safety are required. Prompt and proper attitudes for social behavior improvement can solve harsh work conditions.

In this digital era, AI supply quickly detects and offers an ending to this problem with positive changes.

Usually, medical conditions alter the individual judgment and actions toward others, especially for senior adults; we may tolerate their social behavior deviance, but not in repetition and not too much, to protect ourselves.

Time slowly undermines all, early enough for each one, and it is better not to get its work done in advance.

Sofica Bistriceanu, MD, PhD, is a Family Physician and the representative of the Academic Medical Unit- CMI in Romania.

Reference
Sofica Bistriceanu. "Limits for Acceptance of Patient's Social Behaviour Deviance." PriMera Scientific Medicine and Public Health 2.2 (2023): 01-02.

Verbal and nonverbal communication generates various debates and feelings between individuals, finally improving knowledge and experiences and, last but not least, influencing people's health.

Mental activity is mainly influenced by visual, sound and smell perception. A person's appearance, colour use, scent and movement in a specific environment create diverse motion pictures going along with excitement, indifference or discomfort, according to data processing; miscellaneous musical compositions decoded by matching corresponding musical instruments or human voice determine a variety of emotions, relaxation and even attentiveness.

Verbal communication skills are necessary to improve an individual's professional, cultural and social life; the words' meaning and energy influence people's well-being. The effects of the usage of the words in the written format are different from the spoken words since the speech energy, controlled by the nervous system, adds value to the words' significance. Communication skills by terms make a difference between individuals and initiate numerous actions according to their relevance, physical characteristics of words' transmission, intended recipient's sensitivity and context.

In this digital era, an individual can put an idea in a writing format or convert it into a saying that instantly goes to the intended recipients using IT devices.

Speech and the words' ordering analysis offer information about the individual:

• Level of expertise
• Skills for knowledge translation in practice
• Emotions
• Possible medical conditions
• Well-being

Speech depicts its coordination in appearance; deficiencies at various levels for command and execution pathways indicate the voice's signs of interest in clinical practice. Voice characteristics, combined with the breathing data, reflect blood flowing in the human body. Heart activity, the respiratory system's function and gravitational waves influence human body fluids movement; the digestive, endocrine, skeletal, respiratory system, kidney and liver functions influence blood composition. The mind activity affects all these variables interplay, conveying the words and voice expression.

The heart function and respiratory system, both under nervous system coordination, are seen as significant contributors to the voice function. Heart failure modifies the body's fluid distribution and, subsequently, voice characteristics that change from one stage to another in its evolution.

Each person's voice is distinctive and adaptable to various internal and external stimuli. AI supply facilitates fast voice analysis and prediction of disorders in appearance or evolution. In this digital era, a video visit or only a phone call visit can offer sufficient details about individuals, including data health. For the medical team, an e-visit may be considered appropriate when necessary. For the patient, an in-person or e-visit represents a convenient option to get care in need. The patient experience can be appreciated/measured by their words' composition to express gratitude, voice attributes and sentiment analysis, preferably using AI supply.

Subjective voice analysis and artificial intelligence utilization offer another perspective in clinical practice. Recent medical literature highlights ambitious AI projects for using the voice function in diagnosis. Therefore, according to individual financial status, there will be a wide range of options for the disease's management in clinical practice. But only by using a mobile phone can the patient and the physician be connected to successfully control the patient's disorders.
The art of using the voice for analysis and decisions in clinical practice defines us as professionals in the community we serve.

Sofica Bistriceanu, MD, PhD, is a Family Physician and the representative of Academic Medical Unit- CMI.

We are taught to think about words and their objective definitions as static. Define doctor, medicine or school—the definitions we are offered will vary with minor differences. When posed with the question, “What is a doctor?” we would all have a standardized answer. A doctor is a medical practitioner, a clinician, a care-provider, etc. We understand, in the abstract, what and who a doctor is. Likewise, we understand the definition of medicine, of school and of healthcare. Those definitions come to us in an innate way because we have been the recipients, the providers or the passive and active bystanders of medicine working on, in and around us.

One word (and the conjugations therein), often thrown around with the same definitional innateness, is profession, professional and professionalism. According to Creuss & Creuss (2010), a profession is often considered to be a social contract between one party and another, the profession—occupation, vocation, or service— often has financial reward or benefit. The definition of profession (professional and professionalism) has been hotly contested, especially within medicine and the social scientific fields, as evidenced by the APHC's Navigating the Professionalism Challenges of Evolving Technologies Virtual Conference.

Instead of a singular, linear and static definition, is it possible to present a bracketed, inclusive and branched definition of the profession, professional and professionalism? A definition that is steeped in theoretical and methodological consideration, while including assessable and accessible student-action items? Although a work in progress, the Career and Professional Development team at Rocky Vista University has chosen to create a career and professional development model that will serve medical students and medical professionals. This developmental model considers culture, religion, neurodiversities, and equity while challenging assumptions that “being professional” means showing up in a prescribed way.

Professionalism is as varied as medical specialties—it is not one size fits all.
Our proposed model rests heavily on the NACE core competencies, McGovern SCoPE’s definitions of professionalism and the panels from the Navigating Professionalism Conference. Presented as a puzzle, with interlocked pieces and rough edges, there are eight-core competencies related to being professional, acting with professionalism and leaving medical school with career and professional goals and competencies. During the “How Would You Define Professionalism” panel, five presenters share their ideas about definitions of professionalism. These five definitions allowed the Career and Professional Development Team at Rocky Vista University to think about how we incorporate professional behaviors and models into our student development plan.

The decision to create a puzzle allows students to visualize how these competencies interlock, while the rough edges allow them to consider other pieces that may fit into their own personal development, before, during or after their medical education. These eight pieces offer a student development model that considers the hyphenated identities that students hold and the ways that those identities come forward in professional conduct—things like eye-contact, fidgeting, etc.

The competencies we identified are:
1. Resilience
2. Equity and Integrity
3. Collegiality
4. Culturally Aware Care
5. Service
6. Demonstrable Dependability
7. Career Skills
8. Innovation

Each of these competencies, when presented to our students, will include the following things: A definition of the competency as defined by our institutional core values, the student affairs core values and the student-learning outcomes of the career and professional development team. Each competency will also include a framework that is theoretical and/or methodological in nature, meaning it is grounded in student development methods or theories. Finally, a “Piece in Practice” component will advise students how to practice this competency as a student doctor.

Ultimately, this new model came to fruition after a conversation about medical student professional development. What began as a pursuit to define professionalism, resulted in a developmental model steeped in considerations of what it means to be a “medical professional.” Defining professionalism with nuance will allow our developmental model to grow with, for and in service of our students. The next pieces of the “puzzle” are to determine assessments and learning outcomes that will evaluate the students’ development.

Madison Tarleton, MA, is a Career & Professional Development Counselor at Rocky Vista University.

I commend Mohamud Verjee's promotion of professionalism and the respect expected of people with professional titles in December’s Professional Formation Update. However, Dr. Verjee posited that scientific and non-medical health doctors are "parading" our degree and "eroding" the respect of MDs. The title Doctor is the Latin word for teacher conferred by universities, not a privilege reserved for a single profession.

Although there are several views on the exact origin of making Doctor an academic title, universities used to have Latin as the language of instruction; so, addressing an instructor in any field as Doctor would be expected.[1] The title was granted for academic achievement as early as the ninth century for degrees in law and theology as well as medicine.[2] The Doctor of Philosophy degree, PhD, became a recognized degree in the twelfth century and became recognized as the highest level of academic achievement in the eighteenth century.[3] We earned the title, typically with eight to ten years of full-time academic programs. After completing bachelor and master degrees, we studied additional graduate courses and conducted original research—we have earned the title Doctor in part by publishing new information, thereby teaching other members our profession. Customarily, completing such research has been a requirement for the title Doctor that nowadays is not part of the curriculum for most programs in which students earn an MD or DO, though there is a reasonable argument that their interactions with patients and each other constitutes the teaching activities and creation of new information consistent with the meaning of title Doctor. Students in health professions educate their patients, mentor each other and conduct diagnostic services, thereby generating and disseminating information.

In contrast with the coursework requirements and original research for the PhD and similar non-medical doctorates, there were no universal minimum standards for earning a medical degree until the latter half of the sixteenth century. Only in the eighteenth and nineteenth centuries did medical students have to complete a dissertation to earn their degree and the title Doctor. Medical students did not universally face nearly today’s level of academic rigor and quantity of scientific premedical background and post baccalaureate medical program until the middle of the twentieth century. The academic requirements to earn the title Medical Doctor continued to increase from the 1950s through the 1980s, at which time the amount of education surpassed that of a PhD student and became onerous enough at the postdoctoral level that the people governing medical residency curriculum recognized reducing the workload was not only better for the student physicians but also safer for their patients.[4]

Given Dr. Verjee's recognition that veracity is an important component of professionalism, I hope he takes this opportunity to reconsider the criticism of non-medical doctors using the title Doctor. He lamented that consumers and colleagues are becoming more informal in addressing physicians as Doctor, suggesting a diminution of respect. My impression after 30 years of clinical practice is that respect among all health professionals is becoming more egalitarian. The equality of status in addressing the person by name rather than by title indicates to patients that when they enter a health care office there is not only one expert; each team member is an expert in a particular aspect of the patient’s care. He also lamented that female physicians are often assumed to be nurses, presumably because of the loss of formality in title usage. Ironically, the subjugation of women in the health care industry leading to that assumption was developed in the same political movement that confounded the definition of Doctor as exclusive to, rather than inclusive of, physicians.[5] Ultimately, I hope we can respect all people by acknowledging their actions, not their titles.

Howard M Notgarnie, RDH EdD, is a retired clinical dental hygienist, owner of Advanced Professional Education, member of the Governing Council of American Association of Dental Hygiene, and Secretary of the New Jersey Dental Hygienists’ Association.

References
[1] Thornton T. Why do universities have Latin names? https://communityliteracy.org/why-do-universities-have-latin-names/ 2022
[2] Hall S. The history of the doctoral degree. https://www.theclassroom.com/history-phd-degree-5257288.html 2019
[3] Chauhan T. What is PhD: History, definition, origin, requirement, fees, duration and process. https://thephdhub.com/what-is-phd-history-definition-origin-requirement-fees-duration-and-process/ 2020
[4] Custers E, tenCate O. The History of Medical Education in Europe and the United States, With Respect to Time and Proficiency. Academic Medicine 93, S49-S54, 2018 doi: 10.1097/ACM.0000000000002079
[5] Adams TL, Bourgeault, IL. Feminism and women’s health professions in Ontario. Women & Health, 38(4), 73-90, 2003; Bourgeault IL. The provision of care: Professions, politics, and profit. In D Raphael, T Bryant, MH Rioux (eds.), Staying alive: Critical perspectives on health, illness, and health care (pp. 263-282). Toronto, Ontario, Canada: Canadian Scholars’ Press, 2006; and Bourgeault IL, Mulvale G. Collaborative health care teams in Canada and the US: Confronting the structural embeddedness of medical dominance. Health Sociology Review, 15(5), 481-495, 2006.

There is a (seemingly) ever-increasing literature on the role of artificial intelligence and its implications for healthcare practice and ethics; however, one set of questions germane to these discussions has received less attention: those surrounding professionalism and artificial intelligence. As the power and influence of AI expands within healthcare, the potential for benefiting health outcomes is significant – but has enough work been done to properly conceptualize the role of this technology within professional spheres? In particular, we must ask, “What is the professional status of AI ‘colleagues’?” – that is, are they indeed coworkers or are they merely tools.

The question may seem like a bit of philosophical fancy, at least a first. Surely AI is a tool, just as a scalpel or a suture is. Even if we ratchet up the degree of complexity of the object – consider laparoscopic cameras or even robotic surgery machines, such as the Da Vinci Si – we describe situations involving these items as cases of professionals operating machines: “It was useful for the surgeon to have that third robotic arm in that case” or “This nurse is particularly adept in employing those suture” or “Which scalpel did the scrub tech prep for the physician to use?” However, upon further reflection, artificial intelligence may not merely a more complex robot, especially when it is used to assist in a healthcare professional’s decision-making. In this latter case, it might be that the AI is a professional colleague.

In “Colleague or Tool: What Professionalism Norms Ought to Govern AI Decision Assistance Algorithms?” which was presented at the recent Academy for Professionalism in Health Care conference Navigating the Professionalism Challenges of Evolving Technologies: Getting Serious About Digital Professionalism - from Social Media to Electronic Records to Artificial Intelligence, this topic was taken up. In particular, two potential answers to categorizing this kind of AI task, decision support: as a fellow professional colleague or as a tool for the use of professions, was addressed. It was argued that if AI systems are to be consider “colleagues,” then the norms of professionalism apply to those systems and their creation and programing must internalize such norms; however, if AI systems are merely tools for the use of professionals, then they need not be built in accord with professional norms, as the healthcare professional is where the professionalism onus would exist.

Depending on the details of one’s particular account of professionalism, the answers might differ. If one prizes the professional duty to place the patient first or to avoid discrimination,[1] these might be duties that can be written into an algorithm and, in fact, done so in such a way that AI is “more professional” than its human counterparts. To the contrary, if one prizes openness and honesty with patients, then AI might be incapable (at least currently) of being a professional since it cannot explain (to a patient or even to another healthcare professional) why particular decisions were made in particular cases, what AI experts often refer to as the explainability problem.[2]

Whether one considers AI to be a tool or a colleague, it is important that scholars and practitioners ask and think about these kinds of questions and their answers. Even if viewed as futuristic as opposed to current or philosophical to practical questions like the status of AI are significant. Sometimes the more theoretical or more philosophical questions in healthcare and healthcare education can seem less important, given the urgency of caring for the patients and their families who are right in front of a clinician. However, the answers to these questions about AI in healthcare have implications that bear on the relationship between practitioner and patient, the privacy of patient information, and the role of informed consent in therapeutic and palliative procedures. They will greatly impact how healthcare is delivered in the years to come and the human professionals who deliver that care.[3]

Bryan Pilkington, PhD, is Associate Professor at the Hackensack Meridian School of Medicine and at Seton Hall University.

[1] For one example of a discussion of discrimination and AI, see: Binkley CE, Reynolds JM, Shuman A. From the Eyeball Test to the Algorithm - Quality of Life, Disability Status, and Clinical Decision Making in Surgery. N Engl J Med. 2022;387(14):1325-1328. doi:10.1056/NEJMms2207408
[2] For a discussion of this problem in connection with healthcare, see: Binkley CE, Green BP. Does Intraoperative Artificial Intelligence Decision Support Pose Ethical Issues? [published online ahead of print, 2021 Jun 16]. JAMA Surg. 2021
[3] For a critical discussion of AI decision support in terms of ethics-specific issues, see: Bryan Pilkington & Charles Binkley (2022) Disproof of Concept: Resolving Ethical Dilemmas Using Algorithms, The American Journal of Bioethics, 22:7, 81-83, DOI: 10.1080/15265161.2022.2087789

What is in a name? What is in a title? When a title belongs to professional physicians, is there a protocol for patients to address them in a specific format today? Has formality been forsaken for a more relaxed social introduction? Do physicians prefer to be called with the earned attribute, or do some prefer an informal way? No one doubts that all professionals deserve respect, whether a judge, a pilot or a doctor. Titles are part of that format, as recognition, without airs and graces – Your Honor, Captain or Doctor.

Professionalism, or lack of, by medical doctors has become highly visible in the Covid-19 era. There are incidences when physicians have abrogated their Hippocratic Oath (or equivalent) with fraudulent claims for fees, undertaking procedures that caused patient harm or death, sexual inappropriateness or failure to provide the expected level of care. Recent examples include physician denial of Covid-19, disinformation, acting with impunity as anti-vaxxers and administering unproven and excessive medications such as hydroxychloroquine. These transgressions all detract from the professional body’s sound reputation in public. Nevertheless, physicians must adhere fully to ethical practices and maintain high standards.

A few disreputable doctors have acted shamefully over past decades. The cruelty of people like Dr. Joseph Mengele in World War II will forever be an example of inhumanity with his distorted and fiendish mind. History will never erase the indelible stain imposed by him. Rightly, not a lot of respect is afforded to such an individual. The Jewish population is painfully aware of the horrific experiments undertaken by this “Medical Doctor.” The disgraceful Tuskegee racial syphilis maleficence is also cited repeatedly. A relatively recent abomination, once discovered, was unacceptable, hence the instigation of IRBs.

Most ethical and dedicated physicians work tirelessly through some of the most stressful trauma emergencies. It takes its toll on their reserve and resilience. Unfortunately, some non-medically qualified health professionals have paraded with the advertised title of “Dr.” notably NAs, PAs and non-medical PhDs (Science & Nursing). While still respected, one can say that their sense of entitlement erodes truly qualified MD standing.

Do patients fully retain respect for their physicians of care? Do they fully understand the training and time invested in a professional consultation? Untitling was found to be significant in women with titular omissions in correspondence and more dropped titles for DOs compared to MD physicians. Primary care physicians were also more impacted by dropped titles when addressed than specialists (Harvey et al., 2022). In addition, female MDs are frequently mistaken as nurses by patients, an irritating and insensitive denigration of MD respect. Inherently, the title “Dr." removes gender bias and levels the playing field.

The relationship between patients and medical doctors has changed with social media, online consultations and modern day “pizza service” expectations. Justified complaints abound about waiting times for appointments. Others post derogatory physician comments or fake news online over which we have no control. People are gullible and often believe some unsubstantiated viral rumors that spread. No longer is there the old-fashioned rigid hierarchy, where partners in practice addressed each other by their last names, preceded by the word “Doctor.” Preserved video recordings from the mid-60s portray inherent communication skills between physicians, nursing staff and patients, exemplifying the banter, humor and caring that all could applaud (Dr. Findlay’s Casebook – Gifts of the Magi). Watch and listen to the dialogue. Although times have changed, we cannot lose the heart of professional care.

We should always remember that patients are people we must care for, whether there is a computer in the room, a patient in need or a social conversation demonstrating humility, kindness and empathy. Using a title may be regarded as hierarchal and a privilege. However, if supported, it should be recognized in society and not minimized to be supernumerary. Practicing medicine is a vocation, not an objective to operate a business or be on a first-name buddy with patients. It represents an individual’s achievement. Factually, it protects relationships for patient and doctor, educated or not, young or old, rich or poor, able or disabled, for all time.

Mohamud A. Verjee, BSc (Hons), MBChB, DRCOG, CCFP, FCFP; MBA Assistant Dean, Medical Student Affairs, Associate Professor of Family Medicine in Clinical Medicine; Weill Cornell Medicine – Qatar; Senior Research Fellow in Mental Health, Clare College, Cambridge University, England, UK

References
1. Harvey JA, Butterfield RJ, Ochoa SA, Yang YW. Patient Use of Physicians' First (Given) Name in Direct Patient Electronic Messaging. JAMA Netw Open. 2022 Oct 3;5(10):e2234880. doi: 10.1001/jamanetworkopen.2022.34880. PMID: 36197668; PMCID: PMC9535496.
2. Dr. Finlay’s Casebook – Gifts of the
Magi https://www.youtube.com/watch?v=VbWE4pL-XY4

It was 1998 at the busy safety-net labor and delivery unit when a woman arrived who needed an emergency cesarean section to save the baby she had carried for only seven months. The baby passed away soon after delivery despite our team’s expert care. The next day her paper medical records from various prenatal visits arrived making it clear that her baby could not have been saved by us. It had a lethal birth defect. Having information from those records when she arrived would have resulted in a much different conversation with her at 2:30 AM about the value of a cesarean. Also in 1998, seeing that computers were revolutionizing other industries, I discovered the emerging field of clinical informatics, whose goal is the wise integration of information technology into clinical care.

It is very likely that over less time than you spent in college, your health care institution surrendered its decades-old, comfortably paced, manual paper record process, that required providers to spend most of their time getting information directly from patients. Now our attention is consumed by tightly integrated computerized documentation tools that require detailed data entry and present us with huge volumes of data that expect our constant attention. Of course, electronic health records have made care safer and more efficient and created unimaginable collaboration, they have also resulted in a loss of autonomy for many caregivers, and some would say a threat to the future of our profession.

Why did this happen? In short, because technology has provided every individual, every organization, every third-party payer, and the federal government with a means to act on every important idea: improved safety, reduced spending, closer patient engagement, population health, robust research, etc. That is quite a firehose for caregivers to drink from.
Practicing clinical informatics means that you work to bridge the three overlapping interests of a.) Direct patient care, b.) the Health care system we practice in, and c.) the capabilities and limits of information and communication technology. When bound into interdisciplinary teams, informaticians help these domains set priorities and see their co-dependency. Most organizations that utilize electronic health records today have such teams.

How do we meld the principles of personal and organizational professionalism with the need to solve problems with information systems? It may already be happening. Interprofessional teams of individuals trained in informatics working in organizations guided by the principles of professionalism are the way forward. For example, where I work at Harris Health System in Houston, the informatics team works every week with IT, Quality and Risk Management, and many clinical care providers from hospitals, clinics and two medical schools to minimize unnecessary work, design more efficient ways to manage necessary work and create educational approaches for greater EHR proficiency.

Interdisciplinary informatics teams are positioned and should be supported to guide the use of technology that allows us to stay true to our professional identities, building trust and applying virtue.

John Riggs, MD, MS, is a Professor, Department of Obstetrics, Gynecology & Reproductive Sciences - LBJ Hospital and McGovern Medical School at UTHealth Houston.

"I do not strive for a clear and unambiguous definition of 'professionalism' because I do not believe one is possible" (Erde, 2008).

Over the last several years, medical education has paid more attention to professionalism (Huddle 2005), or humanism (Swick, 2007), as it is also known. Professionalism, for some, entails protecting one's profession against external dangers, particularly in the healthcare system, while others believe that it implies an effective and efficient physician. According to DeWitt Baldwin, professionalism is a "value-oriented ideologically driven concept" (Baldwin, 2006). Professionalism is defined as "independence of judgement and freedom of action" (Swick, 2007).

Current research studies have shown that the perception of professionalism in the healthcare industry is lacking (van Mook et al., 2009b). Several factors contribute to this problem, including society's perception of medical staff's lack of professionalism, a lack of operational knowledge/definition of professionalism, and shifting healthcare/educational systems (Swick, 2007). The notion of a decline in medical professionalism is cause for concern for all the stakeholders involved. It has fueled the professionalism movement in medicine, compelling researchers in the medical field to talk about it more, particularly in the recent decade (van Mook et al., 2009b).

Professionalism in medical education is vital for the professionals in coordinating and providing effective and competent management in health care. Professionalism at medical school is required to serve patients with moral values and the public and for medical practitioners to develop interpersonal and professional skills (ABMS, 2012). The American Board of Medical Specialties summarizes medical professionalism as an approach of belief in which members of the professionals" affirm ("profess") to one another and the people at large (ABMS, 2012).

The COVID pandemic and the imposed regulatory constraints shifted the teaching-learning and assessment activities from face-to-face to remote online. The students and staff were isolated socially and took to social media and other online platforms for communication, teaching-learning, and entertainment. And following this, we had adverse posts on Facebook, reports of unprofessional behavior during online teaching-learning sessions and various incidences of misconduct.

E-professionalism is defined as the attitudes and behaviors that reflect traditional professionalism paradigms but are manifested through online media. Principles of e-professionalism provide a way for medical students to embrace the positive aspects of online media use while being mindful and deliberate in its use to avoid or minimize any negative consequences. "E-professionalism can be integrated into medical education using strategies based on awareness, alignment, assessment and accountability" (Kaczmarczyk, 2013).

In this new paradigm for a digital age, e-professionalism must involve teaching-learning and assessment of medical professionalism. E-professionalism must increase learners' engagement, improve communication, promote professional development among peers and stakeholders, and enhance entrepreneurial skills. The medical curriculum must include a positive approach to students' professional use of social media.

Rohini Karunkaran, Associate Professor, Unit of Biochemistry and Medical Education, Preclinical Coordinator, Medical Education Unit Coordinator, Faculty of Medicine, AIMST University, Kedah, Malaysia.

References:
ABMS Definition of Medical Professionalism. American Board of Medical Specialties. Adopted by the ABMS Board of Directors, January 18, 2012.
Baldwin DC, Jr. Two faces of professionalism. Healing as Vocation: A Medical Professionalism Primer, K Parsi, MN Sheehan. Rowman & Littlefield Publishers, Lanham MD USA 2006.
Erde EL. 2008. Professionalism’s facets: Ambiguity, ambivalence, and nostalgia. J Med Philos 33:6–26
Huddle TS; Accreditation Council for Graduate Medical Education (ACGME). Viewpoint: teaching professionalism: is medical morality a competency? Acad Med. 2005 Oct;80(10):885-91.
Kaczmarczyk JM, Chuang A, Dugoff L, Abbott JF, Cullimore AJ, Dalrymple J, Davis KR, Hueppchen NA, Katz NT, Nuthalapaty FS, Pradhan A, Wolf A, Casey PM.
e-professionalism: a new frontier in medical education. Teach Learn Med. 2013;25(2):165-70.
Swick HM. Viewpoint: professionalism and humanism beyond the academic health center. Acad Med. 2007 Nov;82(11):1022-8.
van Mook WN, van Luijk SJ, O'Sullivan H, Wass V, Harm Zwaveling J, Schuwirth LW, van der Vleuten CP. The concepts of professionalism and professional behaviour: conflicts in both definition and learning outcomes. Eur J Intern Med. 2009 Jul;20(4):e85-9.

Prehealth students are generally aware of the steps needed to present a desirable application. Most successful applicants understand the importance of clinical shadowing, community service and academic accomplishments to demonstrate a foundation in critical thinking and pre-professional attributes for subsequent education and training. However, the COVID-19 pandemic and a revived awareness of racial and social inequities have reminded all health professional educators about the moral responsibility placed on healthcare providers and leaders to ensure fair, quality access to care. In spite of many schools’ desires to recruit and nurture future healthcare leaders who could be community advocates, there lacks a definitive curricular resource that provides a deep understanding or discussion of critical issues of national and international importance for the future of healthcare delivery.

The Health Professional Student Association (HPSA) developed the Becoming a Student Doctor course project to serve as an online “coursepack” by curating journalistic-quality resources that could stimulate personal or collective introspection on the social impact of healthcare. The content incorporates contemporary priorities and topics that could affect public policy and community health which can be further exacerbated because of social determinants of health. Insights into the expected roles and scopes of expertise from interprofessional healthcare providers allow for a discussion of the different competencies and expertise that are valued when working together. It is hoped that students can access these resources to further contribute to preclinical or experiential discussions and further nurture them on their journey to be healthcare professionals.

The Becoming a Student Doctor content is organized into 10 topics consisting of written journalistic articles and audiovisual materials.

1. National/International Priorities
2. Healthcare Shortages
3. Interprofessional Healthcare
4. Academic Competencies
5. Pre-professional Competencies
6. Embracing Inclusion
7. Systems Competencies
8. Situational Judgment Assessment
9. Making a School List
10. The Voyage Ahead

Access to these materials is limited to HPSA members and individuals who qualify for free scholarship access. Qualification includes providing a copy of a diploma from a high school located in a medically underserved area, a copy of the FAP approval letter from AAMC or a similar educational organization or attestation of being a participant in a pipeline program with a mission to help prospective healthcare providers from rural or underserved communities.

The Becoming a Student Doctor resource project can also be used to supplement existing curricula or developed as a bridge to continued engagement after the conclusion of a pipeline program experience. Over 20 documentaries or journalistic reports are embedded within the course to inspire and provoke discussions. I also seek collaborators to assess the effectiveness of the curriculum and further improve or enhance this collection as well as grant funding opportunities to scale-up access to the materials, as we have a limited class size in Google Classroom.

Emil Chuck, PhD, is Director of Advising Services at Health Professional Student Association. You can reach him at emilchuck@hpsa.org.

Building Trust
by Maya Van Geison

“Espera…” (wait…) said the female patient for whom I was translating. We stood in the patient checkout line at one of Remote Area’s Medical Clinics (RAM), which provides free healthcare services to underserved populations. I was on my 18th hour in two days working at the clinic which had seen over 1,000 patients that weekend. Nonetheless, this one word captured my attention. I could feel the worry in her voice and see it in her eyes. I also sensed she was debating whether to say anything at all.

I ushered her out of the checkout line. We sat together, and I asked what was wrong. She paused and then explained her husband cheated on her, and she was worried about her sexual health. This moment was an incredible experience of trust. I was honored she shared something so personal with me and admired her vulnerability. I reassured her, thanked her for trusting me, and offered the clinic’s Rapid HIV test. She agreed and asked me to stay with her to wait for the results. I did so without a second thought. When the results came back negative, she was relieved and put at ease. She thanked me for listening, waiting and staying with her.

This interaction made me appreciate the importance of trust in relationships. Trust is a priceless and fragile entity. For once it is broken, it is difficult to be fully regained. However, complete trust allows for vulnerability, sharing of stories, and understanding. Unfortunately, this patient experienced trust being broken due to her husband’s actions. Yet, she and I both experienced complete trust when she confided in me.

When I first reflected on this interaction, I wondered, “What did I do to deserve this patient’s trust?” I realized it was not one moment that deemed me trustworthy, but rather my continued transparency and compassion throughout the visit. Although I only met her when she arrived, I smiled and introduced myself. I asked how I should address her and informed her of how the clinic worked. We would begin by seeing a general practitioner, then any specialists as needed and end at the checkout desk. During the visit, I translated directly between her and the doctor and ensured all her questions were answered. I believe these simple introductions, manners and informing the patient of what to expect laid the foundation of trust in our relationship. Then, ushering her out of the checkout line was the pivotal moment when she decided to trust me with more personal matters. Bringing our conversation to a private area, sitting next to her and being patient for her response, helped show I truly cared. It also demonstrated I appreciated the uniqueness of her story and her needs, permitting her to receive additional care. It is our responsibility to lay a foundation of trust, so it may grow and allow for superior patient care.

As a medical student and future physician, I plan to foster a foundation of trust with my patients, so I can care for them to the best of my ability. As with this patient, I plan to have an unrushed introduction between myself and the patient. This attentiveness to the introduction exemplifies that I see the patient as an individual and establishes our relationship as a health care team. I will then ask what brought them in today and listen to their response without interruption. This further solidifies my appreciation for their unique story and my ability to listen. Throughout the visit(s) I will be transparent, informing them how the appointment or treatment plan will proceed. Finally, I will always allow for questions, ask if my explanations were clear and give time for the patient to respond. Giving patients this opportunity is imperative, as it helps define the doctor-patient relationship, rather than simply the unidirectional care of a physician. After all, patients are people, people with emotions and people with a story. They deserve to be heard, be cared for and have people to place their trust in.

Ultimately, it is our commitment to actively listen, provide information and allow for silence that demonstrates we truly care about the patient and their individual needs. This appreciation of their individuality and unique story then cultivates the vital foundation of trust. Trust then culminates in a greater understanding between physician and patient and enhanced care. As a future physician, I hope to appreciate, build trust and provide the best care possible to each unique individual seeking care.

Maya Van Geison is a second-year medical student at Geisinger Commonwealth School of Medicine.

It has been said that “If you really want to know what my life is like, then walk a mile in my shoes.” That concept was explored by looking at the data pertaining to patients in Appalachia and through interviews with indigent individuals, who reside in Central Appalachia. The statistics stated that Appalachians have higher mortality rates than the nation in several areas, such as heart disease, cancer, chronic obstructive disease (COPD), stroke and suicide. These statistics were both staggering and upsetting. The question asked was how did our Appalachian patients get here and how can health care professionals make a positive change in these numbers. To answer these questions, a unique approach was taken.

First, it was important to take a look at the most recent statistics. For developing COPD, stroke, diabetes, depression, obesity, and opioid deaths, Appalachians were at an approximately 15-35% higher risk, compared to the nation. For heart disease and cancer, the risks compared to the nation were even higher. The poverty rate in Appalachia was 5% higher than the nation, and, added to this, almost 30% of Appalachian adults were considered functionally illiterate.

The next step involved going deeper than just making observations about the numbers. Through interviewing five indigent Central Appalachian individuals, a new perspective was gained. Even though the study group was small, the insight was significant. All of the interviewed individuals, to some degree, did not trust health care providers, did not have the same access to health care and health information as the non-indigent, and had experienced some form of health disparity due to their inequity.

The suggested last step is to combine the data from the statistics and interviews to find potential paths for positive change in Appalachia. Finding those paths involves getting to know indigent patients on a professional and deeper level and identifying their possible disparities. Once these disparities are identified, professionals could make plans, within their professions, to help their patients avoid them. For example, for illiterate patients, a clinic could make a call list, which could be used each month, to go over any new medications or to discuss new updates on health maintenance, such as vaccines.

By getting to know the individuals interviewed, an empathetic knowledge beyond statistics and a deeper understanding of the problem was acquired. Although it is said that everyone should be treated equally, that ideal does not apply here. Appalachian indigent patients are already experiencing inequities, so a special effort is necessary to provide equity. The UK’s Royal College of Physicians defines professionalism in healthcare as “as set of values, behaviors, and relationships that underpins the trust the public has in doctors." Healthcare professionals who demonstrate professionalism are committed in “day-to-day practice of Integrity, compassion, altruism, continuous improvement, excellence, and collaboration with colleagues.” Hopefully, the conversations started with this article, along with the love of an individual’s health profession, professionalism and the love for patients will help experts discover a more positive path for their indigent patients and to improve the statistics for Appalachia.

Amanda Blankenship, PharmD, RPh, MS, is Associate Professor of Pharmacology at the University of Pikeville-Kentucky College of Optometry and Kentucky College of Osteopathic Medicine.

References
Creating a Culture of Health in Appalachia: Disparities and Bright Spots. https://www.arc.gov/images/appregion/fact_sheets/HealthDisparities2017/AppRegionHealthDisparitiesKey Findings8-17.pdf
Creating a Culture of Health in Appalachia: Mortality. Health Disparities in Appalachia: Mortality (PDF: 6.5 MB) (arc.gov)
Demonstrating Professionalism in Healthcare Settings. Demonstrating Professionalism in Healthcare Settings - USF Health Online
National Association of Counties: Opioids in Appalachia: The Role of Counties in Reversing a Regional Epidemic. Opioids in Appalachia: The Role of Counties in Reversing a Regional Epidemic (naco.org)
Opioids in Appalachia: The Role of Counties in Reversing a Regional Epidemic. https://www.naco.org/sites/default/files/documents/Opioids-Full.pdf

Learner perspectives and co-producing curriculum was one of the main aims of our planned research on professionalism undertaken at Touro University Nevada. Dean Wolfgang Gilliar commissioned this piece of work funded internally. Dr. Nagina Khan led the research as the primary investigator having sought collaboration with colleagues in the Netherlands and the UK. This work was a valuable opportunity for the students to take part in an international study and science that will impact future undergraduate medical education.

The students were involved from the very beginning in the planning phase. They learned about the research design, suitability of research questions, the stages of research, the qualitative research designs and leadership.
Students successfully led and produced a poster presentation which was presented at the Leaders in Healthcare 2020.

Authors included Joshua Sagisi, Nicole Davi, Dr. Nagina Khan, Chantel Aftab, Sohyun Ha, Prof. Walther N K A van Mook, Prof. Subodh Dave, Prof. Wolfgang Gilliar and professionalism facilitators in undergraduate medicine. The research was a mixed methods systematic review. The abstract was selected for an ePoster display at Leaders in Healthcare 2020, 2021 and was published in BMJ Leader.

Entering from a health sciences background, this was also a novel opportunity for Dr. Khan to be involved in medical education via hybrid identity. This was also an innovative opportunity for Touro University Nevada to explore and find out how students experienced working and being taught by someone who wasn’t a clinical doctor or from someone who was not trained from solely the same lens. This has been successful both for Dr. Khan and the students who gave positive feedback.

Students also chose to apply for a Research Clerkship Elective in the 4th Year.
Feedback: “Thank you again for helping me apply for a research month in April! I think it'll be perfect to be full-time with the project” (Student 4th year)

You can access the final accepted version (not copyedited yet) and share the preprint of the research protocol on social media sites with your contacts: #JMIR #Preprint: Learner perspectives of professionalism: a mixed method systematic review protocol https://preprints.jmir.org/preprint/37473 #digitalhealth via @jmirpub

Subodh Dave, FRCPsych, MMedSci (Clinical Education) is a Dean at Royal College of Psychiatrists, & Consultant Psychiatrist. He is a Professor at Bolton University & Deputy Director of Undergraduate Medical Education, Derbyshire Healthcare Foundation Trust, UK.
Wolfgang G. Gilliar, DO, FAAPMR, is the Dean of the College of Osteopathic Medicine at Touro University Nevada & currently serves as a member of the Executive Committee of the American Association of Colleges of Osteopathic Medicine (AACOM).
Walther Van Mook, MD, PhD, is a Chair of the Committee on Professional Behaviour, a Postgraduate Dean at Maastricht University Medical Centre. He is a Professor of Professional Development Chair at Maastricht University, Netherlands
Nagina Khan, PhD, is a Scientist & Senior Research Associate, at the College of Osteopathic Medicine at Touro University Nevada. Nagina is an Editorial Board Member of the BioMed Central - Medical Education Journal. She is an Executive Committee Member - Association of University Teachers of Psychiatry (AUTP). Her research is focused on context & service user/learner perspectives, complex interventions in medical education & mental health.
Chantel Aftab, DO, MPH, is a psychiatry resident physician in Las Vegas, Nevada and former Department of Defense research contractor.
Marie Hickman, BA, is Library and Knowledge Manager at Derbyshire Healthcare NHS Foundation Trust, UK.
Joshua Sagisi, MS in Health Sciences, BS in Biology, is a 3rd-year medical student at Touro University Nevada School of Medicine.
Sohyun Ha, DO, is a current Pediatric resident and Captain of the U.S. Air Force Medical Corps at Naval Medical Center Portsmouth, VA.
Sucheta Tiwari is a specialty registrar in general adult and old age psychiatry in London and has a special interest in exploring the role of humanities in medical training.

AAMC DEI Competencies Endorsement

The Association of American Medical Colleges (AAMC) recently released medical student competencies around diversity, equity and inclusion, which was criticized by the Wall Street Journal editorial board. The Academy for Professionalism in Health Care board of directors voted to endorse these competencies in the following position statement. You can find the AAMC document at: https://www.aamc.org/data-reports/report/diversity-equity-and-inclusion-competencies-across-learning-continuum

The Academy for Professionalism in Health Care mission is to optimize patient care through professionalism education, scholarship, policy and practice in all health-related fields. To that end, we endorse the Association of American Medical Colleges (AAMC) Diversity, Equity and Inclusion (DEI) Competencies for medical students.

Best practice in medicine and other health care professions are grounded by competencies that evolve to address current and urgent health issues, particularly those that adversely affect care such as racism.

There are undisputed vast disparities in morbidity, mortality and health care between whites and communities of color. A legacy of false beliefs about biologic racial differences continues to affect medicine, such as race corrections for kidney and pulmonary function based on incorrect historical assumptions, which can adversely affect care. Implicit and explicit clinician biases disadvantage patients and practitioners of color. The AAMC competencies and others like it are necessary to help the next generation of health care practitioners close this gap by understanding that race is socially constructed, and a social determinant of health.

We believe that health care practitioners are more than just diagnosticians; they are healers who must understand their patients, including those with multiple intersecting identities. Health profession schools teach communication, empathy and compassion, so students can understand and address how context can affect their patients’ health. Not only racism, but biases abound in health care - gender bias, ageism, homophobia and others. Clinicians need to ensure their biases don’t adversely affect care. The DEI competencies address this.

We believe that the goal of understanding historical and structural racism is to facilitate caring for all patients with understanding and empathy and to strive for just and equitable care for all.

The people’s interaction generates various effects on them, according to the type of interaction [virtual vs. physical], information, sensitivity and vulnerability of the intended recipient. Each individual’s energy interferes with that of others existing in the environment, generating various, occasional or persistent electrical game which orchestrates the variation of the individual energetic picture in action, finally facilitating, maintaining, or declining the person’s well-being.

The people’s communication through words, sounds, colors and images influences them, improving or altering their welfare, its restoration - according to the signal magnitude, time exposure, quality of transmission and its resonance in the individual. Best communication determines delightful moments, and inappropriate interaction between them affects their health.

Distress is attenuated using selected revitalization instruments or recuperation tools such as [e]-lectures, musical compositions and pictures – according to the individual’s preferences. IT devices allow us to join such programs where and when necessary. IT advancement puts forward another perspective for disorders’ management improvement, which never existed before; its use assists us not only in the recovery, but also in relaxing for a better life.

Applying artificial intelligence in daily practice increases work efficiency, analyses precision, eliminates more physical and mental activities and improves satisfaction. Learning and analyzing machines fascinate us by exactitude, the time-consuming.
In this digital era, instant networking increases the connectivity between society and facilitates information flooding rapidly.

Even so, people’s communication by words remains a key to improving or deteriorating people’s health and their power. Words’ energy utilization in clinical practice has to be of interest to public health. Inappropriate verbal and nonverbal communication may initiate, maintain and accelerate the evolution of hypertension, type 2 diabetes, dyslipidemia and brain hemorrhage in vulnerable individuals. The evidence in clinical practice supports these unwanted consequences of improper communication, which significantly impact the life quality, expectancy and cost of healthcare services.

Corrective actions are required in such situations. In person or hybrid model for the communication skills’ educational programs improve the end-users' knowledge and its use in practice. Promoting good habits in interaction with other persons from different industries assures work efficiency, quality, respect and appreciation from the society we serve. Art of knowledge transfer in daily activities assists us in achieving excellence in clinical practice. Acting as professionals in all domains is a key to a better personal, professional and social life.

The patient experience reflects our ability to cope with their harsh conditions; how the health care team interacts with the patient and the illness evolution certify our expertise and capacity to deliver the information in practice. Integrated health care, including social, emotional, and scientific support, is mandatory. Our investment in alleviating suffering will return to us in the form of material and spiritual gifts from the patient, his family and the community.

In addition, verbal and nonverbal communication skills pave the route for society’s evolution. The advancement of its economic, cultural and social pathway is connected with the refinement in the usage of specific information when necessary. Failure in doing so deteriorates its corresponding segment, weakening it in interaction with other parts. Inadequate centralized and analyzed data, miscommunication, dominance or weakness of some personality traits amend the partnership between corporations leading to unwanted, detrimental outcomes. War at a micro or macro level, in the society or the world, is, in fact, inadvertency in public relations. It leads to the moral and physical distress aligned with affected social, economic and cultural life, announcing sequels with bad memories over time.

The power of the words and attitudes to destroy or ameliorate and improve human life to illuminate has to be considered.

Sofica Bistriceanu, MD, PhD, is a Family Physician and the representative of Academic Medical Unit-CMI in Romania.

The Forgotten Text is 12 chapters of narrative medicine about the formation of a physician from 2015 to 2020. The book was a Bioethics Practicum written deliverable— a required course where master students are exposed to bioethics field experience. The Forgotten Text was written by Vivian V. Altiery De Jesus, MD, at the time a Master of Bioethics student at the Johns Hopkins Berman Institute of Bioethics, who was on an academic leave between her third and fourth year of medical school in Puerto Rico. Her third-year medical education was atypical - Hurricane María, a Category 5 hurricane, razed her island on her very first third-year clerkship.

The Forgotten Text explores, under an ethical lens, the encounters and challenges that medical students may face during their education. The analogy is akin to a butterfly’s metamorphosis, which convey a mysterious transformation process from caterpillar to a butterfly; or maybe a caterpillar enhanced with wings.

The medical note is a unique language system, its own narrative text that is focused on diagnosis, assessment and management. The medical note has a specific format - “Mr. R is a 47-year-old male with history of diabetes and hypertension that presents to the emergency department with a 8/10 chest pain since 30 minutes ago” - which omits non-relevant medical information about the patient. Anthony Moore describes the patient’s story as the missing text in the medical note in his 1978 book, The Missing Medical Text: Humane Patient Care.

But what about the medical student’s story? Would that be forgotten? Medical school is transformative; therefore, pre-medical students need to be equipped with the skills and tools to thrive in the medical field. The Forgotten Text discusses three components of narrative medicine described by Charon: physician self, physician-patient, and physician-public trust (2001). In the case of this book, the physician-self will not reflect the physician’s practice experience, but her formation into a physician during medical school.

Narrative medicine is a tool that allows the writer to share her experience, breaking time and space barriers. It also allows the reader to continue the dialogue with a different kind of text found in the medical literature. The handprint of The Forgotten Text is the incorporation of emoji inside the text, which hallmarks the everyday written conversation of the writer’s time. Even though narrative medicine cannot be generalized due to the particularity of the situation and interpretation of the author, it still sparks conversations, points out possible grey zones and, most importantly, shares insights about what others in the profession may also be enduring.

Vivian V. Altiery De Jesus, MD, is an internal medicine resident at Johns Hopkins Bayview Medical Center.
Amelia Hood, MA, is a Research Associate at the Johns Hopkins Berman Institute of Bioethics.

References
Charon, R. (2001). Narrative medicine: a model for empathy, reflection, profession, and trust. Jama, 286(15), 1897-1902.
Moore, A. R. (1978). The missing medical text: humane patient care.

Reflection has been advocated as an essential ingredient for enhancing learning and contributing to practice improvement. Although engaging in reflection can result in learning; however, it does not necessarily lead to the higher level of evaluation, which is required for transformative learning. Consequently, there is the need to engage in critical reflection.

According to Mezirow (1) critical reflection is ‘the process of becoming critically aware of how and why our presuppositions have come to constrain the way we perceive, understand and feel about our world; of reformulating these assumptions to permit a more inclusive, discriminating, permeable and integrative perspective; and of making decisions or otherwise acting on these new understandings. More inclusive, discriminating, permeable and integrative perspectives are superior perspectives that adults choose if they can, because they are motivated to better understand the meaning of their experience.’

In simple words, it is the process of evaluating, questioning and reframing an experience for the purpose of learning (reflective learning) or to improve practice (reflective practice). This links to the concept of reflection as a single, double and triple loop learning (2). Single loop learning focuses on the ‘what’ questions such as “What did I do, notice and feel? What is the difference between what I thought and happened? What shall I do about it?” In single-loop learning, entities (individuals, organizations) modify their actions according to the difference between expected and obtained outcomes.

In double-loop learning, the emphasis is on the values, assumptions and policies that led to the actions initially and seeks to answer the ‘why’ also. “Why did I do it that way? Why did I get those results? Why do I have those and its impact?” The triple loop, addresses the complex conceptual frameworks and systems of power and how learning from the selected incident will impact on other situations. The current trend is more towards double loop, positioning towards the ‘self’ in reflection, and reflection as a learning tool and measuring performances of reflection.

Although this approach holds its own value, the nature of reflection as a critical social inquiry needs to be revived. As practitioners, we need to deepen our understanding around the assumptions embedded in thought processes and power relations and to consider how social and systemic forces influence practices and exert changes on one’s decisions resulting in transformed beliefs and behaviours (3-4).

This can be achieved by engaging in critical inquiry and dialogue to become more aware of the social, cultural, economic and political forces at work (5). Within the era of rapid technological enhancement, more interprofessional and transdisciplinary collaborative reflective practices will enable multiple ways of thinking about complex challenges in healthcare settings to continue to enthuse ethically, socially responsible patient-focused care.

Sonia Ijaz Haider, PhD Clinical Education (UK) is an Associate Professor at the Department for Educational Development, The Aga Khan University, Karachi, Pakistan.

References
1. Mezirow J. 1990. Fostering critical reflection in adulthood. San Francisco:
Jossey-Bass
2. Argyris, C., & Schön, D. (1974). Theory in Practice Increasing Professional Effectiveness. San Francisco: Jossey-Bass Publishers.
3. Ng SL, Kinsella EA, Friesen F, Hodges B. Reclaiming a theoretical orientation to reflection in medical education research: a critical narrative review. Med Educ. 2015;49(5):461-75.
4. Morrow R, Torres CA.Reading Freire and Habermas:Critical Pedagogy and Transformative Social Change. NewYork, NY: Teachers College Press 2002
5. Brookfield S. Critically reflective practice.J ContinEduc Health Prof1998;18:197–205

Entering my first year of medical school, I was apprehensive of the gross anatomy laboratory (GAL). Having never completed a cadaveric dissection before, I was excited to participate in what is widely considered a rite of passage in medical school. I heard from many doctors about their experiences with cadaveric dissection, and been regaled with stories of scalpels and the smell of formaldehyde. Becoming a medical student and preparing for the gross anatomy laboratory felt like I was joining a long-time tradition, fully bridging the divide between hopeful pre-med and future doctor. However, I was nervous about the breadth and depth of anatomy knowledge required, not having had prior experience with learning anatomy. On a deeper level, I wondered how the GAL would impact me, both as a medical student and a person. As a highly empathetic person, I wondered if I would be able to handle my emotions being around a cadaver. I wondered if I would need to harden myself to cope.

During my GAL experience many of my expectations were met. I recognized that the laboratory is a vital educational tool, clarifying anatomical concepts in a way that no other teaching modality can. I consistently struggled to learn anatomy, spending hours poring over pictures of the brachial plexus, not understanding the complex innervation. Seeing the plexus in the flesh, being able to trace the nerve pathways with my fingers, greatly enhanced my understanding. Anatomy was not the only thing I learned in the GAL. I began to develop my professional identity. Initially I pushed away any emotions the experience stirred up within me, choosing to focus on the dissection, not the human body in front of me. However, over time, this was more draining than helpful. I would walk home from GAL emotionally exhausted, thinking incessantly about the woman who had donated her body to science and to my education. I slowly learned to embrace my emotions while in the laboratory. I took a few moments in each dissection to think about the human behind the body and to express gratitude for her selfless gift. Taking time to reflect while in lab helped me stay focused and retain the knowledge I acquired. This personal discovery, that I need to give myself space to feel, is something I will carry forward into my career as a physician.

As the GAL continued, I wondered if my peers were similarly impacted by the cadaveric dissection experience. At Geisinger Commonwealth School of Medicine, personal and professional development is a component of the curriculum. My class was assigned a reflective writing assignment about our initial experience in the GAL. As I submitted my reflection, I thought about my classmates doing the same. I wondered if the GAL had stirred up similar thoughts and emotions within them. I was excited to learn about a research opportunity to explore professional identity formation through reflective writing on our GAL experience. During GCSOM’s Summer Research Immersion Program, I joined a team of students and faculty conducting a qualitative study on the cadaveric dissection experience. I reviewed reflective writing pieces on my peers’ first experience in the GAL. I met with our team to discuss excerpts, develop our codebook, and develop themes and subthemes from the data.

This research experience was enlightening. Reading my peers’ reflections made me feel bonded to my classmates in a unique way. I realized that although everyone looked like they were holding it together in the GAL, many of us experienced a torrent of emotions that first day. Knowing I was not alone in the emotional struggle made me feel viscerally connected to my peers. The experience also taught me about the use of reflection as a pedagogical tool in medical education. My peers and I were positively impacted by the reflection assignment, as it gave us a space to process our difficult emotions about the GAL. We were vulnerable, acknowledging the complexity of regulating our emotions while also meeting our responsibilities to ourselves, peers and future patients. We wrote about honoring our patients, learning, growing and becoming accountable in the practice of medicine. We can apply our reflective abilities and knowledge when confronted with challenges in our careers.

Ultimately, this experience confirmed the importance of cadaveric dissection in holistic medical education. In an educational climate where cadaver labs are being replaced by virtual alternatives, I learned that cadaveric dissection is not just a way for medical students to learn anatomy, but a vital component of professional identity formation for future physicians.

Ceili Hamill, BS, MD Candidate, Class of 2025, Geisinger Commonwealth School of Medicine

Acknowledgement
I would like to acknowledge our research team, both my peers and faculty members, particularly Dr. Halle Ellison, Dr. Amanda Caleb and Dr. Michelle Schmude for support and collaboration throughout the Summer Research Immersion Program.

The introduction of artificial or augmented intelligence (AI) into the practice of pediatrics should come as no surprise to clinicians caring for children in the 21st century. After all, children are now growing up in families where their parents have welcomed digital devices – cell phones, tablets and wearable products such as the Apple Watch or Fitbit – as part of the everyday use of technology. These devices capture and share data that may be an accepted norm for some parents but come as a surprise to others. How and where do ethics interface with the development and use of AI as it pertains to children?

First and foremost, the potential for AI to bring improved health care access, utility and disease-specific outcomes should be recognized. Proof of this concept can be seen in at least three such cases. In a study published last year in JAMA Pediatrics, AI was used by experts in child development at Duke University (1). They tracked the visual gaze preference and focus in over 900 toddlers – identifying the typical scanning of the entire screen and focus on a woman’s face among the majority, but a narrowed focus on only the side of the screen with a toy among the 40 toddlers who were later diagnosed with autism spectrum disorder (ASD). Such methods could help diagnose ASD earlier and improve access to appropriate care.

In addition, the utility of AI in both diagnosis and streamlining care in emergency departments (EDs) has demonstrated increased efficiency in diagnosing COVID-19 and, in other studies, the preferred choices of clinical diagnostic tests – reducing both the costs of ED care and length of time spent in the ED. Also, the way asthma is managed – both in an ED and even at home, using wearable device technology – has been a recent focus of attention, as has the real-time monitoring and management of insulin-dependent diabetes mellitus.

With these and other potential benefits, should we be concerned about the role of AI in pediatric health? Let’s consider another three events that may be problematic ethically. First, we must realize the potential misuse of data that represents a privacy breach – wherein data that is unnecessary for disease evaluation and management is incorporated into AI formulations and protocols. Personal health information (PHI) must be minimized and protected in any such situations. Think about how ZIP code data might inform disease severity, social determinants of health, or reasonable expectations of adherence to prescribed therapies or disease management. But think also of how such data, perhaps when coupled with adverse childhood events (ACEs) and the use of child welfare referrals, might be misused by law enforcement. We must remember that data breaches do occur and when children might be the victims of such breaches, we should be especially cautious.

Second, the potential for bias may exist when AI algorithms are predicated only for certain populations – thereby not necessarily applicable to the broad population of children. Think here of both inadequate information input resulting in imperfect diagnosis and management protocols (output), and of the potential to perpetuate racial and ethnic disparities in health.

And finally, both parental authority and the autonomy of their children should not be ignored or usurped by big data digital health technology companies and their partnerships with Big Pharma. Wearable technologies can include microphones to detect cough characteristics, but also voice biomarkers; and companies could sell such data to insurers and health plans – all for the sake of profit.
So, as we move forward with AI in pediatrics and all of medicine, let’s keep an eye on its ethical ramifications.

Brian Carter, MD | Neonatal/Perinatal Medicine | Interim Director, Pediatric Bioethics Center | Professor of Pediatrics, and Sirridge Endowed Professor and Chairman, Department of Bioethics & Medical Humanities, UMKC School of Medicine

Reference
Chang Z, Di Martino JM, Aiello R, et al. Computational methods to measure patterns of gaze in toddlers with autism spectrum disorder. JAMA Pediatr. 2021;175(8):827-836. https://doi.org/10.1001/jamapediatrics.2021.0530

I’ve been engaged in remediation work in ethics and professionalism for about 15 years, working with a wide range of regulated professionals. I retired in 2020 from the position of Faculty Lead, Ethics and Professionalism with the Temerty Faculty of Medicine at the University of Toronto, where I worked with medical student and residents. I decided to upgrade my skills by enrolling in a Leadership and Performance Coaching Certificate course run by ACT Leadership Corporation, associated with the School of Professional Studies at Brown University. I’ve now completed two of three intensive modules and am working through the required number of practice coaching sessions. This article is an attempt to capture what I’ve learned and how it could be applied in my remediation practice.

A quick review of this model: coaching is “about building the client’s capacity to solve their own problems.’’ The client is “creative, resourceful, and whole’’ and the coaching relationship is not hierarchical. The coach leads the client through a journey from awareness through choice to transformation. Through this process the client reframes the problem, chooses how to react and manage and commits to some action.

In contrast, in remediation the trainee does not choose the topic and the relationship is not a partnership. Further, confidentiality is not assured (generally, I am required to report to the faculty in the case of trainees or the regulatory body in the case of licensed practitioners). The trainee must satisfy the faculty or regulator that they understand and will incorporate professional behaviours.

How then, is it possible to apply the principles and techniques of co-active coaching to remediation? Let’s take the example of appropriate responses to feedback, a common professionalism issue with trainees. My usual practice is to have the trainee engage in readings – in this case some parts of the book Thanks for the Feedback. We might then discuss triggers or ego, and they would identify how they could better self-regulate. Their strategies would be captured in a reflective paper.

In contrast, in co-active coaching I would lead the trainee through a discussion intended to identify the topic – or what’s really going on. We would then work through the awareness-choice-transformation process to identify the choices they could make in response to feedback they felt was unfair, unreasonable or unkind. We might undertake an exercise in identifying their values and the extent to which they were honoring each value. We might name and consider their relationship to their inner critic. We would consider how to reframe their response to feedback. Through these sessions we would “’explore multiple causes of learner struggle beyond educational or workplace issues’’ or Guideline 13 (a strong recommendation) as described by Chou et al. (2019). Those multiple causes could include, for example, disappointment with the program, being overwhelmed with the rigors of residency, not understanding the feedback or issues with ego. We might end in the same place as the more traditional approach outlined above, but the co-active coaching approach arguably gives the trainee more agency, more control and, hopefully, more insight into professional behaviors.

So, it is possible to address the trainee’s own problems, even though the original topic is not their choice. It is possible to develop a learning alliance or partnership even though there is an evaluative component to the relationship. While full confidentiality cannot be assured, it is possible to report at a high level, focusing on choices and commitments rather than details.

Admittedly, this approach does not address institutional issues. But the remediation coach is working with the individual rather than the institution. And the individual may need to reframe their relationship and approach to the institution to better manage the feedback. Part of that reframing might even include some action to effect institutional change.

Erika Abner, LLB, LLM, PhD (Higher Education) can be reached at erika.abner@utoronto.ca

References
Chou, C., Kalet, A., Costa, M., Cleland, J, and Winston, K. Guidelines: The do’s, don’ts, and don’t knows of remediation in medical education.’’ Perspec Med Educ (2019) 8:322-338.
Stone, D. and Heen, S. Thanks for the Feedback: The Science and Art of Receiving Feedback Well. New York: Penguin Books 2014.

Aspects of professionalism’s duties are not safe to emphasize and under the heading of compassion are announcing and denouncing. Compassion is not only feeling with but requires acting: announcing when public health strategies are beneficial or at least not harmful to a particular patient and /or populations of patients, as well as denouncing when they are not beneficial but outright harmful.
Transformation (2) to act, not only for the patient under one’s care but for the good of communities and populations of patients, is a professional duty. The duty for the patient was emphasized by Pellegrino as a covenant and for groups of patients by Cooke.

The same holds true for professional associations, hospitals, universities and other institutions, as moral agents they, too, have the duty to announce and denounce. When moral theology embraces proportionalism, bioethics moral relativism and law and science deny objective reality, shunning questioning or inquiry as sedition to be cancelled: Who shall kindle the flame of virtue and professionalism?

When medical vigilantism is the rule...the patient-physician relationship gone, consent coerced, unduly influenced and not adequately informed, is the damage irreparable? When politics and ethics are hiding their guiding lights under a basket, where should the professional in formation turn for guidance? Esthetics? Perhaps. “If nothing is true or false, good or bad, if the only value is that of efficiency, that is to say the strongest, the world is no longer divided into just or unjust but into masters and slaves, and he is right is he who dominates” (3).

“We have a right to think that truth with a capital letter is relative. But facts are facts. And whoever says that the sky is blue when it is gray is prostituting words and preparing the way for tyranny” (3).

Raul Perez, MD, is Professor of Ophthalmology and Medical Ethics at the University of Puerto Rico School of Medicine.

References
1. “Woe to you.” Biblical admonition.
2. Cooke M. (2010) Educating Physicians. San Francisco, Jossey Bass
3. Camus A., (1951) The Rebel. (Rebellion, Resistance, and Death: essays.) Paris Gallimard

Though almost 30 years have passed since its publication, the influential Academic Medicine article by Hafferty and Franks remains instructive. That piece sought to expose and highlight the influence of “the hidden curriculum” and its power in medical education. Hafferty and Franks argue that “most of the critical determinants of physician identity operate not within the formal curriculum but in a more subtle, less officially recognized ‘hidden curriculum’” (1). Academic medicine (the institution, not the journal where the publication appeared) is now rife with discussions of this issue – where only a few articles existed before the Hafferty and Franks piece, PubMed now lists 539.

This short article reflects on only one of their many insightful observations, so readers are encouraged to revisit that piece or discover it for the first time. Much of the ethics education that occurs in medical schools, as Hafferty and Franks note, is case based, but this piece asks if that is the best approach to ethics teaching today. Case-based ethics teaching has the allure of reality and the ease of analysis – the former is encouraged because it is said to “enhance relevancy, authenticity, and thus student interest” (2) and the latter allows busy learners (in graduate or undergraduate medical education) and their teachers to apply a set of fairly straightforward, if sometimes conceptually uninteresting, set of principles as analytic tools.

The Haffertian-Frankian insight about “the case-study,” which serves as a jumping off point for this article is this: “What becomes lost is a view of how medicine in general or medical schools in particular might be considered as moral agents or moral entities” (3). They continue, “Organizations such as medical schools, hospitals, and clinics are not often thought of as ethical entities. This benign neglect is compounded by the fact that within medicine, matters of ethics are framed most often at the individual level and not at the organizational level. Even when topics, such as the allocation of scarce resources are discussed, the frame of reference is more often at the level of the physician-patient rather than that of the organization” (4).

Though case-based discussions still dominate ethics teaching in medical schools, the cases – at least some of them – have broadened, whether in response to the Haffertian-Frankian insight or simply as a matter of course. Medical students might now be found discussing cases that engage ethical considerations of social justice, health care disparities, and the structural and resource inequities, with critical consideration of health system features or social structures that can serve as obstacles to good and necessary patient care. However, has medical ethics education progressed far enough? Do more expansive and creative cases avoid the critique leveled three decades ago?
An adequate answer to this query requires a deep dive into both formal and hidden curricula in medical schools. There is not space in this short piece to undertake that set of complicated tasks, but the challenge can be clarified in at least two ways: first, in terms of the prominent relationship at the heart of case-based medical ethics teaching; second, in terms of two potential curricular-specific methodological responses. I take up the first here and the second in a subsequent piece.

First, the short-coming of the case-based approach is not its focus on the physician-patient relationship – contra Hafftery and Franks – in ethics teaching (5), but the failure to think about the broader implications of one’s actions or omissions as a professional whose work possesses so much societal value. To think critically about institutions of which one is a part, the traditions of one’s profession, and features external but related to one’s practice is not something that naturally comes with a principles-mediated, time-bounded, case-based ethics discussion. This leads to the admittedly provocative suggestion of this piece that ethics education of the medical profession must be rethought – not in whole, but in part – and augmented with what we might call philosophy-based medical education (PBME).

Without space to detail the curricula of a PBME, suffice it to say that critical engagement with all aspects of medicine with a focus on ethical questions, would serve as the backbone of such curricula. Critical philosophical questions, such as “What it is to be human?”, “How do we know?” and “Do we truly know x?” “What is it to reason well?”, “What might it be to live a good human life?” and “What might it be to be a good health professional?”, would inform such ethics curricula.

Second, two responses to this suggestion can be put to the side. I address one here. First, the defender of the status quo might object to PBME at the outset, arguing that case-based ethics education, in addition to the other virtues it may possess, simply need not be solely about isolated features of the medical encounter. That is, case discussion could – and, in fact, many now do – engage systemic issues. For example, consider the discussion of a case involving the death of a mother, which does not stop after the case details are presented, but engages issues of maternal mortality in the United States and not only highlights issues with, say, informed consent itself but also issues of structural injustice and internalized racism.

Such a discussion raises issues beyond simply the physician-patient relationship (reinforcing the previous point), but it does not vindicate a case-based approach. This is because the ethical “tools” that students need to critically evaluate this new kind of “case” are insufficient if they are not taught elsewhere in the curriculum. Can medical students reasonably be expected to critique current structures, and then reconstruct in a better way the profession they aim to be a part of and the institutions in which they will work, without these tools? Putting to the side these important and far-reaching questions, how might medical educators even evaluate this new set of tools which was not part of the curriculum but expected to be employed?

Augmenting and expanding the usual kind of ethics education in medical schools is needed. The challenge of case-based education, noted by Hafferty and Franks three decades ago lives on, and it is high time it be addressed.

Bryan Pilkington, PhD, is Associate Professor at the Hackensack Meridian School of Medicine and at Seton Hall University.

References
1. F W Hafferty and R Franks, “The Hidden Curriculum, Ethics Teaching, and the Structure of Medical Education:” Academic Medicine 69, no. 11 (November 1994): 861–71, https://doi.org/10.1097/00001888-199411000-00001.
2. F W Hafferty and R Franks, “The Hidden Curriculum, Ethics Teaching, and the Structure of Medical Education:” Academic Medicine 69, no. 11 (November 1994): 861–71, https://doi.org/10.1097/00001888-199411000-00001.
3. F W Hafferty and R Franks, “The Hidden Curriculum, Ethics Teaching, and the Structure of Medical Education:” Academic Medicine 69, no. 11 (November 1994): 861–71, https://doi.org/10.1097/00001888-199411000-00001.
4. F W Hafferty and R Franks, “The Hidden Curriculum, Ethics Teaching, and the Structure of Medical Education:” Academic Medicine 69, no. 11 (November 1994): 861–71, https://doi.org/10.1097/00001888-199411000-00001.
5. Note, much of this analysis could be applied interprofessionally and fit a discussion of nursing, dental, or OT practices (adapted for the particular features of each profession); for ease, and in line with the article that inspired this piece, I simply focus on medical education.

The Challenge of Reciprocity
By Bryan Pilkington

What does medicine owe society? What does society owe medicine? These are longstanding questions about the relationship between a particular profession and societies in which its members are embedded and serve. The ongoing pandemic offers an opportunity to revisit this relationship and to ask if the medical and social landscapes have changed sufficiently to rethink some commonly held ethics- and professionalism-related answers to these questions. One set of answers is rooted in consideration of a social contract that might still exist between the health professions and society. In this short article, there is insufficient space to explore this idea related to a variety of health professions, so I focus on one, physicians.

The hallmark of a profession is that exists to be in the service of others. This is a necessary but not sufficient feature of a profession (1). As Allen Buchanan argues in his influential piece “Is there a Medical Profession in the house?” professions are social constructions, not facts of nature and, therefore, must be justified. One, albeit not very complicated justification for the set of privileges afforded to many members of the health professions and, in particular, members of the medical profession, is the service they offer in caring for members of society and the great need that exists for this care.

The wide array of privileges discussed include a variety of external goods: great salaries, parking spots closer to door and professional courtesies (in a previous age). Further, they are often afforded a respected status in society. If members of such a profession are seen to stray from their service orientation (e.g., making too much money from referrals for MRIs at imaging centers they own, failing to provide needed care or being plagued by conflicts of interest) and other members of the profession cannot curtail these behaviors, regulatory bodies enter the picture. With this admittedly quick and simplistic discussion of the social contract between medicine and society, let us turn to the question at hand: Might it be time to reconsider and, with a critical eye, this social contract?

In doing so, consider the COVID-19 pandemic and the challenges that it continues to raise. The established social contract provides great benefits to members of society. (Granted, it works better in some cases and worse in others. In exchange, the salaries, the parking spots and last year’s “healthcare heroes” signs and the 7 p.m. cheers were all responses to this. However, as the pandemic continues, as resources remain strained, health professionals are plagued with increasing fatigue and stress. Should this change the social calculus? That anyone can walk into a hospital and receive care is unquestionably a good thing and a hallmark of the medical profession is this constant aim to care. Consider the title of the aforementioned analysis of the medical profession by Buchanan, appealing to the common line, “Is there a doctor in the house?” If the answer is “yes,” the physician, whether tired, engaged in other things or simply on vacation is obliged to respond.

To hold up the other side of this bargain, ought members of society do more than simply accept financial and social privileges for physicians? Should we modify behaviors in ways that might reasonably better our health or at least reduce the chances of ratcheting up the costs that healthcare providers pay for their privileges? If the answer is “yes,” what would this entail? Should members of society engage in less risky behavior during a pandemic surge and not drive quickly, train too hard for a triathlon or race a friend down a ski slope or across a parking lot? Should members of society (and the changes in societal structures needed to support this) take more time for self-care, consume healthier food and gently exercise more regularly? Or should the modification be restricted more tightly to the healthcare matters such as taking one’s prescribed medication, visiting the dentist and doctor regularly and – in a pandemic – affording oneself of the protection vaccination provides?

Physicians should and will (one hopes) always care for those in need and, to take up the last example, this includes those who are unvaccinated even if by choice. This may be a test of their empathy; it may be a test of their resilience, and health system-based programs and increasing conversations around practitioner wellness – when done properly – are excellent things. However, members of society ought to reflect on this social contract and ask, as many health professionals are leaving their fields or retiring early, not only the old questions of whether health professionals have done enough to justify the privileges they enjoy, but whether we are doing enough to uphold our end of the bargain.

Bryan Pilkington, PhD, is Associate Professor at the Hackensack Meridian School of Medicine and at Seton Hall University.

Reference
1.Buchanan, A. 2009. Justice and Health Care: Selected Essays. Oxford: Oxford University Press.

Burnout is a chronic response to prolonged workload-related stressors. The advent of burnout has been on a progressive rise among learners due to individual and organizational factors. Health Profession (HP) learners and educators experience burnout, since they lack the emotional, physical and mental means to overcome the demands of their professional duties, their careers and life in general. There are a myriad of factors for the rise in the burnout rate among HP learners. For example, the literature suggests that interpersonal strain can lead to suboptimal functioning, emotional exhaustion, depersonalization and decreased job performance. These factors have a direct impact on compassion in clinical care, professionalism and identity formation. In a broad sense, burnout and professional identity formation and clinical outcomes have a significant relationship with each other. Occupational stress and exhaustion have a negative impact on one’s professional life leading to poor quality work, low morale, absenteeism and decreased motivation. Learners’ burnout also has a direct impact on professionalism and identity formation in HP learners’ success in their careers.

A method of protection against burnout, for example, is meaningful professional engagement, which may lower rates of burnout. According to a recent systematic review and meta analysis, some useful interventions include reducing duty hours, learning about mindfulness practice and stress management, and being involved in small group reflection. There are different types of skills: life skills, coping skills, generic skills, skills you can learn and some that are relatively fixed that can be improved. Although there are many interventions to overcome burnout, the prognosis is uncertain from one individual to another. Health profession schools and education leaders should take the initiative and need to recognize what promotes joy, effectiveness and engagement among learners and educators. HP learners should be aware of the various ways to combat burnout to improve work performance, motivation, learning and patient safety. We have highlighted a few examples from both personal and professional experiences and observations over the past few decades. This is a list of skills and attitudes that can help HP professionals. For more details, please read the full paper.

List of Attitudes and Habits for Academic Success and Well-being:
· Build and maintain social networks
· Develop study habits that work
· Learn to manage both time and yourself
· Study hours must match the number of sleep hours
· Punctuality is not optional
· Not all stress is bad; find methods to manage stress differently.
· Ask for advice instead of feedback
· Care and learn from patients
· Learn how to handle the fear of failure and avoid marginal cost mistakes
· Dress and act professionally
· Be nice to everyone including patients, peers and public

Rajput V, Mookerjee AL. The skills medical students need to succeed in medical school and prevent burnout. Indian J Med Spec 2020;11:1-4.
DOI: 10.4103/INJMS.INJMS_1_20

Vijay Rajput, MD, is Professor and Chair, Department of Medical Education at Nova Southeastern University, Dr Kiran C.Patel College of Allopathic Medicine.
Anuradha Lele Mookerjee, MD, MPH, is Associate Professor of Medicine and Life Stages Course director in preclerkship education at Cooper Medical School of Rowan University.

As 2021 draws to a close and people anticipate a fresh start in 2022, journalists and writers reflect on the previous year, highlighting top stories and events. Here are a few notable stories that intersect with medical professionalism, in no particular order.

#1: The COVID-19 Vaccines
Most people drew a sigh of relief as the first shipments of the COVID-19 vaccines were distributed across the United States. Slow uptake, vaccine resistance, inefficient distribution policies, limited access for some populations, and misinformation all contributed to a less-than-ideal process. Scientists from countries worldwide jointly developed a vaccine in record time. Understanding why some people choose to remain unvaccinated and how to allocate COVID-19 vaccines ethically are issues governments and healthcare systems are still struggling with.

#2: Medical Providers and PTSD
Medical professionals worked long hours, witnessed their colleagues struggle emotionally and physically while caring for the ill, feared for the safety of their families, and, in some cases, succumbed to COVID-19. Now many are left with symptoms of anxiety and depression. Even before the pandemic, 11.9% of emergency room resident physicians met the criteria for PTSD. Now, up to 36% of 1,833 healthcare workers surveyed met the diagnostic criteria for PTSD. Many more have symptoms consistent with the disorder. Of those surveyed, healthcare workers with PTSD had a higher rate of suicidal ideation than those who did not (16.8% vs. 3%). Making truly effective wellness supports and mental health services available for our colleagues who need them and encouraging them to prioritize self-care while meeting the community's needs is a challenge for leaders in both teaching and non-teaching hospitals.

#3: Long COVID
Long COVID is not rare and will have a long-term impact on individuals and society well into the future. The symptoms are puzzling and inconsistent, ranging from shortness of breath that comes and goes, gastrointestinal symptoms, rashes, brain fog, loss of taste and smell, unexplained fevers, and memory lapses that all add up to debilitating conditions with full-body symptoms that can last indefinitely. The Patient Led Research Collaborative comprises 3,762 patients with long COVID in 56 countries. They report an average of 14 symptoms lasting at least six months. Long Covid makes no distinction between the young and old. Besides dealing with persistent and unexplainable symptoms, those affected have lost jobs, healthcare benefits, and, sometimes, the support of friends, family, and medical providers. Researchers and clinicians are working hard to better understand this condition and provide effective treatment. In the meantime, long Covid will continue to strain society and the economy for the foreseeable future.

#4: The Effect of COVID-19 on Medical Education
The path to becoming a doctor is long and challenging but predictable—complete your pre-med requirements, get accepted into medical school, assimilate vast amounts of information in your preclinical years, pass Step 1, do your clinical rotations, pass Step 2, finish medical school and get accepted into a residency. Unfortunately, for medical students across the U.S., COVID-19 altered this predictable path. Opportunities for collaborative learning and in-hospital clerkships were canceled. Research and shadowing opportunities and the ability to attend medical conferences in person were all canceled. Instead, classes and interviews were conducted online. Whether it was the inability to gather as a group, a need to 'flatten-the-curve,' or a lack of personal protective equipment, the reasons were valid, but medical students were adversely affected. Leaders in medical education will need to understand the implications of these changes in medical education and determine how to help students navigate their academic, financial, and psychological challenges.

#5: Nursing Shortages
There was a nursing shortage even before the pandemic. The enormous pressure of caring for critically ill patients and nurses who are either physically ill or are dealing with mental health issues will compound the nursing shortage crisis. Governments and health policymakers will need to develop strategies to manage the healthcare crisis as hospitals face nursing shortages, the COVID-19 pandemic, and an unprecedented increase in mental health conditions and long-COVID in clinicians.

#6: Social Determinants of Health and COVID-19
The COVID-19 pandemic has ripped open the patchwork of services known as American healthcare, revealing its deep flaws — a lack of personal protective equipment for healthcare providers, the inability of hospital systems to respond to the surges, how some ethnic and racial groups have suffered disproportionately throughout the pandemic, discrimination and inequality and its effects on access to care, the risks taken by frontline workers for whom missing work or working online is not an option. COVID-19, like all healthcare crises, has disproportionately affected the poor, sick, and most marginalized in our society.

#7: Counting COVID-19 Infections and Deaths
Whether it is a psychological protective mechanism or disbelief, many people worldwide are questioning how COVID-19 infections and deaths are counted. As of December 30, 2021, there have been 286,740,227 coronavirus cases and 5,445,239 deaths worldwide. In the U.S., 55,208,341 coronavirus cases have been recorded. An astounding, heart-breaking, 845,670 Americans have died from COVID-19. According to the AAMC, one of their top stories explains how COVID-19 deaths are counted. Defining how statistics will be calculated is challenging in the best of circumstances. Understanding the distinction between dying "of" or "with" COVID, how deaths are recorded, how the cause of death is determined, and why the numbers do not add up has caused confusion and doubt. Accusations of data misrepresentation negatively affect healthcare providers and families who lost loved ones to COVID-19.

#8: Fighting Misinformation
Scientists have had a unique experience over the last two years. Instead of conducting research, they have lived it. Many non-scientists find it difficult to understand why scientists can only make recommendations and observations based on the information they have. As COVID-19 variant after variant was transmitted worldwide, recommendations for treatment and protective measures shifted. It is hard to understand why masks fell out of favor and then became strongly recommended. Why social distancing made sense for droplet spread, but maybe not for aerosol spread. And, why, in 2020, we were washing our groceries to prevent the spread of COVID-19, and now, we can end isolation at just five days. Everyone with good intentions hoped that each treatment offered would successfully combat the spread of COVID-19 and save lives. But, unfortunately, some saw COVID-19 as a moneymaker, whether it was through monetizing social media or selling unproven or potentially harmful 'treatments and cures' to those who are desperately ill or afraid.

#9: Leaving Medicine
The reasons are almost as numerous as the number of doctors, nurses, pharmacists, and other healthcare providers who have left the profession. Fear of infection for themselves or family members, living with PTSD or symptoms of long-COVID, burnout, stress, anger, and trauma have all taken an emotional and physical toll on healthcare workers. Regardless of the reason, according to the Washington Post-Kaiser Family Foundation Poll, roughly one-third of healthcare workers have considered leaving their profession. Healthcare workers are human beings, not machines. Even before the pandemic, roughly one doctor per day in America died from suicide. Healthcare workers have worked tirelessly to save the sick and have kept their emotions in check as bereaved families begged for a cure.

#10: The Untold Story
The untold story, or how the world will look back on how we handled the COVID-19 pandemic, is still being written.

Leann Poston, MD, MBA, MEd, is a pediatrician in Dayton, Ohio and a freelance medical writer at LTP Creative Design LLC.

Health care is increasingly being delivered by teams of health care professionals. Research has shown that teams that share leadership, perform better than those that rely on an autocratic approach to team management (1,2). Shared leadership is an approach to managing a care team that empowers all members of the team (1,2). It relies on the expertise of each team member to accomplish the functions of leadership: determine strategy for how a team works best together, as well as for patient care, build caring relationships between team members as well as with patients, and enact the best approach to meet mutually agreed-up goals (3). Each team member has strengths in at least one of these leadership functions. Just as every member of a health care team has a critical and unique role in caring for patients, so do they have an important role and a responsibility to contribute to how the team functions. These principles are also relevant to health care research and improvement teams.

Since the most effective leadership style for health care teams is shared leadership, how does a team approach share leadership? A good place to start is to apply the five principles of effective teamwork for health care delivery to how a team functions and manages itself. These five principles were defined by a group of experts convened by the IOM (aka Academy of Medicine): shared goals, clear roles, mutual trust, defined processes, and outcomes and effective communication (4).

Shared goals for team management are developed collaboratively at the beginning of work and frequently revisited to ensure investment of all team members. To identify specific goals, a team can reflect on questions such as: “What allows us to function at our best?” or “When do I feel most supported and appreciated?” While teams are often required to meet institutional goals, these will be more easily met if teams have defined how they work best together.

Clear roles related to caring for patients are traditionally established based on the training and skills of each health care professional on the team. Defining roles and responsibilities for each team member allows others to understand team member capabilities and helps to avoid confusion over who does what. Similarly, roles in team management should also be clarified based on individual team member's personality as well as their talents, skills and training related to organization and management. For example, certain members of the team are skilled at keeping the team focused, while others may be better at communication, facilitation or organization. It is important for everyone on the team to value the contributions of each team member to patient care and team leadership.

Mutual trust between team members entails a commitment to building relationships with each team member, sharing the same values of teamwork and communicating honestly with each other. Building trust with team members is about getting to know each individual as a person. This may require varying levels of effort for each person depending on personality type and can be facilitated by conversations about what is important, learning a bit about life outside of medicine and acknowledging stresses. Team discussions of values such as honesty, creativity, trust, humility, curiosity and discipline can help teams to build relationships. Communicating honestly with team members, fulfilling responsibilities and letting others know when you cannot, is at the heart of accountability and trust relevant to team leadership and patient care.

Defined processes and outcomes begins with a mindset to improve patient care and a desire to create an environment where learning and improvement thrive. Reflection by team members on instances of care delivery or interpersonal relations is a key tool to learn what to do more of and what to avoid. Appreciative inquiry is a valuable practice used in change management that discovers and builds on existing capacity (5). For example, asking questions such as “What worked?” or “What should we do more of?” creates a positive emotional tone more conducive to learning and relationship building. Team members should eagerly expect feedback on their work and interpersonal relations, and receive it as an opportunity to learn. Feedback should be honest, timely, and respectful, and should be given on successes as well as mistakes or inefficiencies.

Effective communication – While health care professionals are taught skills to build meaningful relationships with patients, these same skills are essential for how we relate as team members and as leaders. Key interpersonal habits with team members include taking a mindful moment to adjust our attention, listening carefully without interrupting and being aware of our own reactions before speaking. Looking for emotions in what team members do or say, naming them and expressing our understanding and support is not only humanistic, but also the best way to uncover important issues. The value of having a diverse set of people on a team is to benefit from their different perspectives, but this asset will be wasted if we do not take the time to understand and appreciate those differences. Finally, an essential but difficult aspect of team communication is how we manage team conflict. Again, employing a mindful approach involves listening to assure we understand the nature of the conflict and balancing the importance of the issue at hand with the value of the relationships involved (6). Then, we can choose the best approach to solving the issue at hand peacefully, while also learning from the situation.

Carole Warde, MD, is a Health Sciences Professor of Medicine Emeritus at the David Geffen School of Medicine, UCLA, and a Senior Consultant at Relationship Centered Care.


References
1. Martin J, Cormican K, Sampato SCB, Wu Q. Shared leadership and team performance: an analysis of moderating factors. Procedia Comp. Science 2018;138:671-679.
2. Al-Sawai A. Leadership of health care professionals: where do we stand? Oman Med J 2013;28(4):285-287.
3. Pendleton D, Furnham A. The Primary Colors of Leadership in Leadership: All You Need to Know, Macmillan Publishers Ltd. London. 2016.
4. Mitchell, P., M. Wynia, R. Golden, B. McNellis, S. Okun, C.E. Webb, V. Rohrbach, and I. Von Kohorn. 2012. Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine, Washington, DC.
5. Suchman A., Sluyter D., Williamson P. (2011). Leading Change in Healthcare: Transforming Organizations Using Complexity, Positive Psychology and Relationship-centered Care. New York: Radcliffe Publishing. (Chapter 4, Appendix 1, Appendix 2).
6. Thomas K. “Conflict and Conflict Management.” J of Org Behavior. Vol. 13, 1992, pp 265-274.

Background:
Medical students experience significant stress and anxiety during undergraduate education. Coaching is a possible way of supporting these students throughout this challenging time. To assess the benefits of coaching for medical students, a pilot study providing coaching was performed. This pilot assessed how coaching affected the mental health of medical students and how coaching was received by them.

Methods:
Twelve third-year medical students were each given eight 30-60 minute coaching sessions. Each participant took the Hospital Anxiety and Depression Scale (HADS) and the Perceived Stress Scale (PSS) pre-, mid- and post-coaching. After coaching, there were three open-ended questions to measure the reactions to coaching and a scale to determine the likelihood of accessing coaching in the future.

Results:
There was a significant effect of coaching on perceived stress (p=.023), a trend toward significant effect of coaching on anxiety (p=.057) and no effect of coaching on depression. Qualitative analysis indicated Affective responses (gaining perspective and self-awareness); Cognitive responses (goal setting and working through solving problems) and Skills responses (developing reflection abilities and critical thinking). Attributes of coaching included perceiving coaching as a positive, individualized and supportive experience that students were highly likely to access again.

Conclusions:
Coaching holds promise as an intervention offered to medical students to reduce stress and anxiety, and provide positive support for students, preparing them for their professional futures.

Key Points
1. Appreciate the stress and anxiety that medical students manage in medical school.
2. Coaching is an option that holds promise to support medical students.
3. Coaching has possible long-term outcomes that could help future physicians navigate their professional paths more effectively.
4. Students value individualized, positive support during medical school.

QUALITATIVE RESPONSES EXAMPLES

AFFECTIVE RESPONSES
“This experience made me more confident in myself and equipped me with the tools to address and conquer any stressor or source of anxiety facing me in my professional life.”

“To be able to share freely and be asked open-ended questions where I could problem-solve and think through my challenges was empowering.”

COGNITIVE RESPONSES
“The coaching experience was able to reflect back to me my thoughts, feelings and concerns in a way that was just different enough to give me insight and a new perspective…motivated me to pursue my own definition of success… will push me to ask myself what the next steps would be to achieve what it is I am working on.”

“Perhaps the most useful thing for me was goal setting and then discussing what steps need to be taken to get there.”

SKILLS RESPONSES
“I was able to walk away from each session with actionable items and the sense that I was working on ways to handle whatever issues I had discussed in the meeting…helped me feel more in control of my situation or at least with tools to handle a situation in ways I wanted to.”

“My coach helped me think about how I can most effectively explore my interests. She helped me think critically about how I approach problems in my life. These are skills I will take with me.”

ATTRIBUTES OF COACHING EXPERIENCE
“I loved having someone from a different perspective to talk to me about strengths and challenges. It was just an invaluable resource.”

“Everyone can benefit from a coach and coaching is flexible and customizable”

STRENGTHS OF COACHING
“I enjoyed the safe space created for more abstract discussions on purpose, meaning and motivation. It helped make the experience about self-transformation as much as it did about setting and achieving goals.”

“Coaching is a wonderful tool that helps me work out any issues or focus on any personal development I want to do. It is more personal than advising, but more professional than therapy.”

IMPROVEMENTS FOR COACHING EXPERIENCE
“Having coaching opportunities from the beginning of medical school would have been extremely helpful in my development over these formidable years. While eight sessions were better than no sessions, having an even longer longitudinal experience would have been great.”

“Although we had a limited number of sessions, it would have been great to meet more frequently as it allows for greater accountability with goals and closer check-ins.”

VARIETY OF TOPICS DISCUSSED
“I appreciated that we covered every topic that I wished to. Having never been coached before (outside of sports), I was fascinated by the approach”

“Whether it was with my research, my plans for residency, or lifestyle goals we always discussed how to break it down into manageable elements, manage time, and deal with challenges that arise.”

Elizabeth Ross, DPT, MMSc, FACH, is Associate Certified Coach and Associate Consulting Professor in the Department of Orthopedic Surgery at
Duke University School of Medicine

The debate on promoting professionalism in medical practice has been going for more than a decade; however, globally, efforts to promote medical professionalism have had limited success, and time after time lapses in students and practitioners professional behaviour have been reported (1). Additionally, the term professionalism has been around for quite sometime, however globally there is still no consensus on its definition. Consequently, there is still no unifying theoretical or practical model to use as a format for teaching of professionalism in the medical curriculum that has gained wide acceptance.

More than a century ago, a good doctor was considered as a thoughtful scientist and a man of character; however, as time elapsed, the focus was more on the scientist, and character became enmeshed under the umbrella of professionalism and ultimately vanished. Existing evidence indicates that efforts to measure professionalism using checklists or rating scales are more orientated towards developing the practitioner as a professional, rather than fostering professionalism (2).

If 21st century physicians are to engage in transformative learning, and act as change agents, the characteristics of the doctor as a man of character should be clearly articulated, re-emphasised, developed, practiced and measured to ensure enduring outcomes (3). Character traits influence behaviour, they become stable over time and are subject to changes, particularly when individuals keep on assimilating the values of the profession as they move up the hierarchy of community of practice (4). Through character education we can aim to nurture the development of traits and practices in students and practitioners that could eventually facilitate wise actions and enable trustworthy behaviours. Additionally, it is imperative to highlight that nurturing these behaviours not only influences professional work, but also impacts individually and socially, succeeding in the formation of their own unique identity.

Sonia Ijaz Haider, PhD Clinical Education (UK) is an Associate Professor at the Department for Educational Development, The Aga Khan University, Karachi, Pakistan.

References:
1. Lefkowitz et al (2020) Can doctors be taught virtue? Journal of Eval.in Clinical Practice. 27-3-543-548.
2. Pinto et al. (2019) Just a Game: the Dangers of Quantifying Medical Student Professionalism. J Gen Intern Med. 34-8:1641-1644
3. Seoane L, Tompkins LM, De Conciliis A, Boysen PG. Virtues Education in Medical School: The Foundation for Professional Formation. Ochsner J. 2016;16(1):50-5.Pellegrino, E. D. (2007). Professing medicine, virtue based ethics, and the retrieval of professionalism. In R. Walker & P. Ivanhoe (Eds.), Working virtue: Virtue ethics and contemporary moral problems (pp. 61–85). New York, NY: Oxford University Press.

Will there be two Americas? Not two but many, and from many; One. “Et pluribus Unum.” When the state and science both claim that there will be two Americas one protected, with gene therapy, and the other not, is just to remind us that this nation indivisible will mend with very professional virtues; compassion (1) and veracity. They are not promoting vigilantism (2) but reflection on what is the common good.

Ideology reigns as seen by the lack of productive conversations regarding mandates. While local mandates should answer to more particular needs, they could become a tool of ideology endangering the most basic human rights and the most important human good from which all other human goods flow (3) a Kingdom of Ends (4): principles and norms cogent with the human condition, human nature, and truth.

In the religious dimension (One nation under God…) that would be the ten Commandments, Leviticus… in the political (human flourishing) and ethical realms it would be the USA constitution and the Bill of Rights (…. indivisible with liberty and justice for all.) Well intentioned efforts to improve the human condition, be it by tweaking the human genome (a most valuable human good) or gain of function in viruses, avoiding poverty through mass medical interventions or selectively choosing the fit who reproduce, will take us again to uncharted waters; the “shoat” catastrophe is knocking at our doors, warns Robert Sarah (4) citing Tocqueville that without shared moral convictions institutions won't endure … majority decisions won’t loose their condition of being truly human and rational (only) when they presuppose a basic substrate of humanity, and respect it as the true common good, and source of all other human goods.

Assuming true voluntariness that is free from undue influence and coercion except from the one entailed by disease itself, these Americas ought to be commended by their actions - one for allowing an unproved, unknown to them, gene therapy, injected into their muscles within an uncertain research/protection/indemnity situation.

The protection naïve for being the standard against which safety and efficacy of the former can be proved. For safety and efficacy determination different populations must be compared - one intervened the other naïve. Both are laying their lives on the line.

A state arbitrary determination (mandate) renders healthy, asymptomatic, non-contagious (5) competent individuals as unfit, not the disease itself. They are perceived by the state as being not fit to work and the source of infection (6). Forced injection amounts to assault and battery in an informed consent plagued with uncertain information, comprehension and voluntariness as per Belmont Report standards. “Every human being of adult years and a sound mind has the right to determine what shall be done with his own body, and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages except in cases of emergency where the patient is unconscious, and where it is necessary to operate before consent can be obtained” (7). Those workers rendered disabled by state mandates (8), deprived of their right to medical choice, not an imminent danger to self or others, ought to be considered Americans disabled by the state and in need of special accommodations such as working shifts/flextime to guarantee access to the workplace, public, services and facilities: Monday, Wednesday, and Friday the “protected” Tuesdays, Thursdays, and Saturdays the “protection naïve.” Access to restrooms, medical care transportation and the most basic human goods should be guaranteed to each. For yes, life, body, health, family are important humans’ goods, but the fountain head and guarantee of all human goods, and the most important good itself is a compassionate pattern of practical reasoning cogent with human nature, the human condition and truth.

Raul Perez, MD, is Professor of Ophthalmology and Medical Ethics at the University of Puerto Rico School of Medicine.

References
1. Beauchamp T. Childress J. (2013) New York, Oxford University Press pp. 37
“.. the virtue of compassion presupposes sympathy, has affinities with mercy and is expressed in acts of beneficence that attempt to alleviate the misfortune or suffering of another person. Compassion is directed at others.”
2. Hussain Waheed (2012) “Is Ethical Consumerism an Impermissible Form of Vigilantism?” Philosophy and Public Affairs 40 (2): 112 – 143. “The political relationship allows for a certain degree of competition among citizens, but it constraints how severely institutions can pit people against each other when it comes to goods that are part of the common good, e.g., health care, education, and the social bases of self-respect.”
3. Miller David (2020) Georgetown, Washington DC, Encyclopedia of Bioethics. “The political bond requires not only that we act in certain ways, but also that we give the interests of our fellow citizens a certain status in our practical reasoning... The first feature that most conceptions of the common good share is a pattern of reasoning that is meant to be realized in the actual thought process of the members of a political community. The point of inception of the common good is to define a pattern of practical reasoning, or way of thinking an acting that constitutes the appropriate form of mutual concern among members.”
4. Kant, I. (1993) The Metaphysical Foundations of Morals, Indianapolis, USA Hacket.
5. Sarah R. (2019) Madrid, Ediciones Palabra “Le soir approche et deja le joir baisse”
6. In a situation of power imbalance, the state against the individual; the burden of proof ought to be in the strongest. The state has the means through contact tracing of identifying possibly infectious individuals and the facilities to confirm its presumption. But the state is not a physician as neither physician’s associations are. An injection is a medical act, hence must fall under the purview and protection from political or judicial overreach, of the physician-patient relationship. Where both physician and her patient, free of coercion and undue influence within rational constraints decide on the morally good and technically correct course of action. UC.DavisHealth.org, Having a positive COVID 19 test: sent home to rest, and physical distancing. More than 95% will not require hospitalization. If symptom less and afebrile after ten days, no longer able to infect others.
7. Mary E. Schloendorff, Appellant, v. The Society of the New York Hospital, Respondent Court of Appeals of New York, March 11, 1914; Argued, April 14, 1914; Decided.
8. Generalized mandates do not consider: 5% of population refractive to proposed protection, unusual genetic endowments resulting in non-susceptibility to the virus, natural immunity, and psychosocial factors. Let us say that we have today 100,000 people who tested positive for the virus. As per CDC constructs: 80 % will have mild symptoms and will be non-infective in 7 to 14 days. Needing emergency room care or hospitalization 20%, with full recovery within 3 to 6 weeks; 3 % death rate in those with, obesity, systemic hypertension, diabetes, older age (medical), and living in, hospices, retirement homes or crowded facilities. All the survivors will have some degree of natural immunity (age dependent). Symptoms, such as coughing, shortness of breath, fatigue and brain fog may persist in 10 % of the survivors for more than 28 days. Chronic COVID 19 or “long haulers.” cdc.gov>coronavirus What is COVID 19 Brain Fog? Budson, AE March 8, 2021, Harvard Health BLOG, health.harvard.edu

The book, Emotions in the Clinical Encounter, provides tools for trainees and practicing clinicians in navigating their own and their patients’ emotion, delivering medical education innovations to support clinician wellness and enhance patient care. Clinicians’ responses to patients’ affective cues are linked to care outcomes, and this book provides concrete training tools to enhance clinicians’ ability to perceive and respond to emotional cues. The book delivers background on the evolutionary and social function of emotion, the role of emotion in illness, gender and cultural considerations regarding emotion, strategies for emotion regulation in self and others, the culture of medicine and its current and historical relationship to emotional management. It focuses on emotion processing for improved patient care and clinician wellness, and delivers medical education innovations that support emotional wellness in trainees. The book translates research evidence for the importance of identifying and addressing emotion in patients and clinicians into actionable clinical behavior. Plus, it synthesizes evidence-based practice to support clinical emotional intelligence.

Emotions are ever-present in the context of illness and in the process of medical care, and have an enormous impact on the well-being of patients and healthcare providers alike. However, patients’ emotions, as well as those of their clinicians, are acknowledged in an inconsistent manner in medical education, and the research that should inform clinical management of emotion is scattered.

The book brings together theory, research and clinical experience on the broad topic of emotions in medical care. Drawing on their expertise in research, medical care, and medical education, the authors provide both basic understanding and practical insights for healthcare providers on one of their most vital yet challenging aspects of patient care: recognizing, expressing, acknowledging, and responding to patients’ emotions as well as their own.

The goal of this book is to promote the welfare of both patients and clinicians (in all healthcare professions) through a better understanding of the role of emotions in health and medical care.

This book will also advance healthcare providers’ knowledge of the science of emotion, providing evidence-based guidance on emotion training and its application in the medical setting. This book provides new guidance for medical trainees, practicing clinicians and medical educators, delivering new tools for navigating the extraordinary emotional demands of practicing medicine.

The book is organized in three sections: Emotion’s Functions, Clinical Emotional Intelligence and Emotions in the Culture of Medicine. Chapters in the Emotion’s Functions section provide transdisciplinary background on the evolutionary, neurobiological and social function of emotion, the role of emotion in illness, and emotional dialogue in the medical encounter.

The Clinical Emotional Intelligence section covers the importance of identifying patients’ emotional cues and provides evidence on the role this plays in the clinician–patient relationship and in clinical outcomes. This section contains chapters on nonverbal cues of emotion, emotion regulation techniques, the intersectional relationship between patient and provider background (including gender, nationality, and race/ethnicity), strategies for emotion recognition, the role of emotion in clinical decision making and available training tools for honing these practices. Three chapters are devoted to specific patient populations: pediatric patient encounters, patient populations with impaired affect, and patients with a history of trauma.

The Emotions in the Culture of Medicine section addresses the professional challenges of honoring emotion in a medical culture that praises stoicism and analytical reasoning. One chapter provides strategies for teaching about emotions in healthcare, another describes interventions that can promote emotional wellness in undergraduate and graduate medical trainees, and the concluding chapter focuses on the relationship between emotion and clinician wellness.

Rachel Schwartz, PhD, Stanford University School of Medicine
Judith A. Hall, PhD, Northeastern University
Lars G. Osterberg, MD, MPH Stanford University School of Medicine

Northwell Health System Office of Academic Affairs has launched its Just in Time Teaching (JiTT) Infographic Tools App to aid in the advancement of health professions’ education knowledge and teaching skills for students, trainees and faculty across health professions.
The App is now available in the Apple Store (IOS) and Google Play (Android). The new app uses the Just-in-time teaching (JiTT) model – a pedagogical approach that involves close interaction between instructors and their learning environments – to better provide timely and relevant clinical content with evidence-based teaching tips to assure active engagement of students, trainees and faculty clinical care and didactic teaching sessions. The App framework is built on adult learning principles (1) and the S.A.M.R. technology model (2), with a focus on the “R,” Redefinition, technology that focuses on new tasks that were previously inconceivable.

“The Just in Time Teaching Tools app allows for a more robust teaching and learning environment for everyone in the clinical and classroom setting,” said the app’s developer, Alice Fornari, EdD, RDN, the associate dean of educational skills development at Zucker School of Medicine at Hofstra/Northwell and vice president of faculty development at Northwell. “The use of technology-enhanced learning platforms are feasible and accessible to learners across the continuum of health professions’ education and are especially useful and additive in geographically dispersed academic health systems to assure access to evidence-based content. This new app makes that model even stronger.”

In a pilot study (3)– which utilized email to distribute JiTT infographics – trainees and faculty reported overall satisfaction with the content and technology and a positive perception by trainees of their enhanced teaching skills. Faculty expressed that the JiTT infographics were useful reminders to refresh and guide their teaching skills with trainees and students. Most importantly, it can be reported with certainty that the JiTT infographic program can be incorporated into busy diverse teaching and clinical settings. The next step to achieve overall professional development goals was access on mobile devices as an Application (App).

JiTT infographics are adaptable to an array of clinical specialties and include foundational teaching principles in areas such as setting expectations, questioning techniques, feedback and coaching, and bedside teaching. All foundational JiTTs have an audio recording of the content to increase access. Finally, these JiTTs also have an evidence-based article link to PubMed for additional information. Clinically specific teaching techniques include content pertaining to internal and family medicine, pediatrics, obstetrics and gynecology, surgery psychiatry, and neurology. Sub-specialties are also included. Optional review questions are in each category to self-assess knowledge acquired.
In a recent update in July 2021, we added three new categories: clinical consults, research and social justice. In addition, on the About page there is a link to a YouTube video (How to use the JiTT Infographics App) on how to use the JiTT Infographics accessed on the App in real time with learners. A feedback survey (https://redcap.link/JiTTInfographics) is available and is an opportunity to identify collaborators on future JiTT Infographic content. In an App update in November 2021, we will add three new categories: professionalism, quality improvement and self-care/well-being.

Alice Fornari, EdD, FAMEE, RDN, afornari@northwell.edu, the App developer, is Vice President of Faculty Development, Northwell Health, and Associate Dean, Educational Skills Development, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.

References
1. The Adult Learning Theory - Andragogy - of Malcolm Knowles https://elearningindustry.com/the-adult-learning-theory-andragogy-of-malcolm-knowles; accessed September 5, 2021.
2. Puentedura, R. R. (2013, May 29). SAMR: Moving from enhancement to transformation http://www.hippasus.com/rrpweblog/archives/000095.html &Terada, Y. (2020, May 4). SAMR: A powerful model for understanding good tech integration. Edutopia. https://www.edutopia.org/article/powerful-model-understanding-good-tech-integration.
3. Orner, D., Fornari, A., Marks, S., & Kreider, T. (2020). Impact of using infographics as a novel Just-in-Time-Teaching (JiTT) tool to develop Residents as Teachers. MedEdPublish, 9.

Scott R. Heiser wrote Healthcare Is Making Me Sick: Learn the Rules to Regain Control and Fight for Your Healthcare to share his 20-plus years of experience as a former healthcare industry insider. Heiser’s dissatisfaction with the entire healthcare system is palpable from the first page of the book. His goal is to give readers the tools they need to reclaim their power and become more proactive about taking care of their health.

Heiser provides examples of how other industries are becoming more transparent, enabling consumers to make informed decisions about the quality of the products they buy and the price they pay for them. He believes that healthcare should be the same. The level of care you receive and how much you pay for it should be entirely up to you. Before explaining his three-step approach to taking control of your healthcare, Heiser provides a brief history of third-party health payers and an overview of the pros and cons of the Affordable Care Act.

Step one is to know yourself. Heiser encourages readers to conduct a full Health Risk Assessment, gather their medical records, and investigate their past and present medical history. He claims that to be an effective healthcare consumer, you must first determine your healthcare needs.
Step two is learning how much healthcare actually costs. Even for someone who works in the healthcare field, the list of costs is sobering. Heiser gathered his data from Guroo.com and Sun Life Financial. It is an eye-opening exercise to consider the list of procedures and evaluations you might need in your lifetime and their expected costs.

Of course, the best way to manage the costs of healthcare is to manage your risks. Heiser uses a case study to walk the reader through the rationale for why health insurance is necessary. No previous knowledge is needed. He defines the terms as he goes along and provides practical examples. Next, he uses a second case study and invites the reader to compare potential health insurance policies. I admit I fell into the trap of choosing the one with the lowest out-of-pocket costs. Surprisingly, the high-deductible plan saved $2,500. Scott explains why.

A detailed discussion on insurance options and how to choose one, including a comparison of health insurance plans, gives readers a lot more confidence in their ability to evaluate their insurance options. Heiser also defines industry jargon, explains how hospitals charge for procedures, discusses the risks and benefits of medical tourism, and suggests alternative funding sources such as supplemental insurance plans.

Step three is to learn how to navigate the healthcare system. Following a discussion on health insurance plans, Heiser offers advice on choosing a medical provider, evaluating a potential medical procedure, and accessing lower-cost prescription medications.

Next, he explains the different medical practice options available since the Affordable Care Act. Finally, he offers transparency tools that empower readers to make informed decisions about their healthcare while cautioning them not to self-diagnose.

As a physician, I appreciate how well each option was explained but was not oversold. A list of questions was offered, and website links and data to consider. Heiser made no claims that these options would be the best choice for any one person or situation.

The book concludes by encouraging the reader to take a holistic look at their overall health to prevent healthcare costs. He says being proactive by asking questions, gathering information, and emphasizing preventative care over treatments can improve your overall health and lower your medical costs.

Short sentences, bullet points, charts, and case studies are used to create a conversational tone in the book. When discussing healthcare changes, Scott uses the word "we," which allows him to convey information on how to improve your health that most people would ignore if presented differently. He concludes the book with a stronger call for readers to take charge of their health. "Healthcare is a consumer good, and you're a consumer."

This book is a fantastic resource for healthcare providers to recommend to their patients. Many of your patients' questions about how the healthcare system works will be answered, and they will be empowered to advocate for the best healthcare options for themselves.

Heiser has over 20 years of experience in the industry and a talent for explaining insurance and other healthcare concepts in understandable terms. In addition, he provides cost-saving advice and techniques via his online business UncoveredHC.

Book release date June 25, 2019
182 pages
ASIN: ‎ B07SMB3GYQ

Leann Poston, MD, MBA, MEd, is a pediatrician in Dayton, Ohio and a freelance medical writer at LTP Creative Design LLC.

Fifty years ago, physician scholar and medical humanities advocate, Edmund Pellegrino, MD, called nationally recognized medical educators and humanist scholars together in a secluded upstate New York conference center to discuss ways the humanities might help with “the human problems that arise in medicine” (1). At the time, Pellegrino was a leader in academic medicine and head of the new Institute on Human Values in Medicine. The Institute was a project of the Society for Health and Human Values founded in the 1960s by medical educators and chaplains concerned that medical education had become too scientific and technical and that medical students were suffering as a result.

The 1960s and early 1970s were also a time of change for medicine as it was reeling from the profession’s recognition of past ethical atrocities, society’s response to its failings, and the changes that were quickly happening in the profession as a result of increasing specialization and corporatization of practice. The Institute, funded by a grant from the National Endowment for the Humanities (NEH), was the Society’s action arm to address concerns of training. How could the education of health professionals be balanced to assure both scientific and technical excellence, as well as retention and fostering of the humanity of medicine? Pellegrino and his colleagues believed humanist scholars and the teaching of humanities content could address this training gap and preserve the professional and personal humanity of students. Over the next 10 years the Institute, with continued NEH funding and the dedicated work of a passionate team of academic physicians and humanist scholars, developed a multifaceted brand of programming that reached health professional schools across the country.

The Institute’s programs, which began after planning meetings in 1971 and 1972, were both pragmatic and intellectual. In the 10 years of the Institute’s active work, it conducted seminars across the country on topical issues, ran teaching workshops, and offered personalized resources and training to schools. Through a funded fellowship program, the Institute uniquely cross-trained physicians, other health professionals, and humanist scholars in medicine and the humanities, creating a workforce of clinician scholars and medical humanists that seeded health science campuses with both teaching faculty and scholarly leaders. Many of the most notable medical humanist scholars of the last 40 years were products of the IHVM and many centers of medical humanities scholarship were developed by its resources and faculty development. The Institute and its fellows can be credited with setting the stage for future curricular action and change, including the first required medical ethics curricula in U.S. medical schools.

The Institute was, in fact, a true predecessor of the professionalism movement in medical education and this Academy for Professionalism in Healthcare. In ways the Academy can be considered a direct descendant of the Institute, as the Academy’s founders were directly involved with the Project to Rebalance and Integrate Medical Education (PRIME) in the earlier 2000s, which fed the formation of the Academy in 2012. Several of the authors of PRIME publications were trainees of the Institute or directly benefited from the mentorship of Edmund Pellegrino. Current members of the Academy also enjoy that distinction. The work of the Academy continues the vision of the Institute in the new century, a time that still needs the skills that the humanities offer and the catharsis it provides.

Indeed, five decades later the same struggles remain in medical education - how to balance the ever-expanding amount of scientific and technical knowledge with the humanistic content that fosters the empathy, compassion and sensitivity needed to practice the art of medicine, while remaining a resilient well person. Knowing the history of the Institute can bring clarity to both the depth and difficulty of this goal, as well as guidance and insight into overcoming the challenges. Understanding the successes and challenges of the Institute’s work and its legacies can offer inspiration to current and future medical educators engaged in training the next generation of physicians (2).

Mary E. Kollmer Horton, MPH, MA, PhD, is Assistant Professor, Educational Programs and Adjunct Faculty at the Center for Humanities and Ethics at the McGovern Medical School at UT Health.

References
1. Pellegrino, Edmund D. 1971. “Welcoming Remarks”. Institute on Human Values in Medicine: Proceedings of the First Session. Arden House, Harriman, New York. P.4. A publication of the Society for Health and Human Values.
2. The content of this article is part of a larger doctoral dissertation by the author deposited at Emory University. Horton, Mary E. Kollmer. 2020. "A (Un)Natural Alliance: Medical Education and the Humanities. The Rise and Fall of the Institute on Human Values in Medicine, 1971-1981." Ph.D., Institute for the Liberal Arts, Emory University.

The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age by Robert Wachter opens with the story of Matt Burton, a physician who switched careers from medicine to computer science. Dr. Wachter relays Matt's story about a night on call as an intern that required him to run four codes simultaneously. If only fellow residents at nearby hospitals could access the medical records on one of these four patients and help Matt.

Next, an offhand statistic reveals that an estimated 100,000 Americans are dying each year from medical mistakes. The observation that the fix, decreasing residents' hours to 80 hours per week, compressed the work but did not alleviate the problems. The stage is set. Technology is here to make medical records accessible to all, decrease medical errors, and reduce costs. Will technology be the hero or the villain in Dr. Wachter's analysis?

To begin the inquiry, Dr. Wachter takes the reader on a historical tour of medical records. His easy-to-follow style keeps the journey interesting as we travel from paper records stored in physician's homes to binders placed in racks in nursing stations to the online digital records of today. Readers without a working acquaintance with the politics and mannerisms of the healthcare system may find the trip a bit disjointed. But for anyone involved in healthcare, the journey was enlightening.

Next, Dr. Wachter walks the reader through an analysis of a single medical error that resulted in a teenager receiving 38 ½ antibiotic pills rather than one. In retrospect, the overdose appears ridiculous, but Dr. Wachter's careful interview style and meticulous, nonaccusatory questioning allow readers to see how such an error may have occurred in the digital era of medicine.
He guides the reader through the doctor's thought process and explains the systemic factors that contributed to the error. For example, tiny type on the computer screen, inappropriate default settings, and the inability to add a note to the order were all contributing factors, as were more egregious acts such as ignoring the technology's warnings and alerts.

Other factors that could have contributed to the error include alert fatigue and the fact that technology leads to employee silos with little conversation as each provider stares at their computer screen.

Dr. Wachter evaluates electronic medical records in the following chapters from the standpoint of all involved parties. He captures and analyzes their thoughts, motivations, and emotions. Finally, he observes that while we remember technological advances as gigantic leaps, we often overlook the small steps between, some of which are positive and some not.

Dr. Wachter concludes with an optimistic scenario in which humans and technology collaborate. Humans provide oversight, working at the top of their license, while computers source, analyze, and organize data in a way that is accessible to all. He hopes that when humans and computers work together, the best of both will be brought to patient care, restoring medicine to patient-centered care.

Dr. Wachter does a wonderful job weaving compelling stories and thoughtful analysis together to portray an accurate and thought-provoking picture of the state of electronic healthcare.

The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age by Robert Wachter Release date April 7, 2015, McGraw-Hill, 320 pages

Robert M. Wachter, MD, is Professor and Chair of the Department of Medicine at the University of California, San Francisco (UCSF). He is the author of 300 articles and six books.

Leann Poston, MD, MBA, MEd, is a pediatrician in Dayton, Ohio and a freelance medical writer at LTP Creative Design LLC.

We do not pay athletes millions of dollars because hitting a ball with a racquet, golf club, baseball bat, or cricket bat provide societal benefits. Throwing a touchdown pass or hitting a three-point shot does not feed the hungry or clothe the naked. Instead, we pay people in sports to be entertainers; professional athletics is a form of entertainment. As people in the public spotlight, many professional athletes use their bully pulpit to promote societal issues, such as public health or social justice.

Recently, a professional tennis player withdrew from the French Open because she felt compelled to protect her mental health. She believed it was being threatened by her participation in a required press conference attached to the tournament. We applaud her decision to do what is right for her well-being, and to speak out about it. But we also believe she and other professional athletes/entertainers have obligations to the public to attend required press conferences, speaking with reporters as agreed upon in contract with tournaments. A professional athlete should do the right thing for his or her mental well-being. This athlete either needs to get mental health care, so she can face the public and its media as part of her professional obligations, or she should consider another profession where she does not have to interact with those entities. The public pays athletes through ticket sales, television advertising, and endorsements. In turn, they expect entertainers to perform at their sport which may include visibility through media outlets. If such an athlete chooses not to interact with the public, perhaps he or she should be in another profession, playing sports as an amateur at a local or regional club.

At a major golf tournament in Ohio the same week as the French Open, a professional golfer was removed from the tournament in accordance with PGA guidelines, when he tested positive for COVID-19. He was not fully vaccinated at the time of exposure and protocol testing had been required. When he left the tournament, he was leading the field by six strokes, likely to earn several million dollars in winnings along with resulting endorsements. While he initiated vaccination shortly before the tournament, he had not yet met the criteria of being fully vaccinated. He recently lamented his regret at not having been vaccinated early on. But, he really has not utilized his celebrity to raise critical public awareness of the import of vaccination, whether it be to reap dollar benefits winning a golf tournament, or perhaps more importantly, staying healthy for the sake of self, family, and close friends. As people in the public spotlight, professional athletes have unique bully pulpit opportunities to make a difference promoting societal issues, such as public health or social justice. His mistake in not having been vaccinated sooner could be used to help others choose vaccination as soon as it is available to them. His mistake could turn into saving others from long term complications and risks of COVID-19 illness.

Like professional athletes, healthcare workers are being hailed as heroes these days as they spend time one way or another on the COVID-19 frontlines (albeit without the BIG pro-athlete paychecks). While we are reticent to consider ourselves heroes, we do believe we should be grateful for the public’s respect, as we try our best to serve as educators and role models. We should be taking every opportunity to encourage the public to be vaccinated against COVID-19, telling real life stories of how we and others decided to be vaccinated. And, we should be encouraging our patients and the community to seek out assistance for their mental and physical health issues, irrespective of our pandemic, choosing to support preventive measures for those health issues where possible. We can commit to teaching through community forums, podcasts, and hands on learning opportunities. We should be walking the walk, and talking the talk.

We may not be able to hit curveballs, make foul shots, or block like a soccer goalie, but we can make a difference in our community. Let us earn the mantle of HERO by being steadfast lights within our professions.

Cynthia Sheppard Solomon, BSPharm, RPh, CTTS, NCTTP, is Clinical Assistant Professor, and Glen D. Solomon, MD, MACP, FRCP(London), Chairman, Department of Internal Medicine and Neurology, Wright State University Boonshoft School of Medicine, Dayton, Ohio.

Since its inception, professionalism (as derived by E. Pellegrino (1) translation and commentaries of Scribonius Largus’ work) has been a promise of beneficence. This promise arises from the inequality of power and knowledge between physician and patient. The patient ought to know that the physician’s commitment to their welfare is unshakable, as is the essence of their covenant and shared healing process.

Although human nature and the human condition have yet to change, relativistic interpretations and language use, together with hidden ideologies, require reformulation and review of the groundings of medical morality. It is necessary for revision and strict scrutiny (2) to list the most basic human goods, life, body, health, family, and to discover which actions are right and which intentions are good. The process must be grounded in truth and rationality.

It is rationality (3), not mathematics, according to a German philosopher (4), that determines the correspondence between the rules that govern the natural order and human reason and enables scientific as well as philosophical inquiry. Guiding the human’s inextricably rational relationship with himself, others, and nature and preventing the pursuit of non-existing objects, and the ontological distortions of relativism and some ideologies, professionalism is not just decorum, it is an expression of medical ethics (applied ethics if you will) or, more precisely, virtue ethics.

But how can we prevent the ship of professionalism to be cast adrift in a sea of cultural pluralism? A common morality (5) anchored in the natural order. A common morality is a social institution based on a code of learnable norms. Professionalism and the common morality, like language, precede the individual, are an innate ability, learned in the community (a good moral community) (6), perfected by practice, that evolves within constraints.

This correspondence with the natural order has been shunned by modern ethics and the law. They are divorcing themselves from reality and truth, clouding judgment, and endangering essential human rights, allowing unchecked the growth of structures that perpetuate inequality and systematic disadvantage (7), exploiting the vulnerable, yielding to the solipsism of relativism and the hidden self-interest of ideology (8).

For thousands of years, whether for cultural reasons, to sustain high notes, or to guarantee fidelity, interventions with the human body of others, be it willed, desired, consented to, imposed upon, or coerced, have been more or less a universal phenomenon, just as is gravity. These interventions range from the cosmetic to the more radical, irreversible loss of function of organs or systems while pursuing a non-existent object. All, of course, for the benefit of humanity and the common good.

Is it in silence, free of the incessant chatter of modern civilization, that humans perhaps can establish a fruitful dialogue with truth, where honest, good-willed beliefs can be shared? A dialogue that ideologies and some social structures won’t promote, or will perhaps, if professionalism finds its normative voice.

Raul Perez, MD, is Professor of Ophthalmology and Medical Ethics at the University of Puerto Rico School of Medicine.

References
1. Pellegrino, E.D., & Pellegrino, A.A. (1988). Humanism and Ethics in Roman Medicine: Translation and Commentary on a Text of Scribonius Largus. Literature and Medicine 7, 22-38. Doi:10.1353/lm.2011.0164.
2. Menikoff J. (2001) Law and Bioethics. Washington DC, Georgetown University press pp 25-27. “The meaning of equal protection: prevent the government from arbitrarily treating people differently. Worth revisiting and subjecting to a strict scrutiny: substantially related to an important state objective, compelling need of the state. Is it possible? reasonable (rational basis test for the law)? appropriately narrow in scope?
3. Kant, I. (1993) The Metaphysical Foundations of Morals. Indianapolis, USA. Hacket.
Every rational being ought to treat itself and others not solely as means to an end but as ends in themselves. Spawning in such manner a union of rational beings, following objective and common laws, that is, a Kingdom of ends or “Reich der Zwecke.”
4. Ratzinger, J. (Twentieth Century) University of Milan, Italy.
5. Beauchamp T., Childress J. (1994) New York, Oxford University Press pp. 4-7.
6. Pellegrino, E. (2001) Physician and Philosopher. Charlottesville, VA. A moral community for Pellegrino, is a group of human beings bound by common ethical commitments in which self-gain is a lesser objective. It is not an immoral or amoral, relativistic or an ideology, but just a community that is morally good.
7. Powers. M., & Faden. R., (2006) Social Justice, New York, Oxford University Press
8. Stern, A. (1963) Philosophy of History and the problem of Values. Buenos Aires, Argentina EUDEBA. Moral relativism opens the door to ideology. A group of ideas refracted through the prism of self-interests shared be it by individuals or collectives, hiding the true character of particular social situations that if known would set back the aims of the promoters. Such falsifications either by design or in which actors are just partially aware, strive for concealment of real intentions.

The Josiah Macy Jr. Foundation has awarded a grant to Drexel University College of Medicine to create an antiracism curriculum to promote diversity, equity and inclusion in healthcare education as an online module with workshops for learners, faculty and staff. The module, which will be part of Professional Formation’s platform of 12 modules for learners and two for faculty, will be free.

Co-principal investigators are: Dennis Novack, MD, Associate Dean of Medical Education; and Leon McCrea, MD, Senior Associate Dean of Diversity, Equity and Inclusion and Associate Professor of Family Medicine at Drexel University College of Medicine; and Camille Burnett, PhD, RN, Assistant Dean, Equity, Outreach and Social Justice, College of Nursing, Endowed Professor and Strategic Advisor, Community Engagement and Academic Partnerships in the Office of the Provost at the University of Kentucky. Dr. McCrea and his team will oversee a major faculty development and train-the-trainer initiative in antiracism education in healthcare.

“This generous grant will enable us to address the challenge of racism in healthcare,” begins Dr. Novack. “The purpose is to create an antiracist learning culture for healthcare trainees that honors diversity, equity and inclusion where all trainees are respected, where faculty model respect and empathy for all patients, colleagues and staff, and where trainees feel empowered to contribute to a culture of mutual learning.” Dr. Burnett continues, “Trainees will be able to discuss the history and pervasiveness of structural racism, will be able to provide examples of their own explicit and implicit biases and how these biases influence their interactions with colleagues and patients, will respond appropriately to racist behaviors from patients and colleagues, and will be able to use their understanding to create compassionate care for all.”

If you would like to contribute or review content, or script videos for this antiracism module, please contact the grant project director, Barbara Lewis at BLewis@ProfesssionalFormation.org.

Professional Formation is an online resource that has been free for use during the pandemic. For more information on how to access the 12 modules, email bal326@drexel.edu.

AI & Healthcare: A Guide for Managers, Practitioners, and Policymakers by Mir Mohammed Assadullah DBA, PhD, is organized as a dissertation to answer the question, "What are current barriers to adoption of modern artificial intelligence developments by upper management of healthcare organizations?"

If artificial intelligence (AI) using convolutional neural networks can read brain scans and pick up signs of Alzheimer's disease six years before any symptoms develop and detect tiny changes in lung scans that indicate future lung cancers, why are we not using them in doctor's offices and hospitals?

Many start-ups and online medical businesses are using artificial intelligence to provide a new service, such as determining the likelihood that a nursing home resident will require hospitalization or tracking home monitoring devices to anticipate an impending medical emergency.

Artificial intelligence has been used for decades, sometimes in ways that are so unobtrusive that you may not even know it is at work. AI techniques are used to rid your email of spam, map your journeys, and determine your credit score.

Convolutional neural networks (CNN) used in AI are so complex and multi-layered that they are difficult for the human mind to comprehend. The inability of humans to see the many layers that make up CNN means that it has opacity. A failure to understand how CNN reasons and arrives at an answer has implications for its use in healthcare and society in general.

According to Dr. Assadullah, to use data to solve medical problems, the following steps are taken:
· The problem must be delineated with an objective and measurable success criteria.
· Data that is likely stored in different formats must be collected from various locations.
· The data must be cleaned by correcting inaccurate information and restoring missing data.
· A modeling technique is selected.
· The model must be trained using large amounts of cleansed data.
· The model is then tested using a new set of data.
· The model's performance is fine-tuned by tuning parameters around modeling called hyper-parameters.

Preparing data requires time, expertise, and education. The process may be standardized, but the methods are not. This means that one company's approach to developing its AI software can be radically different from another's. Artificial intelligence has been used to allow website visitors to self-assess their symptoms, insulin pumps to provide personalized recommendations, fitness watches to read EKGs, and smartphone audio to record and identify arrhythmias.

Dr. Assadullah points out that even though the US spends $3.5 trillion yearly on healthcare, approximately 25 percent of the population is uncovered. The high costs and the deficit of practitioners means that we need to seek alternative solutions.

The next two chapters explain the methodology for the study. Chapter 2 describes the literature review. Chapter 3 describes the process for developing the themes and coding the literature. Chapter 4 presents the results.

Findings:
· When physicians meet to discuss cases, they must defend their reasoning. They can't unless AI's process is transparent. In most cases, doctors do not know how CT and MRI work, but there is a performance evaluation standard. If one were developed for AI, it would go a long way toward gaining widespread acceptance.
· Since the inner workings of AI models using neural networks are generally opaque to humans, there is no way to detect potential bias. Training data could be biased by sex, age, race, or ethnicity.
· There are medico-legal challenges in terms of responsibility. Who is responsible for a poor decision: the physician, the healthcare system, AI system vendors, or the developers?
· Building trust is an integral component of the physician-patient relationship. It would be difficult to build this trust using AI. Trust concerns include data privacy, trust in the system's performance, trust that laws and regulations will evolve in tandem with AI, and issues regarding patient awareness that a machine is making its diagnosis.
· Integrating data from multiple systems and software vendors is a challenge.

Ultimately, a machine cannot take the place of a human when it comes to bearing responsibility.

Following a presentation on how the literature review was conducted and a summary of the findings in each of the themes explored, the author concludes that significant investments in training and testing programs will be needed to use AI in healthcare properly. Large data warehouses must be built so everyone has access and can collaborate.

The arguments in AI & Healthcare: A Guide for Managers, Practitioners, and Policymakers were well-structured. Readers were taken through a step-by-step process. However, structuring the book in this way meant there was much redundancy.

Using AI in healthcare will require input from ethicists and medical professionals to consider utility. A machine cannot consider a patient's long-term outlook, the risk of misdiagnosis, or patient treatment preferences. Currently, data is taken from the healthcare system, and technology is being developed. Dr. Assadullah stresses the importance of incorporating AI technology within the healthcare system, a unique ecosystem with medico-legal implications, privacy protections, and a requirement for equitable treatment options for all. The issues raised in this book illustrate the many questions that need to be answered in the realm of medical professionalism concerning the use of technology in healthcare.

Leann Poston, MD, MBA, MEd, is a pediatrician in Dayton, Ohio and a freelance medical writer at LTP Creative Design LLC.

What is the proper role of conscience within a professional’s practice? This is a big question and one that, unfortunately, receives stark and polarized responses in light of its connections to socially and politically charged conversations about conscientious objection in medicine. For APHC members or anyone interested in this question, I would humbly encourage you to read the forthcoming issue devoted to this question in Healthcare Ethics Committee Forum (https://www.springer.com/journal/10730). In this forthcoming issue, a variety of perspectives on the role of conscience within healthcare practice, as well as a variety of issues related to conscientious practice, conscientious objection, and civil disobedience are taken up.

I had the pleasure of serving as the issue editor, so take my plug for this issue with a grain (or two) of salt. There is an excellent and critical piece by Mark Wicclair, the philosopher and bioethicist who wrote the book on conscience in medicine (Conscientious Objection in Healthcare: An Ethical Analysis, Cambridge University Press, 2012). There is another excellent piece by APHC President, Tom Harter. This is not President Harter’s first engagement with the topic. In his influential 2015 piece, he argued for public disclosure, and he builds on that earlier work in his piece in this new issue. Some articles take up specific cases up, including those which fit the “classic” categories of conscience-in-medicine discussions. Other articles engage broad theoretical questions, including conceptual work on conscience. In some of those pieces, authors argue that we need to rethink our usage of the term “conscientious objection” and instead propose the usage of conscientious practice. Finally, there is some new work pushing for discussions of “CO” – conscientious objection – to recognize the tripartite relationship between physicians (though this can be extended more broadly to healthcare professionals in many cases), patients, and the physician’s employers, and moving beyond the dated two-sides model.

For those interested, here is a blub from the issue which describes its content in a bit more detail: The proper role of conscience in healthcare continues to be a topic of deep interest for bioethicists, healthcare professionals, and health policy experts. This issue of HECForum brings together a new collection of articles about features of these ongoing discussions of conscience, advancing the conversations about conscience in healthcare from a variety of perspectives and on a variety of fronts. Some articles in this issue take up particularly challenging cases of conscientious objection in practice, such as Fleming, Frith, and Ramsayer’s contextually rich piece on Midwives in Scotland or Harter’s professionally grounded analysis; others engage the changing institutional landscapes which impact considerations of conscience, such as Cummins’ work on the role of employers in institutional policies about conscience and Ben Moshe’s discussion of publicity and institutional committees. Pieces by Howard and Pilkington both raise conceptual considerations about how we think about the role of conscience in medicine, questioning the use of “conscientious objection” in these discussions, and Byrnes pushes back on the most influential work in this area by Mark Wicclair. The issue concludes with a piece by Wicclair, which engages each of these distinct offerings, further extending the discussions of conscience in healthcare and helpfully connecting key themes discussed by authors in this issue his contributions and to the longer tradition of discussions of conscience in medicine. This issue challenges readers to engage different arguments from different perspectives and asks them – in some cases – to be open to revising how they think about the role of conscience and the existence of and justification for conscientious objection in the dynamic, interdisciplinary fields of healthcare.

Bryan Pilkington, PhD, is Associate Professor at the Hackensack Meridian School of Medicine and at Seton Hall University.

Keynotes
A New Definition of Professionalism
Saleem Razack

Dr. Razack begins his address by presenting three case studies. His first is an 11-year-old boy who drowned and was resuscitated but did not survive. The young boy was discussed in morbidity and mortality rounds. Four black children have died in the intensive care unit. What social determinants of health might be a factor? When a trend is noted, what is the physician's responsibility to the family and community?

The second case involves a 22-year-old man in a wheelchair who is living with myotonic dystrophy. He is being discussed at discharge planning rounds. The conversation becomes quite judgmental of the young man's mother and grandfather. They appear to want a break from his care. A medical student discovers that the elderly grandfather must carry the young man up the stairs. There is an extremely long waiting list for an adaptable wheelchair.

The third case involves an Indigenous man admitted to the emergency room with a diagnosis of alcohol intoxication. This man filmed racist interactions between the E.R. staff and posted the video to Facebook. He later succumbed to his injuries, secondary to internal bleeding. This story is fabricated, but the parallels with the death of Indigenous woman, Joyce Echaquan, are clear.

Dr. Razack says that when you examine these cases through the lens of professionalism, you notice patterns. What is your responsibility as a healthcare professional? If there is language that crosses the line, what is our role in addressing it? How can we hold professionals who engage in racist interactions accountable?

Professionalism is sometimes viewed as a social contract. We, as professionals, have specialized knowledge and thus a privileged role and responsibility to society. If you have privilege, you have the responsibility to take care of those who do not.

Dr. Razack made a powerful statement. Discrimination in medicine is a sign that the medical system is working.

He continues by stating that we are bound by history. We are in full continuity of the past injustices in healthcare. For example, we trained the physicians who performed forced sterilizations on Indigenous women.

Flexner introduced the concept of standards to train people. These standards impacted training for African Americans and women. Flexner advocated for segregation of care and specialized training for doctors who care for different populations.

This history affects the diverse learner who may feel a tension between their personal and professional identities. The past that we are remembering is only in the eyes of those who were powerful in the past. Dr. Razack advises against nostalgia. Nostalgia for one person brings up a painful history for another.

He suggests a need to think about how we teach about diversity. He likens it to still-life paintings. Initially, we look at the colors. Then we might notice some of the fruit is exotic and needs a different lighting, but we cannot stop there. Next, we need to teach people the logic of the painting.

We must examine patients within the context of a history of marginalization and oppression. We must introduce the concept of critical consciousness. We are conscious, reflective beings capable of recognizing social injustice. Awareness is not enough. We need to act with populations and empower them to share solidarity. We need to understand the logic of our system, including the racial hierarchy and the system's effects on promoting patriarchy, heteronormal, and ableism. To move forward, we must engage in deep listening.

Is merely noticing enough? Are we teaching the primacy of adding social context to health? Do we understand that institutions are key players in systemic racism?

Contract or covenant? A covenant is a binding promise that emphasizes relationships. Whenever there is a covenant, there is pain. We need to employ the skills of structural competence to appreciate how social determinants of health influence symptoms, disease, and attitudes toward patients and populations. Then we can develop an understanding that societies are designed to discriminate and cultivate a critical consciousness to better understand them.

The ideas and insights Dr. Razack shared in this address will take time to process, but there is no better time than now to investigate the iniquities of healthcare systems and their consequences for structurally marginalized patients.

Saleem Razack, MD, is a Practicing Pediatric Intensivist and Professor of Pediatrics and Health Sciences Education at McGill University/Montreal Children's Hospital, in Montreal, Canada. He is the inaugural director of McGill's Office of Social Accountability and Community Engagement and is a member of McGill's Institute for Health Sciences Education. His research interests in health professions education are broad, encompassing equity, diversity, inclusion, and antiracism, which he studies through qualitative and quantitative methods.

Creating a Resilient Organization: Moving from Post-Traumatic Stress to Post-Traumatic Growth
Christine Sinsky

Dr. Sinsky says that the way to lower costs, improve patient experiences, and get better patient outcomes is to focus on clinician wellness. Nearly half of all U.S. physicians show signs of burnout, even after controlling for confounding variables. Medical students start with higher mental health measures than their age-matched peers.

The burnout that develops in a medical student and beyond has serious consequences. Burned-out physicians make more mistakes and have decreased patient satisfaction. They have higher divorce rates, death, and in the organizations they work within, there is higher turnover and difficulty with retention.

Students with higher levels of burnout have lower levels of professionalism. There is a relationship between burnout and racial bias. Burnout is not a result of a resiliency deficit. Dr. Sinsky says it is a systems problem for which we need systems solutions.

The "Caring for Caregivers in Crisis" model starts with a crisis in which individuals respond with stresses and a natural progression to stress injury. What the organization does determines whether individuals develop chronic stress reactions or begin a road to coping and recovery.

Steps organizations can take:
· Develop well-being programs
· Have a plan for caring for caregivers during a crisis
· Develop communication plans
· Institute ethics plans
· Show human-centered leadership

Leaders of organizations can also have a plan for stress first-aid, such as meeting basic needs, providing psychosocial support, encouraging communication, and providing relief from regulatory requirements. Dr. Sinsky says that these supports need to be continued for months after the crisis. Healthcare organizations can measure how physicians are doing using tools such as the "Coping with COVID" survey. The survey found that the feeling of anxiety was high but feeling valued by the organization was protective.

Steps some organizations have taken:
· Scheduling listening sessions
· Providing PPE
· Instituting moral resiliency rounds
· Developing peer-support programs

Some healthcare providers have said that being a part of a larger cause or organization was helpful. Developing a culture of wellness can help. The AMA has practical toolkits that can help organizations implement these concepts. They were written by physicians for physicians. Using these toolkits can help increase the efficiency of practice and develop a culture of wellness.

Resources are available via the AMA's no-cost Steps Forward toolkits (www.stepsforward.org).

Dr. Christine Sinsky is Vice President of Professional Satisfaction at the American Medical Association. A board-certified internist, she practiced at Medical Associates Clinic in Dubuque, Iowa, for 32 years. Dr. Sinsky is a member of the Board of Trustees of the ABIM Foundation, serving as Chair from 2018 to 2020 and a Master in the American College of Physicians. Dr. Sinsky focuses her efforts on developing resilient organizations that focus and care for individuals who work within them. Burnout manifests in individuals, but it originates in systems.

Fireside Chat
Dennis Novack, MD, interviews Tom Inui, MD, as part of the fireside chat. Dr. Inui collaborated with the AAMC on the groundbreaking publication, A Flag in the Wind: Educating for Professionalism in Medicine. While reflecting on his career and life, Dr. Inui stresses the importance of developing relationships with patients, colleagues, communities, and oneself.

Dr. Inui discussed his family background, then his time in medical school at Johns Hopkins. His experiences inspired him to devote his career and life to serving the underserved. He made it his goal to live where they lived and spend his time in the neighborhoods that determine the social determinants of health. His history demonstrates that we live in a present defined by the past. We live in a present that is co-created by the people with whom we work.

When asked where we should go as a society, Dr. Inui said he is not sure it is possible to make it free of bias. Instead, it is possible to be so transparent that one's biases are exposed. He claimed he could only truly understand one life deeply, his own.

He said our best shot is to encourage everyone to be in communication with each other. Dr. Inui said that students know "more about the water" than we think. Students could talk safely about their past experiences with a proper facilitator. About two thirds were positive, and one third of the stories would cause you to weep.

When asked what students should do if they witness a senior member of the healthcare team behaving unprofessionally, his advice was to sound like a student. Form your observations into a question. You would not get nailed for that. He says that we can learn more from students as our guides. Appreciative Inquiry can allow the positive stuff to be revealed. The negative is the opposite.

In the discussion that followed, William Branch, MD, said that this discussion awakens us to the loss of empathy we have suffered along the way. The fireside chat ended far too soon, with a remark about how working with students can be a rich and inspiring experience.

We’re here to share the 12th and final module of the Medical Professionalism Project with you! We hope you’ve enjoyed these write-ups and will reach out to try the course soon!

The Medical Professionalism Project (MPP), created by renowned social scientist Dan Ariely in collaboration with Duke Health, is an innovative short film series and CME course that explores the complex expectations, challenges and responsibilities of being a healthcare provider through the lens of behavioral science. In 5- to 10-minute videos, MPP applies research from behavioral economics and other social sciences to reveal how and why we make ethical mistakes, providing strategies for improving behavior at an individual and institutional level.

Module 12, the final in our series, explores how we can encourage ethical behavior moving forward. Research shows that one key element is reminders – the more we are reminded of our ethical code, the more likely we are to adhere to its principles. This module invites ways of building reminders into our work systems and synthesizes the information we’ve presented over the series to offer a robust set of tools and strategies for maintaining professionalism.

Having presented a wide set of research, resources, and programs over the course of the series, we share one final resource after the film, one that fortifies all the fields of medicine – the Hippocratic oath.

The Medical Professionalism Project can be completed online for up to six credits of AMA PRA Category 1 Credit(s)™, MOC Part II credits for numerous member boards, nursing CE, as well as IACET CEU. In addition, we offer the films to be used offline in classrooms and meetings, or incorporated into other online learning platforms. A robust interprofessional educational experience, the Medical Professionalism Project is an engaging and thought-provoking course for students, residents, faculty and practicing physicians, as well as nurses, physician assistants and others on the healthcare team.

All APHC members receive a 20 percent discount on MPP (and 25 percent of the payment returns to APHC!).

If you have any questions, please reach out to Project Director Clare Marash at clare@saltyfeatures.com.

Article Synopsis by Bryan Pilkington

As COVID-related restrictions are relaxed and institutions contemplate return to more traditional modes of interaction, it is essential to understand best practices for doing so. This is especially the case for institutions of higher education (IHEs), which often attract students from a wide range of geographic locations. In a recent article (1) in the International Journal of Ethics Education, colleagues and I took up this issue. Our interdisciplinary team consisted of a virologist with SARS research experience, a biology student, and an ethicist. We began our inquiry by paying attention to a perplexing feature of many infectious diseases, which is the damage they can cause, not only to physical health, but to mental health and to social relationships. With this in mind, we focused on four ethical themes – one of which, professional expertise, will be of special interest to APHC members – and concluded with seven recommendations. We argued that proper ethical analysis, which is necessary for the implementation of good policies, cannot be accomplished without a firm, evidence-based grounding. What follows is a short summary of this article.

The tension between the separation that is required for safety in response to the pandemic and the human need for contact, engagement, friendship, and fellowship is a challenge that is especially felt by institutions of higher education. Many such institutions not only educate students but seek to foster the kinds of communities which have thrived on personal interaction, shared physical space, and faculty, staff, and students working in close proximity to each other.

Though different institutions have responded to COVID and its impacts on their members differently, we argued in favor of seven recommendations for all IHEs:
1. Adopt and enforce masking policies, hand washing, and physical distancing practices; Note that masking policies should include the type of mask that is permissible to participate in classroom activities.
2. Frequently test during the semester for all students (residents and commuters), faculty, and staff; consider sewage surveillance and pool testing as a means to determine additional testing needs.
3. Monitor and improve ventilation for all classrooms to maximize the effectiveness of masking and physical distancing practices.
4. Regularly clean classrooms, laboratories, and similar spaces to eliminate possible transmission by fomites.
5. Wherever possible, grant students and faculty remote classroom engagement options.
6. Provide adequate quarantine space for resident students, as well as safe access to food, tests, and health information.
7. Fully and clearly inform relevant members of the IHE community of all COVID-19 cases that occur on campus in a timely fashion, including informing members of a class, of any positive case occurrences (in a deidentified manner); potentially exposed faculty, staff and students should be rapidly tested.

Our recommendations are supported by scientific research and focused on features of the virus – including, respiratory droplets, aerosols, and how it is transmitted – as well as applicable interventions considered by IHEs – including masking, hand hygiene, physical barriers, and testing practices (2). They are also supported by an ethical analysis reliant on four themes: deference to expertise, the duty to plan, attention to stewardship, and respect for the dignity of members of educational and surrounding communities. Though planning, stewardship, and dignity are all worth reflection, deference to professional expertise is likely to be of most interest to readers of this newsletter.

On that subject, we describe the deference to expertise as a necessary but challenging requirement for institutions of higher learning due to their diverse stakeholders and the variety of disciplines represented therein. However, we argue that IHEs have a special obligation to defer to experts (and, in fact, to proper experts) because of the kind of institutions that they are. Failing to do so raises questions of an existential nature about such institutions, as well as opens the door to question the legitimacy of the institution. This is because such institutions are both repositories of knowledge and also places where research advances and future professionals are taught (3).

Institutions of higher education create and foster expertise and so it is necessary that they not only defer to experts, but that they defer to proper experts. Thankfully, many IHEs have excellent scientific researchers to draw on, e.g., virologists studying COVID, physician and nursing faculty caring for patients with COVID, and ethicists and social scientists thinking through public health policies and institutional pandemic practices. Understanding who is a proper expert is not always easy. Our analysis relies on the classic work on the nature of expertise by Chi, Glaser, and Farr (4) and we argue that deference to proper expertise is necessary for an ethically-grounded response to the pandemic, which includes taking seriously best practices recommended by internal institutional experts.

The full article can be found here: https://doi.org/10.1007/s40889-021-00120-8.
Bryan Pilkington, PhD, is Associate Professor at the Hackensack Meridian School of Medicine and at Seton Hall University.

References
1. Pilkington, B.C., Wilkins, V. & Nichols, D.B. Educating ethically during COVID-19. International Journal of Ethics Education 6, 177–193 (2021). https://doi.org/10.1007/s40889-021-00120-8
2. These recommendations were developed and published prior to the availability of vaccines for COVID. They may be especially beneficial for communities with a high percentage of vaccine hesitant members or for communities that face vaccine access issues. Less stringent versions of these recommendations may be more fitting for communities with a very high vaccination rate.
3. In so doing IHEs uphold necessary features of the professions represented there. For one account of professions which holds this view, see the work of Allen Buchanan (Buchanan, A. 2009. Is there a Medical Profession in the House? In Justice & Healthcare: Selected Essays, Oxford: Oxford University Press, pp. 175-202.)
4. Chi, M., R. Glaser, and M. Farr. 2009. The nature of expertise. New York: Psychology Press.

Health care bills, insurance, co-pays, out-of-pocket contributions, and prescription drug coverage are the bane of anyone who has ever received health care. Understanding how much care will cost and whether insurance or other programs will pay for the care is stressful for many patients. Care costs should be treated as an ethical issue interrelated with medical care rather than a separate issue disclosed to a patient after care has been rendered.

An example of the integral nature of costs to medical care is that financial aspects of health care directly impact at least two of the core principles of bioethics – social justice and autonomy. Additionally, the principle of beneficence is relevant because of the stress if a patient survives the illness but must file for bankruptcy.

With respect to the principle of social justice, access to care includes finding appropriate treatment and being able to afford the care provided. Fear of not being able to afford medical care is a matter of social justice because people who need care will avoid medical care for financial reasons. Both the perceived cost and the actual price dissuade those in need from accessing care.

The consent process should notify the patient of the economic burden of the medical care to the extent it is known to fulfill the ethical duties of enabling patient autonomy. Respecting patient autonomy involves an informed consent process that discloses risks of bad outcomes. Similarly, charges are a risk worthy of telling a patient. Without disclosing the costs of care, a patient is unable to exercise autonomy in the choice of care, choice of caregivers, and negotiations with health insurers.

Framing billing as an ethical issue integral to medical care should encourage hospitals to respect the burden of charges on patients and to improve billing practices. Doing so will likely improve patient satisfaction and reduce uncollectable charges. There are several steps to improve the patient experience related to billing and collections.

First, Patient's Rights should include clear access to billing information before delivering care whenever possible. Patients should have the right to receive information as soon as possible regarding expected charges, insurance reimbursement, and charges that are the patient's responsibility. Clear, timely billing enables patients to understand their obligations, detect overcharges, and identify billing mistakes.

Second, hospitals should be encouraged to provide better information to patients throughout their health care experience and reduce the opaqueness of medical billing through common surveys. For example, separate questions about billing should be incorporated into the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Measuring and reporting patient satisfaction with the economic aspect of medical care will encourage improved billing practices and accurately assess patient satisfaction with the entire delivery of care. By utilizing the survey results, patients will choose hospitals with more patient-friendly billing practices when selecting a health care provider. Of course, this will not help hospital selection for emergency care.

Finally, to help patients navigate the billing morass, every hospital should have a billing ombudsman who is available to prospective patients, inpatients, and discharged patients to help with health insurance, charity care, and all the other resources available to manage the cost of care. An ombudsman will help patients address the costs of care and will also help hospitals receive payment promptly because patients will know their obligation, seek accommodations, charity care, and begin the process of paying the bill.

Jeffrey W. Loebl, d.bioethics from Loyola University Chicago, is a practicing attorney in Ojai, California.

Let us begin this narrative with my favorite definition of mentoring:

Daloz (1999) speaks powerfully—and metaphysically—about the mentor:

…It is more than passing interest that the original Mentor was inhabited by Athena. Clearly, the mentor is concerned with transmission of wisdom. How, then, do mentors transmit wisdom? Most often, it seems, they take us on a journey. In this aspect of their work, mentors are guides. They lead us along the journey of our lives. We trust them because they have been there before. They embody our hopes, cast light on the way ahead, interpret arcane signs, warn us of lurking dangers, and point out unexpected delights along the way. There is a certain luminosity about them, and they often pose as magicians in tales of transformation” (1).

To continue, Daloz (1986) guides me with his model of mentoring relationships as he highlights the connection between challenge and support. I find this fascinating as an educator. I use the paradigm presented in Make it Stick: The Science of Learning (3) that describes the ‘zone of proximal development,’ the optimal space for learning to avoid boredom or on the other extreme anxiety in my design of curriculum and educational strategies. Daloz’s description is parallel to the learning zone, where low levels of both challenge and support result in stasis and high levels of challenge and low levels of support result in retreat. On the other side is high levels of support and low levels of challenge produce confirmation and most important high levels of both challenge and support generate growth, my desired outcome for mentoring that measures success in the relationship and also for learning (2).

In my own professional identity formation as an educator of health professionals, some of my most gratifying moments are serving as a mentor for others. I see this as a professional responsibility to help others with their career development. As I am helping others on their journey, I am also nourishing my own journey. The gift of paying forward! How many of you have a favorite definition to describe a mentor ? If so, consider adopting one as you prepare to become or continue as a mentor.

How to make this definition come alive requires relationship building with your mentee. Skill sets easily overlap advising, coaching and mentoring. It is important to clearly understand your role. Can you have multiple roles with a mentee? Yes, after you understand the nuanced differences of this terminology (4).

As a member of the Academy for Professionalism in Health Care whose “purpose is to optimize patient care through professionalism education, scholarship, policy, and practice in all health-related fields,” I do feel there is a role for mentorship as a core component and skill to promote professionalism in healthcare. Personal beliefs of mentors shape their mentoring style and influence the goals and purpose of mentoring, the possible activities associated with it, who decides on the focus of the mentoring relationship, and the strategies mentors choose to enact these beliefs in practice.


A new area to explore is “patients as mentors” to guide learners (and maybe faculty too) to construct their professional identity and support exploration of and commitment to the professional values that society expects of physicians (5).

I will conclude with another consideration, when do you need a sponsor to continue to develop your professional identity and growth. A sponsor is someone who assumes an active role to promote a protégé and puts him/her forward to advance his/her career. A mentor can be a sponsor, or it can be two different individuals. Both roles require trust respect and loyalty. Sponsorship and mentorship are professional relationships that foster continued professional identify formation, which is critical for career advancement (6).

To end I will quote, with gratitude, one of my valued mentors who has taught me so much, about professionalism, William Branch (2011). “Seeking wisdom should become embedded in the culture of medicine.” Mentorship is a path to wisdom. Choose wisdom and accept, as Bill Branch states, “The pathway to wisdom is a crooked one” (7).

Alice Fornari, EdD, FAMEE, is Professor of Science Education, Occupational Health, Family Medicine, and Associate Dean, Educational Skills Development at Zucker SOM at Hofstra/Northwell. She is Vice President, Faculty Development, Northwell Health.

References
1. Daloz L. Guiding the Journey of Adult Learners. 1999.
2. Daloz L. Effective Teaching and Mentoring. Jossey-Bass; 1986.
3. Henry L. Roediger HL, McDaniel A, and Peter C Brown PC. Make It Stick: The Science of Successful Learning. Harvard University Press. 2014.
4. Marcdante K, Simpson D. Choosing When to Advise, Coach, or Mentor. J Grad Med Educ. Apr 2018;10(2):227-228. doi:10.4300/JGME-D-18-00111.1
5. LM L. Mentors' Beliefs About Their Roles in Health Care Education: A Qualitative Study of Mentors' Personal Interpretative Framework. Academic Medicine. 2020;95(10):1600-1606.
6. Ayyala MS, Skarupski K, Bodurtha JN, et al. Mentorship Is Not Enough: Exploring Sponsorship and Its Role in Career Advancement in Academic Medicine. Acad Med. 01 2019;94(1):94-100. doi:10.1097/ACM.0000000000002398
7. Branch WT, Mitchell GA. Wisdom in medicine. Pharos Alpha Omega Alpha Honor Med Soc. 2011;74(3):12-7.

In the foreword to Dr. Gia Merlo's book Principles of Medical Professionalism, she reaches out to physicians at all training levels. She invites them to read and discuss the book's topics, hoping they will feel empowered with the practical knowledge, tools, and techniques she provides. She begins by defining the fiduciary relationship a physician has with his or her patients, emphasizing the need for physicians to care for their patients even at a cost to themselves. This relationship is set against a backdrop of systemic problems that physicians must consciously work hard to overcome.

Readers will find that the responsibility for self-care is not only towards patients. Throughout the book, Dr. Merlo advises readers that physicians have a responsibility and a duty to take care of their own mental and physical health. One eye-opening statistic cited in the book is that around 30 percent of medical students and residents live with depression and depressive symptoms. Depressed medical residents have been found to make 6.2 times more medication errors than their colleagues who are not struggling with depression. This statistic illustrates the importance of taking care of oneself in order to care for others.

Dr. Merlo begins the reader's journey by exploring the tenets of medical professionalism and providing a brief history of how professionalism has evolved in healthcare. She then makes a convincing argument for the power of reflection and how it can help with the rampant physician burnout that is causing many physicians to either leave the field or continue practicing without the joy and passion that brought them to medicine.

In each chapter, Dr. Merlo introduces a new facet of medical professionalism. She provides background information and summarizes the research but does not stop there. She provides self-assessment exercises. For example, in the chapter dealing with happiness and self-care, she asks the reader to write their eulogy. A practice that will help readers clarify their lifelong goals and identify which activities truly lead to happiness.
One of the many strengths of this book is that Dr. Merlo drew from a wide range of fields, including learning theories, cognitive biases, narrative medicine, the benefits of studying the humanities, financial planning, assessing aging, substance abuse, and mental health. She gives the reader enough detail on each subject to feel familiar with the issue, but not so much that a follow-up book diving into each topic more in-depth would not be welcome. This level of detail is ideal for a book club or small group discussion.

Dr. Merlo does a masterful job of thoroughly covering each topic in her book without overwhelming the reader with details. When statistics are relevant, they are presented, and anyone seeking additional information on any subject can find a wealth of references and resources.

This book is extremely well-researched and easy to read. It is chock-full of practical ideas and guidance. My only criticism is that as a reader, the shift in perspective may be disorienting. Within the same chapter, a third party, objective style is used to present research and background before switching to second person later. This switch involves the reader in the conversation at times and makes the reader the recipient of information at other times. Once you adapt to the pattern, it is apparent why it was written this way.

Dr. Merlo's book, Principles of Medical Professionalism, is unique in that it addresses such a wide variety of topics. The scope discussed and how she maintains the focus on physicians and professionalism requires a talented writer who can convey information without sounding preachy. I can easily see this book being used in the medical school classroom to prepare physicians in training on managing their expectations throughout residency as burnout, overwork, and fatigue increase and in mid and late-career as a guide for reflection.

Dr. Merlo addresses the profession's taboo or unanswered questions, such as what to do if a colleague has a mental disorder. I believe every reader will be thoroughly impressed with how modern and up-to-date this book feels from a discussion on artificial intelligence and its use and how deep and spiritual it feels as the author expresses her concern for physicians after the COVID-19 pandemic ends.

Principles of Medical Professionalism
ISBN-13: 978-0197506226
ISBN-10: 0197506224
312 pages

Leann Poston, MD, MBA, M.Ed. is a pediatrician in Dayton, Ohio; freelance medical writer at LTP Creative Design LLC.

We’re here to share another module of the Medical Professionalism Project with you!

The Medical Professionalism Project (MPP), created by renowned social scientist Dan Ariely in collaboration with Duke Health, is an innovative short film series and CME course that explores the complex expectations, challenges and responsibilities of being a healthcare provider through the lens of behavioral science. In 5- to 10-minute videos, MPP applies research from behavioral economics and other social sciences to reveal how and why we make ethical mistakes, providing strategies for improving behavior at an individual and institutional level.

Module 9 begins with an illustrative riddle to highlight the ways subconscious biases influence our perspective. In the video, we review some of the historic abuses of power that have occurred in medical research and practice, which may have contributed to a lack of trust among patients, particularly patients from marginalized communities. While such egregious examples are (hopefully) a thing of the past, there remain persistent inequalities in access to care and participation in research across gender, racial, and economic lines. These inequalities have rippling impacts across the healthcare system. Acknowledging the ways we have developed systems of bias in medicine, we offer strategies to begin to address these concerns, while highlighting the many areas where work still needs to be done.

In our resources, we include papers on the lack of diversity in research and implicit bias among physicians, and provide a link to Harvard University’s Implicit Bias Test, so users can test their own biases.

The Medical Professionalism Project can be completed online for up to six credits of AMA PRA Category 1 Credit(s)™, MOC Part II credits for numerous member boards, Nursing CE, as well as IACET CEU. In addition, we offer the films to be used offline in classrooms and meetings, or incorporated into other online learning platforms. A robust interprofessional educational experience, the Medical Professionalism Project is an engaging and thought-provoking course for students, residents, faculty and practicing physicians, as well as nurses, physician assistants and others on the healthcare team.

All APHC members receive a 20 percent discount on MPP (and 25 percent of the payment returns to APHC!).

If you have any questions, please reach out to Project Director Clare Marash at clare@saltyfeatures.com.

SARS-Co V-2, Severe Acute Respiratory Syndrome Coronavirus 2, Vaccines, and the Nuremberg Code (1)

Centuries ago, A. Hamilton stated the following: “So numerous indeed and so powerful are the causes which serve to give a false bias to the judgment, that we, upon many occasions, see wise and good men on the wrong as well as on the right side of questions of the first magnitude to society” (2).

SARS-Co V-2 vaccination (3) policies are an exception. The Nuremberg Code lists 10 principles that should be followed to avoid crimes against humanity in research. It declares that the voluntary consent of the human subject is absolutely essential and that researchers’ duty and responsibility is to ascertain the quality of the consent. Even health care professionals’ comprehension (4) is challenged when facing the following contradictory statements. We hear a lawmaker who receives full vaccine therapy argue against facemask use on the grounds that the intervention (vaccination) is 95 percent effective. Whereas public health officials advise mask use after vaccination, because it is not yet known if vaccination alone prevents contagion.

The intervention should benefit society and be the least restrictive option for the procured good. In this instance, society or community is in itself a good. A facility (5) to test non-FDA approved interventions will hopefully produce practical applications to benefit humanity. The very term facility evokes a third role: researcher, clinician, and now businessperson (6), which is quite salient in the present research environment. The businessperson role may have less ethical constraints, makes self-serving activities difficult to define, detect and perhaps more insidious than undeserved monetary gain.

A medical intervention ideally should be based on animal experimentation, which is especially useful for pre-clinical assessment of vaccines and therapies for COVID-19. Finding an animal model has not been easy. Mice, the most desirable candidates, were just not susceptible to COVID 19 infestation. Experimental genome or spike tweaking - be it by sequential passaging, transgenic or humanized mice, vector assisted, or other viral engineering techniques - may capacitate the virus to produced mild to severe disease (7). In some models, it would cause fatal brain disease. RNA viruses mutate - it is what they do. Wild mutations are believed not to be usually lethal to their host since that would render the virus host-less and end contagion.

Vaccination, as well as uncontrolled pandemics, can induce resistant variants. Laboratory engineered mutations, on the other hand, could be planned to capacitate the virus to infect species it usually does not, that is a zoonotic jump. In this regard, hundreds of thousands of minks had to be culled worldwide when presumably infected with COVID-19 by sick humans (8). Wild or engineered mutations that harm humans are known as variants. Surges to follow may bring variants or new lineages that hope fully will join in severity their kin the common cold. A universal corona virus vaccine that would offer protection from all variants could be available in one and a half years. Meanwhile, we just should be thankful for having trustworthy (9) clinicians and researchers in charge.

Raul Perez, MD, is Professor of Ophthalmology and Medical Ethics at the University of Puerto Rico School of Medicine.

References
1. “Trials of War Criminals before the Nuremberg Military Tribunals Under Control Council Law No.10”, Vol. 2, pp. 181-182. Washington, D.C.: U.S. Government Printing Office, 1949.
2. Hamilton A., (1787) The Federalist Papers Federalist No. 1., Padget, J. et al (Ed.) The US Constitution and Other Writings (pp. 93) San Diego: Canterbury Tales
3. Muños, C. et al. Animal Models For COVID-19. Nature 586, 509-515(2020)
4. The Belmont Report DHEW Publications 1979
5. Miller D., (2019) The Common Good, Washington DC, Forthcoming in The Stanford Encyclopedia of Philosophy
6. Rosenfeld, F. J. (2019) Informed Consent and the Revised Common Rule. On line at bioethicsjournal.hms.harvard.edu/summer-2019/informed-consent-and-revised-common-rule
7. Muños, C. et al. Animal Models For COVID-19. Nature 586, 509-515(2020)
8. Denmark to cull 15 million mink… www.nationalgeographic.com/animals/articlecovid19-forces-mink
9. Sheehan, M. (2021) Washington DC, Moderator, John Collins Harvey Lecture: “A Conversation with Dr. Anthony S. Fauci.” Edmund D. Pellegrino Center for Clinical Bioethics https://clinicalbioethics.georgetown.edu

Despite the exponential growth of innovative therapies, technologies, and extrinsic motivation, the true meaning of “doctoring” has not changed. To be a modern day physician requires a learner to be a hybrid of a scientist, professional, human being and member of society (Marti-Ibanez, 1970). Recent years have seen a significant loss of the joy in doctoring. The term “burnout,” a chronic response to prolonged professional stressors, was coined in 1986 by psychologist Ron Smith (Smith, 2016). Medical students and health professionals are experiencing burnout because they often lack the emotional, moral, and mental means to overcome the demands of professional work, their careers, and challenges in developing their professional identity (PI) (Wald, 2015). Some of the major reasons for burnout in medicine are (1) the increased clerical or meaningless workload, (2) increased demand for clinical/monetary productivity, (3) moral distress and (4) an unhealthy competition without intrinsic curiosity. These factors have a direct impact on humanistic clinical care, professionalism, PI, and well-being for the clinician and the learner.

As the regulations of institutions grow, the autonomy of the professional is diminished. Moral distress is the result of not being permitted to behave morally in clinical context (Young and Rushton, 2017). Loss of autonomy, moral distress, and stressors can result in anxiety and loss of active engagement. These complex challenges create a sense of moral distress, disengagement, and emotional exhaustion that may contribute to burnout (Rushton, 2017) Young and Rushton, 2017). The continuous rise of burnout has become a major threat to the health care system. The mitigation of those chronic stressors and a moral resiliency can help to overcome burnout (Southwick and Southwick, 2018) (Hartzbrand, Pamela; Groopman, 2020). Regardless of the stages of career or the focus of work, achieving a sense of autonomy, moral resiliency, relatedness and connection with work can improve social and emotional wellness and reduce burnout (Hartzbrand, Pamela; Groopman, 2020)(Panagioti et al., 2017).

Institutional changes including focus on personal meaningful work duties, active learning, peer and superior feedback and advice, collegial and peer social support and active roles in quality improvement, committees, and advisory boards have shown positive effects on reducing burnout. However, these ongoing institutional changes both in academics and practice must continue to expand as burnout is still systemic throughout the field. The physicians caring for their patients and the learner caring for their education, finding meaning in work as physicians and learning allows them to be engaged and exhibit moral resiliency (Hartzbrand, Pamela; Groopman, 2020) (Young and Rushton, 2017). Therefore, a major goal within education should be to encourage the fostering and nurturing of active engagement to their work at all stages in their career and learning. The development and maintenance of a community of practice that embodies these best practices of modern medicine is essential for a sustained and vibrant medical community. The safe, engaging, and meaningful practice of socialization can help in prevention of burnout for both practicing physician and learner in the medical profession.

Vijay Rajput, MD, is chair of the Department of Medical Education and Professor; Lauren Fine, MD, is Assistant Professor of Medical Education and Director of Ethics and Humanities Thread; and Kyle Bauckman, PhD, Assistant Professor of Medical Education and Director of Student Research at Nova Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine in Fort Lauderdale, Florida.

References
Hartzbrand, Pamela; Groopman, J. (2020) ‘Physician Burnout, Interrupted’, New England Journal of Medicine. Available at: doi: 10.1056/NEJMp2003149.
Marti-Ibanez, F. (1970) ‘To be a doctor’, Nippon Ishikai zasshi. Journal of the Japan Medical Association, 63(1), pp. 91–95.
Panagioti, M., Panagopoulou, E., Bower, P., Lewith, G., Kontopantelis, E., Chew-Graham, C., Dawson, S., van Marwijk, H., Geraghty, K. and Esmail, A. (2017) ‘Controlled Interventions to Reduce Burnout in Physicians’, JAMA Internal Medicine, 177(2), p. 195. doi: 10.1001/jamainternmed.2016.7674.
Rushton, C. H. (2017) ‘Cultivating moral resilience’, American Journal of Nursing, 117(2), pp. S11–S15. doi: 10.1097/01.NAJ.0000512205.93596.00.
Smith, R. E. (2016) ‘Toward a Cognitive-Affective Model of Athletic Burnout’, Journal of Sport Psychology, 8(1), pp. 36–50. doi: 10.1123/jsp.8.1.36.
Southwick, F. S. and Southwick, S. M. (2018) ‘The Loss of a Sense of Control as a Major Contributor to Physician Burnout’, JAMA Psychiatry, 75(7), p. 665. doi: 10.1001/jamapsychiatry.2018.0566.
Wald, H. S. (2015) ‘Professional Identity (Trans)Formation in Medical Education’, Academic Medicine, 90(6), pp. 701–706. doi: 10.1097/acm.0000000000000731.
Young, P. D. and Rushton, C. H. (2017) ‘A concept analysis of moral resilience’, Nursing Outlook, 65(5), pp. 579–587. doi: 10.1016/j.outlook.2017.03.009.

We have both been fortunate to have received second doses of the COVID-19 vaccines. There is a feeling that somehow life should be different, somehow better. Somedays it just feels like we are sitting in the backseat of an old Plymouth Fury, asking “Are we there yet?”

The medical literature says we are 95 percent likely to be protected against a bad outcome from COVID-19, once we are two weeks post-second vaccination. But we still wear masks, now double masking in public. We continue to avoid restaurants and hair salons, clean our hands until they are almost raw, and rarely see friends.

Our personal post-pandemic paradigm is little different than the pre-vaccination existence. Whether it is the five percent chance that the vaccine will not be effective or that we may be vulnerable to new viral mutations, the COVID concerns have not abated. However, it does not seem to be slowing other folks down. Airline travel over Presidents’ Day weekend broke records, and in spite of bad weather throughout our area of the country, freeways are very busy. Some choices can put all of us at risk, while other choices may be more reasonable.

As we listen to medical leaders on various channels, we hear deaths are down, hospitalizations are down, and cases are plummeting. We are hearing how happy those experts are with the statistics. We recognize how easy it is for audiences to hear, “the worst is now over.” But, unfortunately the U.S. is not out of the woods yet. Health care professionals need to help encourage hopefulness, but also promote steadfastness. We need to be role models for finding ways people can feel positive, while continuing to protect themselves and their loved ones. We heard one TV program recently where four medical leaders were asked about what they feel comfortable doing post-vaccination. These four physicians’ responses were extremely diverse, from doing virtually anything, to hugging grandkids, holding large family groups, to eating “in” at restaurants, to not wearing masks… No wonder listeners get mixed messages. We decided to ask friends some of their most enjoyable recent activities. Several had driven to a community zoo hosting a penguin walk, which allowed spatial distancing and masking with an outside venue. Another called a local delicatessen for an array of goodies to bring home along with candles as a romantic Valentine’s treat. Another found a weekend day to do a self-guided tour (with brochure) at an arboretum-cemetery historic park area with outdoor displays of architecture and sculpture. There are safe outings and activities to keep us focused and refreshed.

As health care professionals, it is our duty to encourage patients, colleagues, and the public to get vaccinated. We promote the message that through vaccination we can eventually return to “normal.” We are developing through a “COVID-19 vaccine task force” specific video messages for our community which focus on answering vaccination related queries. We have developed topics specific to local communities of color and for special language community educational programming. It is also our responsibility to point out continued masking, social distancing, and hand hygiene – the “new normal.” Our patients want to move beyond COVID-19, to feel safe again. But, as learned voices in epidemiology and public health, we cannot offer that sense of safety or even a timeline of when to anticipate a relief from the burden of COVID. We need a bit more time before we can reduce the banter of “Are we there yet?”

Cynthia Sheppard Solomon, BSPharm, RPh, CTTS, NCTTP, is Clinical Assistant Professor, and Glen D Solomon, MD, MACP, FRCP(London), Chairman, Department of Internal Medicine and Neurology, Wright State University Boonshoft School of Medicine, Dayton, Ohio.

Since “Project Professionalism” was launched in 1995 with the lofty goal of promoting “integrity in medicine,” its foundational tenant has been an informal but presumably collaborative social contract between governments, corporations, and medical professionals (1). Even those who have criticized professionalism as a standard for medical education and practice have accepted uncritically the idea of a contractual association.

The idea of a metaphorical contract (nothing written or negotiated) is problematic not the least because the goals of the presumed partners are distinct. Corporations seek the maximization of profits and revenues from research and resulting pharmacologies (2). Governments seek economic advancement with maximization of population health within the limits of budgetary realities. Physicians seek the best possible treatment for the patient in care, an orientation some have criticized as a failure to serve the goals of officialdom (3).

In contract theory, where conflicts occur some form of mediation would assure the physician’s sense of integrity and care in relation to official desires or corporate interests. More often, however, physician professionalism means towing the official line without mediation. A single example of the way in which the social contract can fail physicians and their goals of integrity may serve, here, to demonstrate the problem. A more comprehensive review is now under way.

The Case
Diagnosed with cancer in 2019, Clint Gossard sought a bed at the Irene Thomas Hospice in Delta, British Columbia, outside Vancouver in January 2020. He also wanted the hospice to permit his medical termination. While “medical aid in dying” (MAiD) is legal in Canada, hospice officials informed Mr. Gossard that it was not permitted in their facility although it was available at nearby Delta Hospital. After his death Mr. Gossard’s widow complained to Minister of Health Adrian Dix, who in response ordered the hospice change its policy or lose provincial funding (4).

In reply, hospice official argued MAiD not only violated the hospice’s internal policies but the guidance of both the Canadian Hospice Palliative Care Association (CHPCA) and the Canadian Academy of Palliative care Physicians (CAPCP). In a joint statement in 2019, these professional organizations stated categorically: “National and international hospice palliative care organizations are unified in the position that MAiD is not part of the practice of hospice palliative care (5). For physicians it is a violation of palliative goals of continuing care.

That, and appeals to conscience rights protected in Canadian law, should have ended the matter. After all, MAiD was readily available to Mr. Gossard and others at a nearby hospital. At the least, this was an opportunity for serious discussion between government officials on the one hand, and on the other, both national and local representatives of hospice and palliative medical care.

Instead, Mr. Dix simply ordered the hospice to change its policy or lose the $1.5 million—47 percent of its funding (hospices are required to raise substantial parts of their budgetary needs). The position of the national professional organizations was ignored. There were no discussions of the merits of MAiD in a hospice setting. Government simply ruled by fiat. The hospice refused and was closed in February 2021 when its patients were transferred to other institutions.

At issue was both the integrity of palliative physicians to determine the type of care they would provide and of the professional organizations representing them and hospices generally. Conscience rights protected by the constitution were also ignored. And yet, those teaching professionalism at local medical schools and local medical associations, said little and did less in defense of the hospice and its personnel. In this case, the ideal of a mutually conceived contract of care was discarded by the government without consideration of the views of medical professionals.

Tom Koch is an ethicist, historian and medical geographer at the University of British Columbia. He is the author of Thieves of Virtue: When Bioethics Stole Medicine and Ethics in Everyday Places: Mapping Moral Stress, Distress, and Injury.

Tossed up and down.
Do you notice that
you want to stand up?

Squeezed from all sides.
Do you notice that
you want to pop back out?

Dropped from a height.
Do you notice that
you want to rebound against the floor?

Stretched to the limit.
Do you notice that
you want to snap back?

Pushed and pulled.
Do you notice that
you want to recoil?

Exhausted.
Still you want to dance to your song.
You remain hopeful.

Submitted by William Agbor-Baiyee, PhD, Associate Professor and Assistant Dean for Educational Research and Student Learning at Chicago Medical School, Rosalind Franklin University

Over twenty years ago, a group of us created a humanistic faculty development program designed to have long-lasting impacts. Based on previous programs that I designed for medical students in the late 1980’s, this program’s small group curriculum synergistically alternated critical reflection with experiential learning sessions and gained depth over time by generating a powerfully supportive group process (1). All of us who facilitated sessions at schools that signed up for the program contributed collaboratively to the content of the curriculum.

Our primary premise was that the most effective means to counter negative aspects of the hidden curriculum that affected medical students and residents, would be a critical mass of influential humanistic faculty teachers and role models. We completed the 9-to-12-month curriculum at least once and often multiple times at 30 medical schools (2). When we reviewed the results of all programs and their evaluations, Richard Frankel and I formed the hypothesis that an important outcome observed in faculty participants was more fully developed and advanced professional identity formation (2,3).

Our program proved generalizable by its completion with few dropouts at the 30 schools. Qualitative studies and participant testimonials suggested highly beneficial impacts. Participants discovered that they were not alone but had many colleagues who cared deeply about humanistic values and patient care. Participants scored significantly higher on a validated humanistic teaching and practice questionnaire comparing them to controls with similar traditional teaching evaluations, age, specialties, and gender (2).

Five years ago, we shifted focus to interprofessional education (IPE). We believed that the educational principles and longitudinal small group organization used in our physicians’ program would be effective in faculty development for leaders of IPE. We completed a pilot IPE group at Emory University judged to be successful (4). Subsequently, using a revised IPE curriculum, we completed two small groups of 8 to 10 IPE faculty leaders at each of seven selected universities. Yet to be published data suggest that this IPE faculty development was highly successful.

We emphasized an important goal for the IPE groups: building and strengthening authentic relationships across professions. We think such relationships are essential to develop the full potential of IPE. This means not only honest, respectful communication between group members, but also taking the time to learn about each other’s work, goals, aspirations, and professional values. It means understanding the challenges faced by colleagues in other professions and listening empathetically to their stories of past interactions - not always good - with those in your profession. Again, we were more than pleased to find strong elements of these relational attributes when we analyzed the early data.

We now offer our open access IPE faculty development in humanism curriculum for use by The Academy for Professionalism in Health Care members. Our curriculum may be adapted flexibly. It has been designated a fellowship by several schools. One school ran revised nine-month versions of our curriculum for selected multidisciplinary faculty members over many years. Two schools have used portions of our curriculum with guidance for large numbers of faculty members selected to teach in their new curricula. We suggest that anyone using our curriculum contact me (Wbranch@emory.edu) for advice and if desired, for guidance by an experienced facilitator.

William T. Branch, Jr., M.D., M.A.C.P., F.A.C.H. is the Carter Smith, Sr. Professor of Medicine, Department of Medicine, Emory University School of Medicine

References
(1) Branch WT Jr, Teaching professional and humanistic values: Suggestion for a practical and theoretical approach, Patient Educ and Couns. 2015; 98: 162-167.http://dx.doi.org/10.1016/j.pec.2014.10.022.
(2) W.T. Branch, Jr., Richard Frankel, Janet P. Hafler, et al. A multi-institutional longitudinal faculty development program in humanism supports the professional development of faculty teachers. Acad Med (2017), doi: 10. 1097/ACM.0000000000001940 (available Online, open access).
(3) Branch WT Jr, Frankel R. Not all stories of professional identity formation are equal: An analysis of formation narratives of highly humanistic physicians. Patient Educ. Couns. (2016), http://dx.doi.org/10.1016/j.pec.2016.03.018
(4) Manning K, Abraham C, Kim JS, et al. Preparing the ground for interprofessional education: Getting to know each other. J Humanit Rehabil. 2016; June. https.//scholarblogs.emory.edu/journalofhumanitiesinrehabilitation/2016/06/20 preparing-the-ground-for-interprofessional-education-getting-to-know-each-other/. Accessed September 18, 2017.

Canada and the United States are struggling to dig themselves out of this awful pandemic. Neither country’s responses has been perfect. Canada built up its testing capacity more quickly than the U.S., to isolate the sick, implementing contact tracing to limit the spread of the deadly disease. Testing faltered some, but in general, Canada was able to implement uniform and broad lock down measures where needed. Where Canadian officials have tried to set aside partisan grievances, the U.S. effort to implement safety policies has often led to political stances in safety recommendations like mask wearing, safe social gathering guidelines, and quarantine recommendations.

In spite of the horrors of more than two million dead worldwide, the situation has presented us with people who have stood up, gone over and above, to help their fellow man (and woman). Here are some examples.

Organizations like the Leapfrog group have chosen to raise up heroes in our midst. Their awards have been directed at the extraordinary commitment some have made to patient safety in the COVID-19 crisis. People like Sergio Alvarez, RN, of Coral Gables Florida, who won the Leapfrog Pandemic Hero of the Year award in the category of individual hero. Sergio demonstrated a “steadfast willingness” to put the best interests and welfare of others above his own.

In trying to assist the elderly in vaccination, what about the health care worker who rushes out to the car pulling up at the vaccination site? The efforts to assist the caregiver pulling the wheelchair out of the trunk and helping to load the elder into the chair for the ride through the lengthy vaccination line? Thank goodness for hometown health heroes.

Good deeds and leadership abound! We just need to keep our eye out for it. In a pandemic, sometimes it becomes difficult to see the waves of success, the raising of leaders.

What about the heroes who have led efforts to develop educational techniques to raise awareness about vaccination in communities? We have our own heroes in this category right here at Wright State Boonshoft School of Medicine, where it took two residents and a medical student to identify the opportunity to gather faculty and community clinicians together to learn the in’s and out’s of currently available vaccines. These young medical professionals went so far as to offer virtual conference attendees advice about vaccine hesitancy and social justice issues that need to be addressed with the public.

When challenges present themselves, people meet them, and rise up to do good work. Let’s look for those examples and acknowledge them. Thank your colleagues, praising those who are showing creativity and caring.

Glen D. Solomon, MD, MACP, is Chairman and Professor, Department of Internal Medicine and Neurology, Wright State University Boonshoft School of Medicine, in Dayton, Ohio. Cynthia Sheppard Solomon, RPh, FASCP, CTTS, NCTTP, Clinical Assistant Professor, Department of Internal Medicine and Neurology, WSU-BSOM, Dayton, Ohio.

The Medical Professionalism Project (MPP), created by renowned social scientist Dan Ariely in collaboration with Duke Health, is an innovative short film series and CME course that explores the complex expectations, challenges and responsibilities of being a healthcare provider through the lens of behavioral science. In 5- to 10-minute videos, MPP applies research from behavioral economics and other social sciences to reveal how and why we make ethical mistakes, providing strategies for improving behavior at an individual and institutional level.

Module 7 of the Medical Professionalism Project addresses the critical topic of Conflicts of Interest. While most providers try their best to allay conflicts of interest, our health care system in many ways has inherent conflicts built in. Practitioners may bill on a fee-for-service model, have part of their work supported by outside sponsors, or develop close relationships with industry partners. None of these things are wrong on their face, but it is important to be aware of how conflicts arise and impact our decision-making, often without us realizing.

To illustrate this, Module 7 begins with the Dots Game. Adapted from a Dan Ariely lab experiment, this quick game illustrates how quickly and easily we can be swayed by a conflict of interest – even in situations as simple (and inconsequential) as getting a few extra points in a game for electing to click a certain side of a screen. Our Conflicts of Interest film dives deeper into this important issue, revealing the places providers may find conflicts arise. Two doctors share their personal experiences of moments they felt themselves being influenced by a conflict of interest and how they handled it. Finally, we discuss the limits of disclosure in mitigating conflicts.

Our additional resources include studies assessing this issue from various perspectives and a link to database that has been tracking what pharmaceutical and medical device companies have paid doctors and teaching hospitals since 2013.

The Medical Professionalism Project can be completed online for up to six credits of AMA PRA Category 1 Credit(s)™, MOC Part II credits for numerous member boards, Nursing CE, as well as IACET CEU. In addition, we offer the films to be used offline in classrooms and meetings, or incorporated into other online learning platforms. A robust interprofessional educational experience, the Medical Professionalism Project is an engaging and thought-provoking course for students, residents, faculty and practicing physicians, as well as nurses, physician assistants and others on the healthcare team.

All APHC members receive a 20 percent discount on MPP (and 25 percent of the payment returns to APHC!).

If you have any questions, please reach out to Project Director Clare Marash at clare@saltyfeatures.com.

As vaccines are becoming available to prevent COVID-19 infections, two major questions about their efficacy must be considered. First, do the vaccines prevent the vaccine recipient from becoming sick from COVID-19, and second, do the vaccines prevent recipients from spreading the virus. The first question addresses the impact on the individual; the second addresses the impact on community.

In the first wave of the COVID-19 pandemic during the spring of 2020, the public health focus was clearly to suggest ways to prevent community spread. After the initial chaos, public health experts recommended we wear masks and spatially distance in order to protect our neighbors. The focus was on the greater good for the community. Little was said about what masks could do for us.

Now we have vaccines. So far, the vaccines appear to reduce the likelihood of a person becoming symptomatic with COVID-19. We do not yet know if they can prevent the spread of the virus. Without full information available about benefits and risks of the vaccines, the public is now being asked to pivot from focusing on protecting our communities to protecting ourselves, by rolling up our collective sleeves and getting the vaccine. And as health care professionals, we are being asked to recommend the vaccine to our patients. The communal value of the vaccine of “WAVE ONE” is that the front line vaccine recipients will not get sick, enabling them to continue to care for others not yet immunized. Nursing home residents, also in the first wave, will be immunized for the individual benefit of not becoming ill and dying from the virus.

We wonder and share concern about the pivot from working for the good of others to focusing on self, because there will be many people who receive the vaccine who ultimately decide they do not need to continue to use barrier protection with spatial distancing. In the early days of this pandemic, we had few choices: follow public health recommendations or DO NOT follow public health recommendations.

In part, initially we had no treatments to effectively treat individuals with the disease. Even today, the one FDA-approved drug treatment, remdesivir, currently does not have evidence of improved survival, causing the World Health Organization to issue a conditional recommendation against its use in hospitalized patients.

With vaccines, people can better protect themselves. The question remains as to whether those vaccinated WILL also remain motivated to protect their communities through wearing masks, avoiding crowds, hand washing and spatial distancing?

Unless we remain vigilant about continuing the barrier hygiene measures, it will take much longer for the virus to come under control returning us to some pre-COVID-19 normalcy. With 70 percent of the population effectively vaccinated for herd immunity, it will require 200-250 million Americans to receive one of the vaccines (hypothesized to be 50 to 95 percent effective). If we have to rely solely on the vaccine without mask use, hand washing and distancing, it will take us that much longer before post-COVID life becomes a reality. With previous timetables not calculating quality control variables between manufacture and marketing of batches of vaccines, and the lack of federal paperwork strategies for things like seeking patient consent of long-term care residents unable to speak for themselves before receiving an immunization, it could easily take much more than a full year to reach administration levels necessary for us to be safe.

It is critical for the long-term health of our community that we continue to wear masks, spatially distance ourselves, and diligently wash our hands. When quantities of safe, effective vaccines become available for public consumption, we will all need to be immunized for our personal health and for the good of all.

Glen D. Solomon, MD, MACP, is Chairman and Professor, Department of Internal Medicine and Neurology, Wright State University Boonshoft School of Medicine, in Dayton, Ohio. Cynthia Sheppard Solomon, RPh, FASCP, CTTS, NCTTP, Clinical Assistant Professor, Department of Internal Medicine and Neurology, WSU-BSOM, Dayton, Ohio.

On November 18th an expert panel featuring APHC President, Dr. Thomas Harter, gathered to discuss the ethics of resource allocation and COVID-19. This panel, the final episode of the second season of the COVID Ethics Series, asked panelists to reflect on what they had learned so far and what still needs to be learned in anticipation of future case spikes in the pandemic. Harter was joined by Professor Jason Eberl, PhD, Director, Albert Gnaegi Center for Health Care Ethics at Saint Louis University; Dr. Hannah Lipman, MD, MS, Vice President, Bioethics, Hackensack Meridian Health; and Dean Kathleen Boozang, JD, LLM, Seton Hall University School of Law.

Each panelist drew the audience’s attention to important ethical considerations about resource allocation in a pandemic from their own perspective. Eberl discussed a series of studies done about resource allocation policies during COVID. Lipman addressed issues in clinical bioethics. Boozang reflected on the proper role of hospital and health system boards in discussions of and policies about resource allocation. Harter highlighted the particular challenges facing rural areas during the pandemic. He also addressed the importance of professionalism for student members of the audience.

Moderated by APHC member, Professor Bryan Pilkington, the COVID Ethics Series brings together multi-disciplinary panels of experts from nursing, law, politics, medicine, bioethics and philosophy to discuss ethical issues which have been exacerbated by the pandemic. Formed with the belief that we arrive at the best answers to challenging ethical questions by practically reasoning together, the COVID Ethics Series has addressed issues of discrimination, racism, voting and health, ethical physical exercise in a pandemic, the duty to plan, how to balance professional duties and safety, and many more ethical issues associated with COVID-19. Past episodes can be viewed at: https://library.shu.edu/COVIDEthics/ or listened to: https://library.shu.edu/COVIDEthics/podcast.

Bryan Pilkington, PhD, teaches ethics at Seton Hall University and at Hackensack Meridian School of Medicine. For more on this series, contact him (bryan.pilkington@shu.edu) or visit https://library.shu.edu/COVIDEthics/. Twitter: @bcpethics

Pellegrino’s warning about the humanistic strain in medicine being eroded by some of the same forces weakening the ancient edifice of medical ethics proved true. The COVID SARS 2 19 pandemic’s unusual circumstances, publicized information, factual or not, will reveal if ethics, public health and other decision-making tools, choose strategies that promote professionalism – that is good intentions and right acts. Issues as masks wearing and non-FDA approved interventions, are emergent. Elements in the following decision-making tools suggest: the “strain” persists.

Pellegrino in describing the duties of physicians and hospitals as moral agents, emphasizes the role of the physician as “… the final common pathway whose assent is required for whatever is done to the patient” (2). He insists that the covenant of the physician is with the patient not with others, sometimes requiring that physicians refuse to comply with public policy or law. The hospital “...must carry the moral obligations it incurs by virtue of its own declaration as a hospital.” As an environment where medicine is to be practiced safely and competently, the hospital has the moral obligation to inform the public if it lacks facilities, devices or anything essential for its functioning so that all are fully informed and “… able to make free choices well beyond usual informed consent” (3).

Moral system-based codes: “The physician has the right and obligation to reaffirm the authority of his professional judgment … over whomever… adversely affects the health of the patient under his care and the integrity of a medical clinical judgment in any stage of the patient-physician relationship” (4).

The Respect for Person Construct (5) with its attributes provide four types of actions that respect humans: Respect for autonomy (vaccine, masks), Veracity - provide precise factual information, Fidelity - duty of the physician to his patient, and Protection of the most vulnerable - avoid killing innocent humans.

The Belmont Report: (6) respect for person, beneficence (non-maleficence) and justice is useful for assessing the porous relationship between clinical practice and research, now blurred by widespread use of non-FDA approved diagnostic tests, medications and/or vaccines; how to guarantee just (7) distribution of goods between populations, burdened by research, that are the most vulnerable; strive for truthful consent well understood by the subject/patient; comprehension of all data needed for a choice; and voluntary consent (8) free from coercion of disease or undue influence of a promised cure.

The human rights approach: Protection of the child (9) before and after birth, and safeguarding maternity and childcare. “State parties shall accord women rights and fundamental freedoms on a basis of equality with men … before the law…” (10). Humans with disabilities, (11) when rendered disabled by an infectious agent, must have “equal recognition before the law.”

Public health consequentialism is humanized by public health ethics. While the first is “… guided by the scientific method, its policies shaped also by ethical values, legal norms and political oversight,” (12) the last offers normative criteria for ethical analysis that is for decision making, striving always for the “least restrictive means” (13).

Critical reflection (14) to prevent exploitation of the weak in settings such as a pandemic when vulnerable populations are exposed to the police power of the state (public health policies). “It is politically skeptical… it looks to see who benefits from the moral order, who has to be pressed into serving others’ interests, who has to be marginalized or excluded if the order is to sustain itself. Where power masquerades as morality and what source of unsavory practices need to be concealed to maintain the fiction.” Elements well within the humanistic tradition are embedded in the above tools.

Raul Perez, MD, is Professor of Ophthalmology and Medical Ethics at the University of Puerto Rico School of Medicine.

References
1. “… compassion, human kindness… thought it wrong to destroy even the tenuous possibility of a man.” Pellegrino E., & Pellegrino A. (1988) Humanism and Ethics in Roman Medicine… Scribonius Literature and Medicine Vol 7, pp. 22-38
2. Pellegrino E. (1989) an approach to bedside ethics The Mayo Alumnus pp. 15 -18, https//mayoalumni.in/publications
3. Bulger, R.J. & McGovern, J.P., (eds) (2001) Physician & Philosopher. Charlottesville VA Carden Jennings Publishing Co. Ltd
4. JLDM https://orcps.salud.go
5. Veatch, R. (2003) The Basics of Bioethics, 2nd Ed New Jersey, NY Prentice Hall
6. The Belmont Report (1979) DHEW Publications Washington DC, w.hhs.gov/chrp/regulation-and-policy/belmont-report
7. “Justice as… essential areas of wellbeing that is the states’ job to provide: health, personal security, reasoning, respect, attachment, and self-determination.” Powers, M. & Faden, R., (2006) New York, NY, Oxford University Press
8. Nuremberg Code 1947, (1960) British Medical Journal Volume 313 NO 7070: page 1448 United Kingdom,
British Medical Association
9. United Nations Office of the High Commissioner of Human Rights. (2014) The Core International Human Rights Treaties, pp. 119-146, New York, NY & Geneva, Switzerland United Nations Publication
10. Ibid 9 pp.93-110
11. Ibid 9 pp. 303-308
12. Gostin, L. & Wiley, L. (eds) (2018) Public Health Law and Ethics, 3rd Ed, Oakland CA University of California Press pp. 3-48
13. [Normative Criteria: Health Benefit, Harms and Burdens, Impact on Autonomy and Equity, and Cost Effectiveness Ratio.] Markmann, G. et al. (2018) Putting Public Health into Practice: A Systematic Framework, In L. Gostin, & L. Wiley, Oakland, CA, Public Health Law & Ethics, 3rd Ed pp. 59-62, Oakland, CA University of California Press
14. Verkerk, M., & Lindemann, H. (2012) Towards a Naturalized Clinical Ethics. Kennedy Institute of Ethics Journal, 22 (4), 289-306. https://www.muse.jhu.edu/article/495156.

Due to its breadth and scope, COVID-19 and the challenges it poses have received a great deal of attention from bioethicists. COVID has killed many, sickened many more and impacted how just about all of us move about our worlds. The need for clear thinking on a wide range of COVID-related topics, which fall under the disciplinary umbrella of bioethics, has become increasingly obvious. From acute issues of resource allocation and prioritization to more general issues of societal planning for subsequent waves and future pandemics, bioethicists have weighed in.
From specific issues associated with restarting schools to broader issues of combatting racism exacerbated by the existence of a pandemic, bioethicists have weighed in.
From engaging ethical issues associated with stopping the virus – challenge trials, privacy, contact tracing or the role of health professions students in treating patients – to how to return to other facets of life – reopening restaurants and stores, returning to public transportation or allowing significant travel – bioethicists have weighed in.

One approach to addressing ethical concerns, which can guide how bioethicists weigh in, is the multidisciplinary approach. In the remainder of this short paper, I discuss an ongoing series of pluralistic ethics conversations that effectively embraces this approach. The multidisciplinary approach (1) is especially fitting given COVID’s scope and breadth, as it increases our ability to address the disparate ethical issues. Additionally, the series had the unintended consequences of strengthening, in some places, and building, in others, an ethics community.

Pluralistic ethics conversations aim to bring together folks from divergent backgrounds, expertise and task spaces to address practical ethical challenges. Such conversations embrace a multidisciplinary approach when they require representation from different disciplines and from perspectives rooted in varying expertise. This model relies on the guiding principle that challenging, large-scale ethics problems are best addressed by a group of folks, from diverse backgrounds, practically reasoning together.

A recent example of pluralistic ethics conversations focuses on issues that have arisen or been exacerbated due to COVID-19. The creatively named COVID Ethics Series began in March 2020 and continues through the time of this writing. In this series, I hold discussions with groups of experts from different disciplines on topics, such as balancing personal risk and duties to care for practitioners and for students, prioritizing present needs and future concerns in a pandemic, addressing vulnerability and dependence in light of contagion, discrimination, exercise and athletics in a pandemic, and protest (2).

For each session, pluralistic ethics conversation partners are sought from different walks of life and with different expertise. For example, given the way that COVID affects our moving about our worlds, one conversation focused on how to exercise and engage in athletic competition in a way that is safe for athletes and others alike. This conversation included a philosopher, an athletic trainer and a psychiatrist, but also a varsity student athlete, a university athletic director, and a local elite athlete. Listening to these partners not merely share their perspectives but practically reason through challenges facing those seeking to exercise in a pandemic allowed for fruitful models of respecting ethical norms, such as social distancing, as well as creative solutions like modulating intensity and timing of exercise (3).

Another pluralistic ethics conversation engaged how to prioritize the needs of the present with forward-looking considerations. Conversational partners with backgrounds in hospital administration, bioethics, medical education, pediatrics, as well as philosophy, economics and political theory were engaged. Other conversations took up themes of discrimination during COVID, drawing on the expertise of practicing physicians and medical educators of color, as well as folks with expertise in the law, bioethics and religion.

Yet another session took up questions of vulnerability and dependence during COVID (4). Conversational partners included folks with expertise in behavioral health, unsheltered living, medical education, diversity and equity, language barriers in the U.S. and bioethics. By listening to conversation partners practically reason through a series of practical ethical issues, participants were not only hearing “another side” to the story but opening up a possible shift in focus.

For example, in this session, Hastings Center’s Senior Research Scholar, Nancy Berlinger, talked through how persons are made vulnerable due to societal structures that are placed in their path. Dr. Berlinger’s framing was followed by a discussion of, among other topics, the dearth of translation resources for folks whose first language is not English, how COVID has affected those without shelter in many areas, and how COVID exacerbates racial inequity and the deep roots of racial inequality in medicine.

Though the existence of and theorizing about societal structures that create vulnerabilities is familiar to many, most obviously those with experiences of such vulnerability-creating structures but also those familiar with work on the concept of justice and autonomy in bioethics or the disabilities studies literature. However, the primary benefit of pluralistic ethics conversations, especially in the time of COVID, is not awareness – though awareness for some is surely a beneficial byproduct. Dr. Berlinger could have easily given a thought-provoking lecture on the subject of vulnerability. Rather the benefit is the opportunity for those listening to how she and others practically reasoned through such issues in conversation with each other (5). Add to this framing the reflection of Ana Campoverde on the need for greater translation resources for those in the U.S. who are not English language proficient (6).

This thread in the conversation allowed for self-critical reflections by those of us who work in bioethics and have spent a good deal of time thinking about and creating policies regarding how to allocate ventilators if crisis standards of care on invoked. Though this is needed and important work, why let this allocation question dominate our work but not give similar attention to a resource allocation issues that currently affects so many? (7) Pluralistic ethics conversations support critique and self-critique through the engagement with different disciplines and focuses. Such critique is a benefit not only provided by but provided to bioethicists.

Though opportunities for critique and self-critique may be the greatest benefits of pluralistic ethics conversations, two other benefits are worth highlighting. First, pluralistic ethics conversations are especially fitting when the ethical issues at stake are multi-faceted, such as many of the issues that COVID brought or exacerbated. To ask whether medical students, nursing students or students training in any health profession are permitted or required to aid in efforts to combat COVID prior to their graduation is a conversation which should engage those learners, as well teachers, scholars of practice and bioethicists. Whether to relax restrictions rooted in physical distancing to allow for greater economic activity or not is a topic about which our own reasoning is benefited by hearing not just from bioethicists but from economists and philosophers, political theorists, business leaders, scholars of healthcare administration and practicing physicians.

Second, the physical distance caused by COVID has led to an upheaval for communities of learning. Pluralistic ethics conversations offer a place where folks from all sorts of backgrounds can engage and learn from and with others. Whether this is unique to pluralistic ethics conversations because so many folks can identify with one or another conversational partner or that COVID was merely present on their minds, the response to this series was quite strong. The most unanticipated aspect of the response was not that folks from across the nation and internationally tuned in to engage with Nancy Berlinger, Sampson Davis (8), Ana Iltis (9) or any number of excellent partners, but that folks from our local community kept calling in. These pluralistic conversations were described as a “habit” and as something “for us all to tune into every week.”

This is not to say that pluralistic ethics conversations lack limitations or their own internal problems. There are risks of superficiality, of conversational partners talking passed each other and of those members of the broader ethics community tuning out because of the potential for disjointed conversations. But for those who tune in regularly, the conversation gains depth and the joints can be put back together.

Bryan Pilkington, PhD, teaches ethics at Seton Hall University and at Hackensack Meridian School of Medicine. For more on this series, contact him (bryan.pilkington@shu.edu) or visit https://library.shu.edu/COVIDEthics/. Twitter: @bcpethics

References
1. For further discussion of the usage of this term, see Pilkington, B. 2018. “The Fiftieth Anniversary of Patient as Person: Paul Ramsey’s Groundbreaking Approach to Christian Bioethics” Christian bioethics: Non-Ecumenical Studies in Medical Morality, 24:2, 111–125.
2. Rivera, M. (2020) “IHS Comes Together for the COVID-19 Ethics Series,” School of Health and Medical Sciences News, https://www.shu.edu/health/news/ihs-comes-together-for-the-covid-19-ethics-series.cfm.
3. Pilkington, B. and R.J. Boergers (2020) “Five Paths to Ethical Outdoor Physical Exercise,” Inside the Hall.
4. Ricciardelli, M. (2020), “Expert Panel with Hastings Center's Nancy Berlinger on How to Protect the Vulnerable in the Time of COVID,” Inside the Hall, https://www.shu.edu/health/news/expert-panel-on-covid-19-and-the-vulnerable.cfm.
5. By listening to experts practically reason through challenging ethical issues, listeners not only hear a potential answer, or an answer with an argument in support, to that issue; they are also exposed to the expert’s process of reasoning about the issue. What other factors come into play? What language is used and avoid? What are seen as grater and less obstacles? With a panel of experts, the benefit is multiplied, as listeners not only hear different answers, but they are exposed to different processes of reasoning. For example, the creativity involved in organizing and assisting unsheltered folks in a move to a hotel for social distancing reasons is different from the creativity involved in guiding underrepresented groups through the often unjust structures of medical education or navigating the communication obstacles to those seeking care from practitioners who cannot speak their language. Yet, engaging these different focuses and different thought processes offers listeners both models for approaching these and other challenges, as well as the opportunity to compare and contrast thought processes. It might even, aid listeners in reassessing and reunderstanding how to apply a broad principle, e.g., justice in resource allocation.
6. Pilkington, B. and A. Campoverde, “The Bioethics of Translation: Latinos and the Healthcare Challenges of COVID-19,” American Catholic Studies, 131:3, Fall 2020 pp. 11-17. 10.1353/acs.2020.0041
7. Pilkington, B. and A. Campoverde, “The Bioethics of Translation: Latinos and the Healthcare Challenges of COVID-19,” American Catholic Studies, 131:3, Fall 2020 pp. 11-17. 10.1353/acs.2020.0041
8. Ricciardelli, M. (2020), “Panel on Discrimination in Time of COVID Features Dr., Alum, Oprah’s ‘Premier Role Model’” (2020), Inside the Hall, https://www.shu.edu/news/panel-on-discrimination-features-dr-sampson-davis.cfm.
9. Ricciardelli, M. (2020), “Panel on Research, Ethics and Expertise in a Pandemic Features President of the American Society for Bioethics and Humanities,” Inside the Hall, https://www.shu.edu/health/news/panel-on-research-ethics-and-expertise-in-a-pandemic.cfm.

The Medical Professionalism Project (MPP), created by renowned social scientist Dan Ariely in collaboration with Duke Health, is an innovative short film series and CME course that explores the complex expectations, challenges and responsibilities of being a healthcare provider through the lens of behavioral science. In 5- to 10-minute videos, MPP applies research from behavioral economics and other social sciences to reveal how and why we make ethical mistakes, providing strategies for improving behavior at an individual and institutional level.

Module 5 of the Medical Professionalism Project delves into the incredibly important topic of burnout in medicine. Burnout is one of the most pervasive and consequential issues confronting the health care fields today, a crisis that not only impacts providers across the system, but can lead to poorer patient outcomes. With over 50 percent of physicians reporting at least one symptom of burnout, it is clear this issue is large and in critical need of attention.

In our Burnout film we explore the enduring impact of the burnout crisis, including compounding factors such as high rates of depression, anxiety, and substance abuse in the provider and trainee communities, as well as the negative impacts on patient care. As providers across the fields of medicine discuss the pervasiveness of burnout, we offer tools and strategies for addressing this important issue.

Following this frank and reflective film, we share scholarly articles that reinforce some of the statistics cited, as well as AMA and AAMC resources for addressing burnout. MPP has also hosted twitter discussions on this topic under the hashtag #MedBurnout. To see what our community has shared online please click this link.

The Medical Professionalism Project can be completed online for up to six credits of AMA PRA Category 1 Credit(s)™, MOC Part II credits for numerous member boards, Nursing CE, as well as IACET CEU. In addition, we offer the films to be used offline in classrooms and meetings, or incorporated into other online learning platforms. A robust interprofessional educational experience, the Medical Professionalism Project is an engaging and thought-provoking course for students, residents, faculty and practicing physicians as well as nurses, physician assistants and others on the healthcare team.

All APHC members receive a 20 percent discount on MPP (and 25 percent of the payment returns to APHC!).

If you have any questions, please reach out to Project Director Clare Marash at clare@saltyfeatures.com.

It is holiday time, with more than 265,000 American lives lost during this pandemic. Things could have been so much different.

As the Thanksgiving weekend provided high numbers on America’s freeways and at major airports, we feel obligated to bring up the impact of college athletics, specifically, football, into the total health care catastrophic landscape. College conferences had choices. Initially, the Big Ten, for example, decided to sit the season out. Wow! We were impressed! Safety and protection of life and body was the early theme of those big choices.

But, reasonably following public health recommendations wouldn’t last. A number of studies in athletes suggest cardiac risks might be high, with myocarditis being reported in at least 15 percent of college athletes in one study. A Penn State medical official has suggested 30-35 percent. Repercussions such as cardiac abnormalities, myocarditis, cardiac arrhythmias and sudden death were seen in the majority of non-athletes in another study. With this data showcasing risks applicable to athletes, coaches and other team employees such as launderers, sports trainers, and sports medicine staff as well, ask why would the conferences that initially opted out decide to opt back in?

When university campuses and stadium stands are without students, how do we justify allowing student athletes to play football? We get it that student athletes want to play, aren’t so concerned about getting sick, and see playing as important for their futures. But what would motivate, for example, the Big Ten conference to unanimously choose to opt back in? A medical official from one of the teams is quoted in TIME magazine (October 22, 2020) saying, “Everyone associated with the Big Ten should be very proud of the groundbreaking steps ….to better protect the health and safety of the student-athletes and surrounding communities.” And, who pays the salaries for the medical staffs helping to make these important decisions? This Thanksgiving weekend, at least 19 college football games were canceled with coaches, players and other staff testing positive on many teams.

How does society value sports? Why can athletic team personnel receive COVID-19 testing daily when even medical personnel on the front lines still have trouble receiving COVID-19 tests when needed?
What concerns us specifically is in an amazingly complicated sports medicine environment with sports medicine gurus galore on college medical staffs, how one priority seems to override public health expertise, sports medicine expertise, morality and ethics, MONEY. It is difficult not to pin some of the university choices on MONEY. Revenue from college football adds hundreds of millions of dollars to university coffers and the surrounding communities, and to numerous industries advertising, running radio and TV, and all that encompasses it. Hotels, restaurants, and bars benefit from football. For college athletes, becoming a high draft choice is worth millions of dollars. The idea that these young athletes are not hearing or recognizing the medical messages directed at their morbidity suggests a wagering of college and pro athlete careers in light of long term cardiac myopathy, myocarditis, or other cardiac sequelae, all for the sake of playing this season.

We have a young friend who is a “walk on” at a very fine football program, and we worry about him and his colleagues. We have other friends with student athlete children who have been impacted. Who will die? Whose coach, or department housekeeper, or launderer will become severely compromised medically? Was it that important for the teams to attempt to fulfill this season? Was it about our economy? Has it contributed to the growing surge that will push us into a nightmare of a holiday pandemic season this year? We respectfully pray for all involved, and for those unknowingly impacted by the decisions that were made in the name of the groundbreaking steps taken to have college football this year.

Cynthia Sheppard Solomon, RPh, FASCP, CTTS, NCTTP, is a Clinical Assistant Professor in the Department of IM and Neurology at Wright State University-Boonshoft School of Medicine and Glen D. Solomon, MD, MACP, is a Professor and Chairman of Internal Medicine and Neurology at Wright State University-Boonshoft School of Medicine in Dayton, Ohio.

Medical Professionalism Project - Module 4
by Clare Marash

We’re here to share another module of the Medical Professionalism Project with you!

The Medical Professionalism Project (MPP), created by renowned social scientist Dan Ariely in collaboration with Duke Health, is an innovative short film series and CME course that explores the complex expectations, challenges and responsibilities of being a healthcare provider through the lens of behavioral science. In 5- to 10-minute videos, MPP applies research from behavioral economics and other social sciences to reveal how and why we make ethical mistakes, providing strategies for improving behavior at an individual and institutional level.

Module 4 of the Medical Professionalism Project discusses the ever-evolving worlds of testing and treatment. While at first glance the central tenet of medicine may seem straightforward – treat patients to improve their health – it is far from simple. Balancing patients’ treatment options, expectations, budgets and ultimately quality life is a nebulous objective. Sometimes it requires going against instinct, changing the question of ‘Can I do this for a patient?’ to ‘Should I?’

In our Testing And Treatment film we explore the competing priorities healthcare providers must juggle in providing excellent care to their patients and highlight a nationwide program that tries to reduce unnecessary medical tests, treatments and procedures. Most critically, we acknowledge that even the most straightforward patient interactions require a reflective and personalized approach, one that factors in the risks and rewards to the individual patient as well as the healthcare system.

Following this thoughtful film, we share scholarly articles that examine the implementation of unnecessary diagnostics and “low-value care,” as well as the impact of providers’ malpractice concerns on patient care.

The Medical Professionalism Project can be completed online for up to six credits of AMA PRA Category 1 Credit(s)™, MOC Part II credits for numerous member boards, Nursing CE, as well as IACET CEU. In addition, we offer the films to be used offline in classrooms and meetings or incorporated into other online learning platforms. A robust interprofessional educational experience, the Medical Professionalism Project is an engaging and thought-provoking course for students, residents, faculty and practicing physicians as well as nurses, physician assistants and others on the healthcare team.

All APHC members receive a 20 percent discount on MPP (and 25 percent of the payment returns to APHC!).

If you have any questions, please reach out to Project Director Clare Marash at clare@saltyfeatures.com.

Pandemics past and present, have raised professionalism issues of justice, veracity, end-of-life shortening protocols and human rights infringements, both for health care providers and institutions as moral agents (1). Differences in susceptibility to infection result from environmental, hereditary and behavioral factors, among others. Some aspects, particularly those that strain the individual rights/common good construct and central versus local controls, merit scrutiny.

“As families and communities begin to see AIDS in their own members, they will perceive it less as being a plague of the ‘other’ and more as part of the human condition (2).

“Those who complain about AIDS exceptionalism (3) sometimes fail to appreciate the significant differences between AIDS and other infectious diseases. HIV infection is not contagious through the air but usually requires conscious behavior (4) for transmission (5).”

“In 2002 the FDA approved a rapid HIV diagnostic test that returns results in less than 20 minutes and is 99.6 percent accurate (6).”

Meanwhile, COVID-19 continues to challenge humanity: no vaccine, no definite cure, unreliable testing and protocols marginally protective of human rights (7). When will the stigma end? After weekly testing? For how long? “Which is the least restrictive alternative for serving the state’s compelling interest in controlling the spread of disease?" (8)

We must not forget the biology. Considering limited knowledge about the virus and its biology, physical distancing and use of personal protection equipment seems the best option (9).

Case study: non-incorporated U.S. territory. An island with about three million inhabitants. A published report in a newspaper (10) identifies outbreak epicenters: airport (travelers) - three percent; community (work place, retirement homes, places of worship) - five percent; mixed workplace/home crossed transmission – five percent; work place (police stations, distribution centers, offices, factories) – 30 percent; family activities (parties, birthdays and wakes) – 57 percent.

Fabiola Cruz, an epidemiologist, argues that early testing strategies are no longer tenable since at this stage of community (11) contagion, testing only the symptomatic when clinical diagnostic certainty is not possible, seems reasonable. She also favors individualized community-based strategies (12), rather than national ones, especially to mitigate COVID-19 stigma (13).

Raul Perez, MD, is Professor of Ophthalmology and Medical Ethics at the University of Puerto Rico School of Medicine.

References:
1. Pellegrino E. Physician & Philosopher
2. The Aids Pandemic, Lawrence O. Gostin 2004 The University of North Carolina Press pp. 7
3. Ibid ii pp. 11
4. Conscious behavior such as keeping physical distancing and wearing a face mask.
5. Ibid ii pp. 7
6. Ibid ii pp. 13
7. International Covenant on Civil and Political Rights Art. 12 & 13. (right to freedom of movement) “no one should be arbitrarily deprived of the right to enter his own country. Everyone shall be free to leave any country… including his own…except… national security… public order… public health or morals…. Covenant.
8. Public Health Law and Ethics, Gostin & Wiley 3rd Ed. University of California Press 2018, pp. 162
9. Pandemic Means the Whole World: COVID 19 and Global Bioethics Webinar May 15, 2020 Pellegrino Center for Clinical Bioethics
10. Municipal Case and Contact Detection System, Fabiola Cruz Epidemiologist, reported 09/08/2020 barbara.figueroa@gfrmedia.com facebook.com@primerahora
11. Stage3: Community transmission, when infections happen in public and a source for the virus cannot be traced. The Print.in/health/the-four-stages-of-covid-19-transmission-…
12. Ibid viii “This determination requires an individualized assessment of the patient and his or her circumstances, including past or present adherence to treatment and degree of infectiousness.”
13. COVID stigma haunts me. primerahora.com 09/14/2020 pp. 14

Fall greetings! We’re here to share another module of the Medical Professionalism Project with you! The Medical Professionalism Project (MPP), created by renowned social scientist Dan Ariely in collaboration with Duke Health, is an innovative short film series and CME course that explores the complex expectations, challenges and responsibilities of being a healthcare provider through the lens of behavioral science. In 5- to 10-minute videos, MPP applies research from behavioral economics and other social sciences to reveal how and why we make ethical mistakes, providing strategies for improving behavior at an individual and institutional level.

Module 3 covers an ever-present issue in our society: money. Broadly speaking, how we engage with money has changed dramatically in the last century. These days, credit cards, stocks and loans are commonplace for many, and most people will utilize one if not all of these financial tools in their lifetime. But these instruments also create a layer of remove. Instead of watching the cash disappear from your wallet as you buy goods, you swipe a card or tap your phone and then later in the month, there is a bill to be paid. Research shows that this remove makes it easier to make poor financial and sometimes unethical decisions.

In the Distance From Money film, we reveal how the systems we’ve built to handle the financial elements of life impact our decision-making and the repercussions of this in the medical fields. These days, electronic health records have altered and intertwined the patient visit and subsequent billing, not always to good results. By instituting an electronic system that creates another layer of remove between the patient and the provider, have we encouraged poor decision-making in how we chart and bill our patients? Social science research in financial decision-making indicates it’s possible. Using a computerized, exhaustive charting system has led to instances of ‘cloned’ notes, which might mischaracterize the patient’s status, and frequent ‘upcoding’ has allowed for billing to increase, contributing to swelling healthcare costs for patients. The subjectivity of the bill coding system, the lack of time to train on these tools and the administrative separation between charting and billing, have contributed to a situation where the sense of responsibility is mitigated, and the impact – the financial strain on patients – is at a distance.

Following this thoughtful film, we share numerous papers on the impact of electronic health records and coding systems in medicine for further study.

The Medical Professionalism Project can be completed online for up to six credits of AMA PRA Category 1 Credit(s)™, MOC Part II credits for numerous member boards, Nursing CE, as well as IACET CEU. In addition, we offer the films to be used offline in classrooms and meetings, or incorporated into other online learning platforms. A robust interprofessional educational experience, the Medical Professionalism Project is an engaging and thought-provoking course for students, residents, faculty and practicing physicians as well as nurses, physician assistants and others on the healthcare team.

All APHC members receive a 20 percent discount on MPP (and 25 percent of the payment returns to APHC!).

If you have any questions, please reach out to Project Director Clare Marash at clare@saltyfeatures.com.

Teaching the Concept of Professionalism
Teaching professionalism in a classroom has been perceived as an unattainable feat for any health professions program. Over the decades, we have witnessed how the didactic nature of instruction has given way to immersion in experiential learning. Professionalism courses target internalization of values and belief systems through active engagement. At Dubai Medical College, we have initiated an activity which stimulates the right attitudes while building on skillsets to enable professional formation. This activity is intended to lift the bar of professional values so as to offset the unintentional negative forces of the hidden curriculum that may nudge the students to undermine the impact of unprofessional behavior.

Many questions were to be answered. Can student’s perspectives change when exposed to their peers in a professionalism setting? Can engaging in collaborative projects enhance inadvertent learning and skill development?

It is important to inculcate professional habits in student life in order to retain the idealistic goals articulated at the beginning of their life as medical students. The overall aim was to introduce students to an experience which would enhance their project management and team building skills in addition to tapping into their underlying vulnerability for peer learning and inclination to collaborate.

The iPASS Project
The project was part of a first year medical professionalism course, which has been known as PASS – Professional Attitudes and Social Skills - since 2009. The PASS course became iPASS when the project transitioned to producing an e-magazine. In the initial phase of the 15-hour course, resources required for the e-magazine were collected through student essays, during which written consent for publication was also sought. Through essays/reflections on professionalism and social accountability, the students were motivated to think about how they would want to support the community.

The students’ essays with written consent for publication were then categorized and provided to each team of six members with specific jobs. They were required to display the author’s names clearly and to proof-read each essay. Instruments for efficient project teams and collaborative work such as job distribution tables and Gantt charts were incorporated in the preparatory phase. These instruments were separately evaluated as managerial inter-professional teamwork reflecting 21st century skills. Creativity was nurtured by permitting flexibility to use interviews or write-ups of their choice. The only condition was that they either use original materials or get written consent for any graphic or textual content they used in the magazine.

Weekly reports from team leaders were sought. The insights of team leaders show that team dynamics among content developers, communication champions, designers and word processors all come into play. Many teams reported learning from their mistakes. The focus on academic honesty was explicitly expressed. A huge number of queries were related to permissions of reproducing material obtained from the internet. Skills required for taking informed consent and citation were shown to be lacking and these findings have paved the way for introduction of a course on information literacy for medical students. At the end of the project, teams were proud to share their e-magazines with the class. This opportunity has been used to coach them on how to provide an appreciative and critical review and how to accept feedback gracefully. The wrap up sessions included leadership and communication styles and peer evaluation.

Student Response
The response of the students who participated in the iPASS project has been very encouraging as they appreciated the learning experience as editors in student life. The covert learning that happens helped them identify how to negotiate team issues and personal traits. Inadvertently, they read what their friends had written. They learned to give credit to other participants and understand how different members of different roles and strengths are able to collaborate to create one final output which looks beautiful and informative. They were proud to be called editors and authors. They expected this project to add to their portfolio as editors and authors.

Lessons Learnt
The project created situations mimicking Interprofessional Education teams in healthcare by demonstrating different roles in an editorial setting such as authors, content developers, designers, plagiarism-police, word-processors, communication managers and project leaders. Each member was important in the creation of a project, which fulfilled the rubrics of evaluating the project. The intrinsic aim to spread awareness was instilled by the possibility of the e-magazine making it to the institutional website and social media.

Their perception of the benefits of this project has shown beyond a doubt that they learned several tenets of professionalism while engaging with peers in developing creative ideas. It was assumed that sharing their beliefs and ideas among peers enhanced the learning manifold. This project elicited a type of intuitive learning as reading is not made explicitly mandatory but was a necessary step for completing the project.

Fouzia Shersad, FRCP(Glasg), FAIMER Fellow, PhD Medical Education, is Associate Professor and Director of the Institutional Effectiveness at Dubai Medical College. She can be reached at fouzia@dmcg.edu.

Investigations into healthcare malpractice and neglect at a U.S. Immigration and Customs Enforcement (ICE) facility, the Irwin County Detention Center in Georgia, are to take place due to a whistleblower speaking out. According to recent news stories, a nurse at this facility was demoted after reporting horrid conditions and mistreatment, which included medical neglect, unnecessary hysterectomies and solitary confinement for detainees who spoke out (1). Situations of unprofessional behavior like these, can be added to the ever-increasing list of failures to recognize the dignity (2) of persons who have been placed under the power of institutions.

These situations call out for two kinds of advocacy from healthcare professionals - advocacy internal to their profession and advocacy external to it. By external professional advocacy, I have in mind advocacy rooted in a professional’s membership in a broader community, e.g., as a citizen or human being. In response to the reported violations of human dignity in Georgia, healthcare practitioners, as persons, might contact local and national politicians to express concern and call for action; they might join organizations working to safeguard the dignity of detained persons; they might volunteer their time to assist or gather protest unjust institutions.

By internal professional advocacy, I have in mind advocacy rooted in a professional’s practice or her identity as a member of a particular profession. The situation in Georgia raises particular advocacy opportunities for members of healthcare professions because many of the alleged violations are specific to healthcare practice. Any person, regardless of professional affiliation, can engage in advocacy about healthcare-specific issues, but healthcare practitioners are especially well placed to do so, in light of their expertise, and have a particular duty to regulate the practices of their profession (3).

The whistleblower, nurse Dawn Wooten, describes unnecessary hysterectomies being performed by an offsite physician: “Everybody he sees has a hysterectomy – just about everybody…That’s his specialty, he’s the uterus collector. Everybody’s uterus cannot be that bad (4).” The gynecological malpractice alleged also includes the removal of the wrong ovary and the performance of a hysterectomy in response to the need to have a cyst drained (5). This situation calls out for internal professional advocacy and healthcare ethics resources exist to guide responses. These cases highlight not only a failure of shared decision-making about patients’ health goals, but a violation of the basic principles of informed consent. One patient, “Ms. Binam, who was 29 at the time of the procedure, told Ms. Huynh that she would never have consented had she known there was a risk of infertility (6).” Fully informing patients of relevant risks and benefits is a standard and required feature of consent. Nurses at this facility obtained consent by “simply googling Spanish,” a federal complaint alleges (7). This practice illustrates a further culpable omission: the failure to adequately plan for the needed translation resources (8).

A final ethical shortcoming is the alleged failure of the ICE facility in Georgia to recognize the professional dignity of Wooten. Whistleblowing is an example of a practice that arises when institutions fail to self-regulate. This kind of critique ought to be welcomed and not penalized. However, Wooten was treated differently. She shared, “I was called in one day. And I was demoted. And I know I was demoted because I raised questions about why. Inside of a silent pandemic, I was told not to tell officers that there were detainees that they dealt with day in and day out that were positive. We have families (9).” In a pandemic context, where contract tracing, sharing of information, and inter- and intra- state collaborating are being called for, this treatment of Wooten is an especially stark mistake.

Situations, like what has allegedly transpired in Georgia, call out for internal and external professional advocacy. Members of healthcare professions should consider both kinds and, in doing so, reflect on the particular opportunities they have for internal advocacy. Focusing on internal professional advocacy in no way discounts the need for external professional advocacy nor deflates the alleged grave violations of dignity to mere instances of professional misconduct. Rather, I have sought to emphasize a kind of advocacy which is necessary to combat the dehumanization of members of our communities by institutions with which we are affiliated.

Bryan Pilkington, PhD, is Associate Professor at the Hackensack Meridian School of Medicine and at Seton Hall University.

References
1. “ICE whistleblower: Nurse alleges ‘hysterectomies on immigrant women in US,’” BBC News, September 15, 2020, https://www.bbc.com/news/world-us-canada-54160638.
2. Documents like the Universal Declaration of Human Rights and the Fundamental Charter of the European Union highlight the dignity of persons: “All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood,” Article I of the Universal Declaration of Human Rights, https://www.un.org/en/universal-declaration-human-rights/ “Human dignity is inviolable. It must be respected and protected.” – Article I of the Charter of Fundamental Rights of the EU European Parliament Committee on Civil Liberties, Justice and Home Affairs, Charter of Fundamental Rights of the European Union, http://www.europarl.europa.eu/ comparl/libe/elsj/charter/art01/default_en.htm
3. Buchanan, A. “Is there a medical profession in the house?” In Justice and Healthcare: Selected Essays , 175-202. Oxford University Press: 2009.
4. Paul, Kari, “Ice detainees faced medical neglect and hysterectomies, whistleblower alleges,” The Guardian, September 15, 2020, https://www.theguardian.com/us-news/2020/sep/14/ice-detainees-hysterectomies-medical-neglect-irwin-georgia.
5. Paul, Kari, “Ice detainees faced medical neglect and hysterectomies, whistleblower alleges,” The Guardian, September 15, 2020, https://www.theguardian.com/us-news/2020/sep/14/ice-detainees-hysterectomies-medical-neglect-irwin-georgia.
6. Dickerson, Caitlin, “Inquiry Ordered Into Claims Immigrants Had Unwanted Gynecology Procedures,” New York Times, September 16, 2020, https://www.nytimes.com/2020/09/16/us/ICE-hysterectomies-whistleblower-georgia.html.
7. Paul, Kari, “Ice detainees faced medical neglect and hysterectomies, whistleblower alleges,” The Guardian, September 15, 2020, https://www.theguardian.com/us-news/2020/sep/14/ice-detainees-hysterectomies-medical-neglect-irwin-georgia.
8. Pilkington, B. and Campoverde, A. “The Bioethics of Translation: Latinos and the Healthcare Challenges of COVID-19,” American Catholic Studies, 131, 3: 11-17.
9. Capelouto, Susanna, “Whistleblower In Georgia Claims High Number Of Hysterectomies At ICE Facility,” NPR, September 16, 2020, https://www.npr.org/2020/09/16/913448209/whistleblower-in-georgia-claims-high-number-of-hysterectomies-at-ice-facility.

“Humanism is a way of being and professionalism is a way of acting. Humanism provides the passion that animates authentic professionalism.” Jordan Cohen 2007

Dr. Cohen provided these words of wisdom in September 2007. The millennium has brought new challenges of clinical teaching with humanism and professional values with more time pressure, an increasing number of students and shorter exposure to patients in competing demands of regulatory measures in the clinical environment. The new generation of physicians, who focus on personal lifestyles and balance with a lack of inner virtues, has created a “crisis of professionalism,” dubbed by Dr. Lawrence Smith, Dean of Hofstra Medical School.

In addition, Dr. David Leach, past president of ACGME, sees humanism and professionalism as moral reflexes in moral agents. He argues that the biggest challenge is the preservation and nurturing of authentic, human and moral reflexes in young physicians. Moral reflex is not just an old concept from psychology but has close meaning to life today. Steve Pinker, cognitive psychologist from Harvard, argues that there is a moralization switch where we are constantly moralizing or amoralizing particular behavior in our society. Many behaviors are accepted morally, a switch from moral failing to lifestyles choices like divorces, working moms. There is a Law of Conservation in moralization, where we remove old behaviors out of the moralized column and add new behaviors that are accepted by society. We are doing the same with ethical and professional behaviors in medicine. Dr. Smith sees this change in professionalism because of the current generation gap. The characteristic of being an “authentic physician in the future environment” may be different than the traditional values seen in our profession in the last 200 years. There is a need to redefine the excellence in professionalism and humanism both generationally and in a culturally diverse pluralistic society.

Patient Centered Humanism and Professionalism:
All teaching should be centered on or start with the patient. It is very difficult to understand any illness and its therapeutic and prognostic implications if it is not seen in the context of patients and their values. This is especially true in the new era of evidence-based medicine. Narrative medicine or a patient’s story must be integrated with evidence-based medicine. The basic tenet of teaching is to develop a new level of understanding. This is true not just for pure scientific facts but also for nurturing humanistic skills and professionalism. Reflection is a key concept in transformative learning. Reflective thinking must be a goal of experiential learning. We need to foster critical self-reflection and self-knowledge on those nurturing humanistic experiences. We constantly need to raise learner awareness of assumptions and beliefs around the changing moral concepts surrounding humanism and professionalism.

We also need to ask open-ended questions to assess not only what they know but how they know concepts. We must strive to ask probing or clarifying questions sequenced to promote thinking at higher cognitive levels with a new level of understanding in humanism and professionalism. This learning has to be based on individual epistemic, moral-ethical, philosophical, aesthetic and cultural habits of the mind. Students and residents make meaning out of their experiences. We need to bring transformative learning processes by which learners examine problematic frames of references in humanism and professionalism to make more open, inclusive, reflective and emotionally intelligent changes. This is essentially a life learning process.

Ultimately, what is the ideal teaching method for nurturing professionalism and humanism in medical education for students or residents? There is no perfect method, but a good method is to identify the teachable moments of critical self-reflection and experiential learning from each patient. I believe that critical thinking starting from the bedside and leading to the classroom is one of the most effective ways to teach. American science philosopher Thomas Kuhn said, “You don’t see something until you have the right metaphor to let you perceive it.” I conclude that teaching and nurturing humanism and professionalism in medicine is as complex as raising a child. It is our responsibility to preserve and teach traditional moral reflexes that are complementary and useful to new circumstances and carefully give up those that are not. Lastly, but the most important, is showing courage to care about your patients, your peers, your career and your society. This is a sign of true professionalism.

Vijay Rajput, MD, FACP, SFHM, is Chair, Department of Medical Education and Professor of Medical Education at Dr. Kiran C. Patel College of Allopathic Medicine in Fort Lauderdale, Florida.

In our 40 years of prescribing, dispensing and educating about medications, we have always taken comfort in the knowledge that medicines approved by the U.S. Food and Drug Administration (FDA) were held to a high standard of safety and efficacy. After all, it was the FDA that protected Americans from the heartbreak of thalidomide. But the Covid-19 pandemic of 2020 has made us rethink our confidence in this agency as well as other health related government entities such as the Center for Disease Control and Prevention (CDC).

Emergency Use Authorizations (EUA) and New Drug Approvals (NDA) must be based on expert scientific evidence and not by politics underlined by wishful thinking. While all of us desire effective therapies and vaccines for COVID-19, we must remember that Fantasyland is part of Disney World, and is not the fifty-first state.

An emergency use authorization for a drug is not an actual drug approval. Instead it is useful for accessing a medication that might save lives prior to drug approval when there is preliminary evidence of efficacy and safety. Our question now is, how does an unproven vaccine fit into this definition? Particularly when vaccines are useful for disease prevention but not acute treatment of illness, how would a vaccine fit into an EUA? With short or long term effects yet unidentified, how can a EUA be granted? Will it be enough if the FDA says there is plenty of proof, but the proof has not yet been evaluated by an independent advisory panel and published in a peer-reviewed journal? If you are a prescribing health care professional, you must have data to make appropriate decisions.

As health care professionals, we must feel confident in the information that has been made available through well researched clinical trials establishing specific guardrails for clinical prevention and management of illness. When politics weakens and destroys those guardrails, our ability to protect patients is damaged.

On a recent visit to our primary care clinician, we were saddened to find the physician struggling with how she would manage the tough discussions in the weeks ahead. As patients seek her advice about how she should provide care for them, our physician may be asked to make decisions that are life giving as well as life taking, just in deciding whether or not a therapy or vaccine, yet inadequately proven, should be administered. We share her concerns about the overwhelmingly difficult decisions we, as providers, may be asked to make. Clinicians should not have to balance politics and science in medical decision making.

The FDA and the CDC have been internationally respected leaders in the evaluation of drug safety, efficacy and global health. When practitioners and international medical organizations lose faith in the professionalism of these revered agencies, our entire planet suffers. It’s a small world after all.

Cynthia Sheppard Solomon, RPh, FASCP, CTTS, NCTTP, is a Clinical Assistant Professor in the Department of IM and Neurology at Wright State University-Boonshoft School of Medicine and Glen D. Solomon, MD, MACP, is a Professor and Chairman of Internal Medicine and Neurology at Wright State University-Boonshoft School of Medicine in Dayton, Ohio.

Another month, another module of the Medical Professionalism Project to share with you! The Medical Professionalism Project (MPP), created by renowned social scientist Dan Ariely in collaboration with Duke Health, is an innovative short film series and CME course that explores the complex expectations, challenges and responsibilities of being a healthcare provider through the lens of behavioral science. In 5- to 10-minute videos, MPP applies research from behavioral economics and other social sciences to reveal how and why we make ethical mistakes, providing strategies for improving behavior at an individual and institutional level.

As we learn in module 2, social norms are a powerful influence on our behavior, and healthcare providers are no exception. In fact, the hierarchies and pressures of medicine may exacerbate the situation, allowing poor behavior to be passed along from one generation to the next. Do you remember being belittled as a trainee? Have you ever lost your temper with a fellow or resident?

As we hear in this module’s film, many providers have witnessed or been the target of unprofessional behavior by a fellow member of the healthcare team. The mistreatment of peers and trainees is an issue unto itself, but research shows that these behaviors can also have a negative impact on patient care, making the need for improved collaboration and communication absolutely essential. The module 2 film explores these themes and offers tools for improving social norms on your team.

Following the film, a “Planning Future Behavior” exercise pops up to help integrate what we’ve learned. Behavioral science research shows that when we make plans in advance, we are more likely to execute on our decisions, particularly when it’s something difficult or unappealing. This exercise asks you to reflect on how you might confront a superior about his or her inappropriate behavior and make a plan for addressing the situation. Hopefully, with this plan in your pocket you’ll feel better prepared the next time you find yourself confronting a colleague acting unprofessionally.

Finally, we offer further resources on how bad behavior can impact the medical team and patients, plus an example of a successful intervention.

The Medical Professionalism Project can be completed online for up to six credits of AMA PRA Category 1 Credit(s)™, MOC Part II credits for numerous member boards, Nursing CE, as well as IACET CEU. In addition, we offer the films to be used offline in classrooms and meetings, or incorporated into other online learning platforms. A robust interprofessional educational experience, the Medical Professionalism Project is an engaging and thought-provoking course for students, residents, faculty and practicing physicians as well as nurses, physician assistants and others on the healthcare team.

All APHC members receive a 20 percent discount on MPP (and 25 percent of the payment returns to APHC!).

If you have any questions, please reach out to Project Director Clare Marash at clare@saltyfeatures.com

As mentioned in the last newsletter, we will be sharing more details on each of the Medical Professionalism Project (MPP) modules in the coming months. Co-created by the renowned social scientist and best-selling author Dan Ariely in collaboration with Duke Health, this innovative short film series and CME course explores the complex expectations, challenges and responsibilities of being a healthcare provider through the lens of behavioral science. In 5- to 10-minute videos, MPP applies research from behavioral economics and other social sciences to reveal how and why we make ethical mistakes, providing strategies for improving behavior at an individual and institutional level.

Module 1 jumps right in with a quick game to get us into the spirit of the program and to begin to illustrate how easily our behavior and decision-making can be swayed. The Dice Game asks you to pick TOP or BOTTOM before simulating the role of a die. Depending on what you chose, you collect the points on the top or bottom of the die cast. After you complete a few rounds, ask yourself – did you feel the pull to choose the higher score? Maybe you did, maybe you didn’t, but you can compare your score to the expected average at the end and might be surprised by what you learn…

After that icebreaker, we dive right into the introductory film, which gives a brief overview of the foundational social science research behind this program, how we see it applying to the fields of medicine and why we think it is so important and beneficial to consider our behavior from this perspective. In it, we meet Dan Ariely, who guide us through MPP, as well as many of the other voices of the providers – physicians, nurses, trainees, administrators and more – who share their experiences throughout this program. A selection of professional ethics codes and research papers offer further reading in our resources section.

The Medical Professionalism Project can be completed online for up to six credits of AMA PRA Category 1 Credit(s)™, MOC Part II credits for numerous member boards, Nursing CE, as well as IACET CEU. In addition, we offer the films to use offline in classrooms and meetings, or incorporated into other online learning platforms. A robust interprofessional educational experience, the Medical Professionalism Project is an engaging and thought-provoking course for students, residents, faculty and practicing physicians, as well as nurses, physician assistants and others on the healthcare team.

All APHC members receive a 20 percent discount on MPP (and 25 percent of the payment returns to APHC!).

If you have any questions, please reach out to Project Director Clare Marash at clare@saltyfeatures.com

The goal of the Healthcare is Human project is to spotlight workers who are often forgotten. We hope to show the human beings, who form the essential core of a hospital, and by doing so, start a conversation - one which challenges expectations and assumptions about the healthcare ecosystem.

The coronavirus pandemic produced much discussion about “healthcare heroes.” It is often doctors and nurses now lauded as “heroes,” but both groups have long been esteemed by the public. Other workers - janitors, clerks, security, IT, cafeteria, facilities and others - are not regarded as “heroes” in a hospital, if they are considered by the public at all.

Our project will involve an unannounced visit by us with hospital staff members. We will describe our project and invite individuals to participate. This project is strictly voluntary, and no one will be compensated. Informed consent and photo release will be signed by participants.

Each participant will have a brief interview with Dr. Ryan McCarthy and Shruthi Sreekumar and pose for a photograph by award-winning photographer Molly Humphreys. Photographs of all individuals will be displayed together with an essay. We hope to display the photos in various formats - digital, physical prints, panel discussions, at conferences, etc. Interviews will be broadcast on radio and formulated into podcast format by radio producer Marsha Chwalik.

Our ultimate goal is to have the photos and interviews show each healthcare worker as a human being - no more or less of a “hero” than anyone else in the hospital.

This project is being conducted in August 2020 at the Berkeley Medical Center in Martinsburg, WV.

Ryan McCarthy, MD, is a faculty member of the West Virginia University School of Medicine. Shruthi Sreekumar is a 4th-year medical student.

Diversity enriches professional spaces and ethical discourse, but an uncritical perpetuation of privileged normativity threatens the theory and practice of professionalism as inclusive. In our forthcoming paper, we invite our colleagues to consider the communication behaviors of muted, non-dominant groups for where they may bear a disproportionate risk of being censured as “unprofessional,” and to freshly reconsider how specific types of access and privilege have been shaping professionalism discourse and curricula in ways that perpetuate “model minority” expectations at the cost of a genuine and trustworthy inclusivity.

It was sociologist Eliot Freidson who expressed concern in his work (1970) that the privileged rhetoric of professionalism endangered the status of the profession itself:

Confusing their knowledge with their practice, and their moral commitments with their knowledge, they claim all they do to be their exclusive prerogative; confusing their intent with their practice, they claim ethicality as their specially redeeming quality...There is a real danger of a new tyranny which sincerely expresses itself in the language of humanitarianism and which imposes its own values on others for what it sees to be their own good … a new privileged class disguised as expert. (p.380-381)

At the time, this was not due to cynicism about the value of a profession but rather his worries that a profession could be “blinded by the glitter of its own status, then made myopic” (p.381) and “whose character is at once obscured and made palatable by the claim of professionalism (p.70).” He would later modify his stance, conceding that a “third logic” of professionalism helped resist the logics of “market forces and bureaucracy,” but continued to worry that the rhetoric could fail to represent a genuinely virtuous community (Freidson, 2001).

There have been other voices that have expressed early and often the concern that professionalism discourse is shaped to persuade through abstract, emotive terms such as “duty” and “altruism,” with insufficient attention to the who, how and under what circumstances this rhetoric is formed and demanded by those with privileged positions (Wear and Kuczewski, 2004). Similarly:

Professionalism is no longer helpful as an organizing ethical framework - that it is too deeply entangled with physician privilege and power … Calls for renewed professionalism in medical education sound to us too much like nostalgic appeals to the good old days when physicians were virtuous cowboys - riding free on the healthcare range, always available and kind to patients, and always with an invisible wife at home to keep dinner warm. (Shirley & Padgett, 2004, p. 37)

We are concerned that well-meaning but systemically privileged professionalisms may result in multi-layered discriminations around “respectability” and “professionalism” for vulnerable professionals from muted cultural or personal backgrounds.

For example, two non-dominant communication behaviors described in co-cultural communication theory are: 1) avoiding dominant group members, especially certain activities or locations where an interaction is likely, and 2) maintaining barriers by using verbal and nonverbal cues to impose a distance from dominant group members (Orbe, 1998). These kinds of behaviors, utilized by muted groups as a strategy for surviving and protecting themselves in places of power disparity and privilege, seem likely to earn these vulnerable persons feedback that they are “stand-offish,” “uncaring,” “disinterested” or “uninvolved” and likely to call into question their competency in professionalism. If supervisors see and understand these behaviors as adaptive strategies by muted groups, the response is more likely to involve support for insight and empowerment towards inclusivity rather than censure and the dismissive adage we hear too often: “Well, you can’t teach professionalism.”

We look forward to exploring these concerns more fully at the upcoming APHC virtual conference, inviting fresh eyes for disempowered behaviors as a signal of muted group vulnerability and the evolution of professionalism discourse to support diverse, equitable and inclusive professional communities. Friday, October 2 from 1:15 to 2:00 ET

Janeta F. Tansey, MD, PhD, is Principal of Virtue Medicine PC and Adjunct Clinical Associate Professor at the University of Iowa and Elizabeth S. Parks, MA, PhD, is Assistant Professor at Colorado State University.

References
Freidson, E. (1970). Profession of Medicine: A Study of the Sociology of Applied Knowledge. University of Chicago Press.
Freidson, E. (2001). Professionalism, The Third Logic. University of Chicago Press.
Orbe, M. (1998) From the standpoint(s) of traditionally muted groups: Explicating a co-cultural communication theoretical model. Communication Theory, 8, 1-26.
Shirley, J., Padgett, S. (2004). “Professionalism and Discourse. But Wait, There’s More!” American Journal of Bioethics, 4(2), 36-38.
Wear, D,. Kuczewski, M. (2004) “The Professionalism Movement: Can We Pause?” American Journal of Bioethics, 4(2), 1-10.

Moral distress is not a new topic in discussions of professionalism within healthcare, but engagement with COVID-19 has led to a less frequent if not novel manifestation of such distress. As many of those who were in training to become future members of a health profession found themselves at home, instead of in the hospital or the clinic, tension built between the desire to aid and concerns for their – and their loved ones’ – safety. Further exacerbating this distress was the lack of control these future professionals had over the decision to remain in the hospital or clinic. For students, this challenging decision was made by those who are entrusted with their education and care within the profession.

As someone who regularly has ethics discussions with students of the health professions, I have seen first-hand the benefits of multi-disciplinary or interprofessional (1) conversations. Relying on the guiding principle that challenging, large-scale ethics problems are best addressed by a group of folks from diverse backgrounds, practically reasoning together, a session was created to address this question at the crossroads of professionalism and ethics: How should students of the health professions, but also practicing healthcare practitioners, balance duties to care with personal safety concerns in the time of COVID?

The aim of the session was not to answer the question for the students or for practicing healthcare practitioners, but to help put them in a better position to practically reason about the subject for themselves. To this end, the session engaged professionals with expertise in medicine, nursing, epidemiology, paramedicine and education. These professionals offered, from their own perspectives, how they themselves were thinking through this question. The primary benefit for students and all of us who learned from these professionals, was not that there was a general consensus tipping the balance toward satisfying their duties to care, albeit in safety-minded ways, but rather a unique opportunity to view how these professionals drew strength from the past experiences which helped to form their character and inform their current practice.

From international medical aid to on-the-ground emergency response to the events of 9/11, from volunteer firefighting to a reorientation of outpatient to inpatient practice, this conversation was littered with examples of experiences which supported resiliency in their own lives and practices and served as models for students. Their stories provided a clear picture of the challenges to come but also hope for students who felt unable to aid in a crisis where their own chosen professions were doing so much good work.

This session blossomed into a regular series (2), where a variety of ethics issues associated with COVID-19 are addressed, some of which include research (3), prioritization and discrimination (4). For more on this session or the series, contact Bryan Pilkington ( bryan.pilkington@shu.edu ) or visit https://library.shu.edu/COVIDEthics / .

Bryan C. Pilkington, PhD, is Associate Professor at the Hackensack Meridian School of Medicine and at Seton Hall University.

References
1. I use these terms inclusively here, but for further clarity see Pilkington, B. 2018. “The Fiftieth Anniversary of Patient as Person: Paul Ramsey’s Groundbreaking Approach to Christian Bioethics” Christian bioethics: Non-Ecumenical Studies in Medical Morality, 24:2, 111–125.
2. https://www.shu.edu/health/news/ihs-comes-together-for-the-covid-19-ethics-series.cfm
3. https://www.shu.edu/health/news/panel-on-research-ethics-and-expertise-in-a-pandemic.cfm
4. https://www.shu.edu/news/panel-on-discrimination-features-dr-sampson-davis.cfm

Recent events from COVID-19 to international protests calling for equity and the end of racially charged police brutality mandate expansion of medicine’s social contract.
For too long we have considered the social contract in transactional terms limited to what the health professions owe society and what, in exchange, society owes the health professional [1]. This consideration of the contract tends to limit the capacity of medicine to expand its responsibility to include promoting justice in health care systems, and society at large.

The conventional contract has been couched in an air of “benign neutrality,” stripped of its ideological underpinnings. The institutions of medicine, such as professional organizations, health professional schools, hospitals and clinics are presented as ahistorical and somehow apart from the injustices of the societies they serve. Yet, the three big tools in the perpetuation of institutional racism wherever it expresses itself have been health care, systems of education and law enforcement. It is in these contexts that oppressed and marginalized citizens are likely to interact with the power of the state and expert practitioners, and the likelihood for interactions to go badly with serious negative outcomes and real-life consequences.

The current pandemic due to COVID-19 has exposed stark disparities and the failure of society to ensure safe working environments illustrated by the lack of personal protective equipment for everyone, fair compensation for employees in situations of extreme risk and financial support for essential and frontline workers who become ill with COVID-19. The disproportionate higher rates of infection and deaths of African Americans from COVID-19 are not just a difference in health outcomes by race or ethnicity, but attributable to factors other than access to care, particularly social determinants of health [2-4].

The right to safe employment and the right to health are foundational human rights, established long ago with adoption of the Universal Declaration of Human Rights [5] in 1948 and in 1946, the establishment of the World Health Organization [6,7]. They go far beyond recently published statements on the principles of professionalism [8].

Medicine, for its part of the social contract, must ensure its practitioners are competent, ethical, compassionate and committed to ongoing quality improvement and just use of finite resources. COVID-19 has revealed health professionals’ incredible sacrifice of time and family, willingness to work beyond human limits while honoring their patients and team members, and to do so often at personal risk without security of employment if they became ill.

At the same time, COVID-19 has revealed the failure of medicine to solve the problem of health disparities [9]. While medicine is rendering heroic therapeutic interventions, as an institution in society, we see clinicians and health professions educators push aside the persistent racial injustice against African Americans and other persons of color. These realities force us to ask questions including the following: What should our schools teach future health professionals?

We train health professional students to believe their role is to treat individuals with a focus on disease without anchoring illness in a social context. Instead the illness narrative remains separated from anatomy, physiology, biochemistry, immunology, genetics, microbiology, pharmacology and disease systems, such as neurology and the brain, cardiovascular, renal, pulmonary, gastroenterology, endocrinology and so forth. This disconnect creates confusion and anger since our students see that the world our patients live in serves as the driver of the mental, emotional and physical diseases they present with. Sadly, discussion of our world and our patients’ lives is left to sessions that are optional or electives that come at the end of medical school.

For over 10 years, one of us (PPR) has taught courses for undergraduate and medical students that focus on the history of structural racism in American medicine, health disparities and the contributions of African American health professionals in the struggle to create a health care system with attention to justice and equity. Truthfully, as committed as we are to social justice, these courses offer a White gaze on health inequities, where the downstream effects of discrimination are experienced by persons that are the “other,” and not by the students in the classroom. The role of medicine and its institutions in the maintenance of systemic racism is rarely, if ever, “owned” as central to the perpetuation of the systemic injustices we teach as historical and current realities.

Year after year, students lament the fact that the content of these courses has for the first time enabled them to understand the discrimination they experience and the problems their patients confront in their struggle to get the medical care they need and their journey to live healthy and vibrant lives.

We must find ways to develop students’ seeing into the invisible: the structures that permeate each clinical encounter. Whether that be appreciating that a child transported 1500 kilometers from his home in a remote Indigenous community without his mother on the flight because the air ambulance staff fears that she will “act-out” is an act of medical colonialism or that police violence against Black men should be understood as a public health emergency, we must provide the opportunities to develop this “seeing,” as a relevant competence to bring to every clinical encounter.

These examples and others that provide possibilities for transformative learning for greater social justice are present every day in our real world of health professions education. In short, we must develop students’ critical consciousness into appreciating the structures that determine the injustices of health inequities.

The broader movement for equity and justice is calling us to reimagine what we can do given that we function in polite, arcane and stodgy health care and educational systems. We believe the content of health professions education MUST be radically transformed to include the history of structural racism in medicine and the medical professions’ unethical role in that history. For too long, we have turned our back on racial injustice, including police brutality. Our students are now challenging us to own this history and, at the same time, to join the movement with protests and training to facilitate deep conversations in the community and among themselves, as well as skills and strategies to eliminate health disparities.

It is time to remove the white gaze of elitism that has been cast on constructs of professionalism. Instead of pledging to students that they will join a profession where they will gain expert knowledge in exchange for privileges, how about this formulation?

“You might be vomited on by a patient, in real life or metaphorically. Your consciousness will be transformed by your experience. A door may be opened to the hidden structures promoting injustice and discrimination at play within each clinical encounter. When this happens, you will do your best to find the cause of the discrimination or injustice and to put a poultice of caring over health disparities and inequities using remedies that come from your best scientific understanding at the time. You will seek to understand your patient’s life in a context of relationships in broader society, some of which may not be helpful to her health. Maybe, she is vomiting because her landlord is not held accountable for the mold that is in her apartment?”

As health professionals, we must expand our concept of the social contract to embrace restorative justice and engage the larger community of health educators and practitioners in understanding the impact that the health professions such as medicine and nursing has had on creating the inequities that are fueling this movement for justice in society. We must stand together in solidarity with our students and those in the community calling for transformation of our society and also our educational and health care systems.

P. Preston Reynolds, MD, PhD, MACP, is Immediate Past Chair of the APHC Board of Directors and Professor of Medicine and Nursing at the University of Virginia. Saleem Razack MD is a Pediatric Intensivist, Professor of Pediatrics and Health Sciences Education, and Director of the Office of Social Accountability and Community Engagement at McGill University, Montreal, Canada. William Agbor-Baiyee, PhD, is Associate Professor and Assistant Dean for Educational Research and Student Learning at Chicago Medical School, Rosalind Franklin University.

References
1. Cruess RL, Cruess SR. Expectations and obligations: professionalism and medicine’s social contract with society. Perspect Bio and Med. 2008;51:579-98.
2. Gomes C, McGuire TG. Identifying the source of racial and ethnic disparities. In Smedley B, Stith AY, Nelson AR, eds. Unequal Treatment. National Academy Press; 2003.
3. Havranek EP, Mujahib MS, Barr DA, et al; American Heart Association Council on Quality of Care and Outcomes Research, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, Council on Lifestyle and Cardiometabolic Health, and Stroke Council. Social determinants of risks and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2015; 132(9): 873-898.
4. Braveman, P. Social conditions, health equity and human rights. Health and Human Rights. 2010;12:31-48.
5. UN General Assembly, Universal Declaration of Human Rights, 10 December 1948, 217 A (III), available at: https://www.refworld.org/docid/3ae6b3712c.html [accessed June 16, 2020]
6. World Health Organization. Available at https://www.who.int/ [accessed June 16, 2020]
7. Wolff J. The Human Right to Health. (New York, NY: WW Norton and Co.), 2012.
8. Medical Professionalism in the New Millenium: A Physician Charter. Ann Intern Med. 2002;136:243-246.
9. Braithwaite R, Warren R. The African American Petri Dish. J Health Care for Poor and Underserved. 2020;)April 15):1-12.

Comic book heroes of our youth, Batman and the Green Hornet, knew how to wear their masks (1). Today, the public is not as secure. Have you been watching? Have you seen what we have at gas stations, on TV, at the grocery and in the garden center???

Some people wear masks, some don’t. Some wear them below their nose, some wear them on their necks, some have them hanging off one ear…. But when the gal making my bagel sandwich reached to pull her mask up when it fell below her nose the fourth time, I decided not to purchase the already placed order.

Whose responsibility is it to help this young lady properly protect herself and consumers? Her boss? Her corporation? The Surgeon General? The state? Should there be written procedures for management? What about a medical receptionist or patient when handed a mask to wear? Should there be some education?

I know many who do not know masks should cover their nose. Some pull their masks down to talk with me. One thanked me, the pharmacist, for making recommendations regarding tightening the elastic ear holders with a paper clip to hold the mask higher for comfort and safety. Why aren’t medical managers giving in-services? Whose responsibility is it?

When I see profound misuse, it is easy to espouse my opinions. Touching the outside of a mask without washing or sanitizing one’s hands as soon as possible afterward can cause harm. The virus can stay on the mask, on hands or on other items that have been touched. Being careful not to touch one’s face and covering one’s nose with the mask are essential to successful protection. But people who are unaware of the benefits of mask wearing may respond negatively to being provided tips from bystanders. Most bystanders have a personal vested interest in everyone wearing masks properly. I have heard wearers complain that the masks are too big or they slide down. And frankly, some wearers could just care less!

We really do not want to be face mask police, but for our safety, we prefer others use masks, handling them properly. But, most people are not informed, and rightfully, they deserve some useful information.

Yes, the Surgeon General has done public service announcements. This spring, he said using masks, especially when used improperly, cause more harm than good – then later, he said masks could help.

There has been no surge in public service announcements clarifying what proper mask management entails. Doesn’t the government have a role? Couldn’t the public health system take up the banner? The CDC has good information about face mask use on their website (2, 3). But government websites are not always easily accessible to consumers. A recent JAMA patient page (4) covers the why, the what and the how, beautifully. This pictorial piece shares the priorities of lengthy hand washing, donning and doffing masks without touching the front of the mask or face, and washing masks to prevent contamination. Can we get this information to consumers???

We must not assume people understand the seriousness of the virus, nor should we assume they will know how to properly use a mask. Health care officials and politicians on TV often do not safely manage their own masks. Putting contaminated masks in a pocket, pulled down on a neck or placing them in a purse, can jeopardize one’s health and the health of others. Touching a mask without sanitizing one’s hands can cause droplets and aerosolized particles to spread.

In response to Governor Cuomo’s 22-year-old daughter telling him he was not communicating clearly about masks, they came up with a contest for all New Yorkers to create an educational 30 second ad on mask wearing. Although focused on getting the public to wear masks, the concept could be extended to focus on proper use. Creativity and fun can be a part of educating others!

Although the politicization of government agencies has been seriously questioned during this pandemic, experts agree the best way to prevent COVID-19 spread is by wearing masks. We suggest prevention is linked to proper use. Masks work – neither Batman or the Green Hornet, nor their sidekicks, Robin and Cato, ever tested positive for coronavirus.

Who should be responsible for educating the public about masks? Many medical professionals are taught to handle masks, but ancillary medical personnel, patients and consumers require education on safe proper use. Boxes of face masks may not come with instructions – and finding evidence-based YouTube videos on the topic may be impossible.

While no one is overtly taking responsibility, isn’t it our ethical duty as health care professionals to be part of the solution by promoting safe use in our communities? Isn’t this part of professionalism?

Cynthia Sheppard Solomon, BSPharm, RPh, FASCP, CTTS, NCTTP, is Clinical Assistant Professor, Department Internal Medicine and Neurology, Wright State University Boonshoft School of Medicine, Dayton, Ohio. Glen D. Solomon, MD, MACP, is Professor and Chairman, Department of Internal Medicine and Neurology, Wright State University Boonshoft School of Medicine, Dayton, Ohio.
References
1. Disclaimer: Batman and the Green Hornet are fictional characters, as are Robin and Cato. While their eye masks obscured identities, they did not prevent disease.
2. https://www.cdc.gov/coronavirus/2019-ncov/communication/print-resources.html
3. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-to-wear-cloth-face-coverings.html
4. Desai AN, Aronoff DM. Masks and Coronavirus Disease 2019 (COVID 19)-JAMA patient page. JAMA 2020323(20):2103. Published online 4/17/2020.doi10.1001.jama.2020.6437.

The recent deaths of George Floyd, Ahmaud Arbery, Breonna Taylor and many others killed or harmed are tragic and stark reminders of the historical injustices that many African Americans and other people of color in the United States have experienced and continue to experience daily.
APHC is a non-profit organization dedicated to enriching professionalism across the full spectrum of health care. Its mission is to optimize patient care through professionalism education, scholarship, policy and practice in all health-related fields. Most APHC members provide patient care and teach and lecture on topics of medical professionalism and ethics, including the character and values of being health care professionals. The Board of Directors of the APHC recognizes that the suffocating effects of structural racism and injustice stand contrary to health care professionalism and the mission of the APHC. To remain silent on these matters would be a form of moral complicity.

Racism and all other forms of racial, cultural, sexual and religious discrimination, intolerance and bigotry have no place in moral societies. Sadly, we know this is not the reality for many of our colleagues, students, patients and members of our local communities.

The eruption of protests we are witnessing around the country and the world are the result of people calling for accountability and justice for those murdered and harmed. All people have inherent moral value and should be treated equitably, unlike the experiences of those who are treated differently because of their ethnicity, culture, sexual orientation, gender, spiritual beliefs or the color of their skin.

The APHC stands with those who wish to use their voice and actions to heal the wounds of systematic racial injustice. To quote Dr. Angela Davis, “In a racist society, it is not enough to be non-racist, we must be anti-racist.” We applaud demonstrations like those in Michigan, in which police and community members marched together in a demonstration of human solidarity.

The APHC values diversity and inclusivity of all who are committed to its mission. We recognize more can and should be done to address historical and systematic racism and all forms of discrimination and bias in the U.S. and throughout the world. As you read this statement, please join the leadership of the APHC as we recommit ourselves to the mission of our organization and to being an agent of change to address the wrongs of systematic racism, discrimination, and intolerance and their negative impacts on the health individual persons and of our communities. We encourage all health care institutions and academic medical learning environments to make a similar commitment by structing their teaching, patient care and research programs to end health disparities and the structural elements that contribute to them.

Each of us has much work to do and as an organization committed to excellence in professionalism, we ask for your guidance in helping the APHC support our fellow health care professionals, trainees, patients and the communities we serve. The Board encourages our members to reach out to us with their recommendations on how we can work together in support of one another.

In early March, the Academy for Professionalism in Health Care (Academy or APHC) leadership grappled with news of a global pandemic. When the Board voted to cancel our scheduled annual meeting, we proposed to launch our first virtual conference, Promoting Professionalism Amidst COVID-19.

This virtual venture proved to be tremendously valued by the 297 individuals who attended from around the world (10 countries on five continents). The APHC is grateful to our sponsors: Drexel University and Professional Formation for the virtual platform and technical expertise, and seven sponsors for their financial support: the AMA Journal of Ethics, Johns Hopkins Berman Institute of Bioethics, American Association of Colleges of Osteopathic Medicine, Loyola Center for Bioethics, American Board of Medical Specialties, Loma Linda University Center for Christian Bioethics and Penn State College of Medicine.

Ten experts addressed relevant topics. Preston Reynolds, APHC Board Chair, opened up with a discussion on professional accountability, weaving together principles of professionalism and human rights to deepen our responsibility to address social justice as the highest calling for the health professions. As she highlighted, pandemics find niches created by economic and health disparities, now exposed with skyrocketing death rates among communities of color and vulnerable groups. Tom Harter, incoming APHC Board chair, described ethical principles concerning risk and duties. How we weigh risks is a personal journey that all health professionals must resolve. At the same time, being a health professional comes with duties to patients and communities that are inherent in the work we do, even if this responsibility exposes us to potential harm of illness and death.

Lynne Kirk, Chief Accreditation and Recognition Officer of the Accreditation Council for Graduate Medical Education (ACGME), and Alison Whelan, Chief Medical Education Officer of the Association of American Medical Colleges (AAMC), addressed changes in medical student and resident training in response to COVID-19. Both emphasized the need to balance our responsibility to educate competent health professionals with the duty to protect patients and health staff from the risk of infection while also ensuring adequate personal protective equipment to front-line workers. COVID-19 is accelerating ACGME’s and AAMC’s move to competency-based education and team-based care while also pushing educators into innovate around telehealth. Similarly, elements of professionalism have shifted with greater attention on social justice and just distribution of finite resources, commitment to maintaining trust by managing conflicts of interest and commitment to professional responsibilities, while maintaining a commitment to scientific knowledge as a driver of professional and community responsiveness.

Kelly Michelson, professor of pediatrics at Northwestern Lurie Children’s Hospital, addressed organization professionalism amidst COVID-19 by first pointing out that even within one hospital or health system, there are many organizations operating simultaneously, such as the emergency room, intensive care unit, ambulatory clinics and the larger organization itself. COVID-19 has stretched different institutions and different elements of an organization in completely different ways, some being overwhelmed, while others remain closed. As the pandemic unfolds, what is the responsibility of the larger organization to the community it serves? Is one life saved the same as addressing the social determinants of health that put many people at risk for death? How can one balance the duties of justice as we shift from conventional care, contingency care and crisis care? In the end, concepts of duty to care with the duty to solidarity are essential to understand.

The next group of speakers described resources and strategies to delivering health and learning virtually. Steven Locke, founder of iHope Network, described tips and techniques for communicating with patients via telemedicine. He shared insights on how to create an effective “clinical space” virtually as well as rules and regulations surrounding telehealth encounters from licensing to billing to confidentiality. Pamela Duke, Associate Director of Clinical Skills and Professionalism at Drexel University College of Medicine shared her years of experience creating a virtual platform to facilitate longitudinal small group learning with the students at Drexel as they move from campus to campus in their distributed network of hospitals and clinics. She highlighted effective techniques for maximizing the value of virtual small group discussions and the value of peer reflection for professional identity formation.

Dennis Novack and Clare Marash described two valuable resources for educating students, residents and practicing clinicians on principles on professionalism. After several years in development and testing, Professional Formation will soon be available to educators around the world. Founded by Dennis Novack and colleagues with many APHC members as module authors, research demonstrated this resource to significantly increase trainees’ understanding of core professionalism principles and enhance their professional identity formation. The Medical Professionalism Project (MPP), developed by researchers and clinicians at Duke University, emphasizes that while we may believe we are demonstrating professionalism, often this is not the case. Each module opens with self-reflective questions and then weaves case discussion with comments by experts, allowing the viewer to reflect on their own behavior and what is expected as professional norms. All APHC members receive a 20 percent discount when signing up for MPP.

The conference closed with two of the most moving presentations. Steven Rosenzweig took us on the journey of reflection and renewal as we embraced the stress of the pandemic not only on our colleagues serving on the frontlines, but also on our patients, our communities, our families and ourselves. Building tools for resilience are foundational to all of our work, all of the time. Timothy Quill, master clinician and educator on end-of-life care, provided us with tools for communicating with patients and families, now faced with very difficult decisions. His years of experience enrichened the discussion and role play as he illustrated how to balance patient autonomy with beneficence, non-maleficence and just use of finite resources.

At the close of the APHC’s first virtual conference, we believe we accomplished our goal: provide our colleagues in the field of professionalism with insights into what this pandemic can teach us, tips on educating trainees through virtual platforms, information about on-line resources and skills in helping colleagues, patients and families as they struggle with stress, exhaustion and death. Solidarity reminds us that we are one profession as we confront and embrace this pandemic and build a future together.

P. Preston Reynolds, MD, PhD, MACP, is Immediate Past Chair of the APHC Board of Directors and Professor of Medicine and Nursing at the University of Virginia.

Here are a few comments that we received about the conference:

“This was the BEST webinar I have ever attended. It was personal, people were very engaged in their topics, the topics were EXTREMELY relevant. I had planned to only stay for part of it, but I could not pull myself from any of the talks! It was amazing.”
“This has been a really informative and useful conference.”
“Thank you for a wonderful virtual conference!”
“This has been very valuable.”
“It was fantastic.”
“It was terrific, and I appreciated that I could attend free of charge!”

The five-hour recording, which can be accessed at https://bit.ly/APHC2020Conference, includes a table of contents, to easily access specific topics. Please support our community by joining APHC or making a donation to ensure that we can continue to bring you virtual conferences and other programs.

The COVID-19 pandemic is stressful, overwhelming, and scary for everyone around the world, regardless of profession and level of exposure. As healthcare professionals, we join the multitudinous in the war against COVID-19. As bioethicists, we are equally concerned with how ethical communication can progressively inform our response and navigation of COVID-19 especially from the lessons learned lens. While the alarmist approach taken by many has intentionally raised awareness of the need for PPE accessibility and public access to evidence-based working understandings of contagion control, we caution our healthcare provider colleagues to consider the implications of employing such language due to the ongoing novelty of the global virus that resists contagion. We hope to serve as canary or a mentor to all other sectors involved in communicating evidence-based, thoughtfully transparent yet compassionate communications, and support advocacy momentum without inciting through fear and threats

In the initial weeks, healthcare providers shared, more than ever, personal narratives that were informative and essential to understanding the needs the general public could help address (e.g., PPE, abiding by social distancing and complying with masking initiatives) but equally motivated by exposing poor health administration, political soapboxing and questionable policy decisions within their institutions. Healthcare providers are faced with, on too many levels, the daunting obligation to manage tensions between two conflicting principles: caring for patients and adhering to responsibilities toward the public.

Responsively, The Hastings Center has published and called upon colleagues to assist the Presidency, state Governors and Mayors, various governmental branches and their associated advocacy organizations in the absence of a Presidential Bioethics Commission (which was disassembled when President Trump took office) to focus on three duties owed by healthcare leadership: plan, safeguard, guide. Accurate and fairly represented communication to the public must carefully balance two key tenets of medical ethics, namely promoting the good of others (beneficence) and preventing harm (non-maleficence). When communicating with the public, healthcare workers have the right to be transparent about their personal knowledge and experience within the healthcare settings. That right, however, should be weighed against the rights of the public to have trust that healthcare institutions offer a safe place to seek care during a pandemic.

It has not been uncommon to find articles written by healthcare providers who opine that current conditions at hospitals might threaten the availability of nurses and physicians. Reports such as these threaten to undermine trust in the public and exploit the public’s faith in the stewards of healthcare. We support and implore healthcare providers to exercise their voice to advocate for sound medicine and patient safety. Likewise, those in the position to do so ought to advocate for robust governmental and institutional initiatives to improve and ensure safe working conditions. Advocacy is the skillful garnering of public awareness and support for a cause. To successfully advocate for the patient and medical community, rather than coerce out of fear, one must thoughtfully navigate educating, empowering and engaging their audience. Those who disseminate or publish such work ought to consider the optics of both the climate and potential misinterpretation by the public.

Given the daily inundation of panic-driven or unqualified information, the public struggles to discern fact from fiction. Oregon Health and Science University reinforces this philosophy by requiring medical students to complete a mandatory evaluation of compassionate communication skills prior to commencement. Communication by healthcare providers transcends empathy to be mindful of how word choice, medium and context impact perceptions for the public. Healthcare providers must balance their duty to the public with accurate and fair representation.

Many physicians and scientists have emerged as examples of transparency, honesty and realism. One such example is Dr. Anthony Fauci and his “truth-telling” approach, in which he may not always give resolute answers, but his words are never minced. He consistently admits that we are dealing with an unknown pathogen and that the impact, presentation, measures needed to fight it are of infinite possibilities. It is expected and reasonable that some information-sharing will later be retracted as inaccurate due to retroactive evidence-based findings. Transparent real-time communication should not cease but baseless claims and communications to incite action out of fear are not acceptable.

The public is inundated with conflicting information — at times feeling as though they are watching a tennis match about how to protect their health. Rather than acknowledging the inherent uncertainties of the current pandemic wherein honest scientific information may be delayed or even redacted later as incorrect, statements are made to shock and infuse reactionary behaviors. Balanced and non-alarmist input from geneticists, virologists and immunologists healthcare professionals would be invaluable in helping the general public understand how and when the answers will come as we work to inform ethically charged policies and procedures. In a time when we are asking the public to trust us, we need responsible discourse to steadily hold a lantern against the darkness of the unknown.

Throughout the COVID-19 crisis, people in all roles have had to rally for action from global authorities, national governments, local governments, public health authorities, employers and healthcare institutions. Healthcare providers are the public’s most trusted profession when it comes to the dissemination of health information. Calm and thoughtful communication from the profession has never been more important. Transparency and effective, ethical communication can unify all toward the greater good.

Emma J. Kagel, JD, MBE, HCE-C is the Manager of Clinical Ethics at Mayo Clinic; Jeffrey Gruenglas, MBE, MA, NREMT is a Lecturer of Bioethics and Health Policy at Boston University and Busi Mafanya Mombaur, MD, MPH, MBE is a neurologist and Elizabeth Sivertsen, MBE, BSN, CCRN is the Medical Ethicist at Grady Memorial Hospital.

The job of the state (1) for justice is to secure the well-being of its citizens. “Well-being is best understood as involving plural, irreducible dimensions, each of which represents something of independent moral significance.” Among those dimensions, two now salient, are COVID-19 related: Health, that is flourishing through biological or organic functioning of the body and Personal Security closely related to health - workplace safety and personal protection equipment issues.

There was ample forewarning (2) of an unavoidable viral pandemic that should have brought about governmental anticipatory measures to offer critical care to large populations of patients. It is hardly surprising that this society, which has largely cast aside Judeo-Christian perspectives on the value of human life in favor of productivity or quality, is not promoting life-sustaining interventions at end of life. The notion of too many lives, population control and lives-not-worth-living; advanced directives and palliative care, influence individual decisions and public health policy.

In this view, it seems, that being intubated and attached to a ventilator is an “indignity” that must be avoided even at the cost of one’s life. Forgotten is the fact that Intubation/ventilation, regularly used in surgery, is safe (3). Many professionals and lay people believe in good faith that there are lives not worth living (4). These beliefs pervade everyday life in a multicultural, pluralistic (5) and democratic society.

Public health policy acknowledges those preferences and promotes compatible social structures. Elected officials can apply the tools the state uses for regulation of commerce, taxes, reimbursements from CMS, FEMA and healthcare insurance, tax relief and others to directly influence and decrease the production of medical devices and critical care facilities. States fiscal constraints disincentivize companies from either manufacturing or having large stocks of life sustaining equipment. A hospital trying to expand its critical care capacity would have to face some issues.

First, polls, media and the bioethics literature may reflect a tendency towards forfeiting critical care by patients. Second, saving the environment through population control and a “death with dignity” are frequent subjects of public discourse and do shape personal decisions. Third, fiscal constraints such as certificate of need, medical device tax (2.3 percent), inventory tax and the expense of keeping facilities and devices ready to go.

End of life decisions may lack information and comprehension (6) and are very likely to change. End of life seems dignified only if life sustaining is forgone (7) and patients meekly cease to be “burdens.” For this COVID-19 pandemic, a highly infectious agent, useful data is scarce, specific treatment and vaccines are non-existent and diagnostics tests unreliable or not available.

Patients suffer from a mostly reversible “diffuse alveolar damage” (8), which requires mechanical ventilation (9) until patients are able to breathe by themselves. In severe cases, ECMO (10) may be used.

Provide reliable data to drive the decision-making process or inform of lack thereof. Afterwards, “… listen to all, then align, communicate and repeat” (11).” Design fair, COVID-19 specific protocols, emphasizing care for the most vulnerable. Monitor for embolic phenomena and treat accordingly. Try all non-invasive supplemental oxygen devices prior to intubation. Have enough ventilators built for the population at risk. Make ECMO widely available. Have the states provide a fiscal environment conducive to manufacture medical devices and maintenance of critical care facilities. Congress could enact legislation to safeguard professionalism promoting medical practices.

Raul Perez, MD, is Professor of Ophthalmology and Medical Ethics at the University of Puerto Rico School of Medicine.

References
1. Social justice, Powers & Faden, Oxford University Press 2006 pp. 3-49
2. … (Influenza: The Once and Future Pandemic, Public Health Rep. 2010;125 (Suppl3) ;16-26.) (“The next deadly disease that will cause a global pandemic is coming.” Bill Gates, Liberia 2015) (Preparing for the Next Pandemic, Scientific American, Sharon Guymipas July 20, 2018)
3. Originally manual, now mechanical. At the end of the procedure, before the patient can breathe on his own, manual ventilation is used. As well as in emergent medical care.
4. Permitting the Destruction of Life Unworthy of Life, Binding & Hoche 1920
5. Physician & Philosopher, Pellegrino Ed.
6. The Belmont Report
7. Self-effacement for the survival of humanity.
8. 2020 COCA Pod Cast, ECMO: Extra Corporeal Membrane Oxygenation
9. “microvascular thrombosis “… all about respiratory therapy support.” david.reich@ mountsinai.org
10. Ibid 7
11. telehealth@providence.org

The COVID1-19 pandemic in Italy and other countries has prompted frequent testimonials in the media from physicians about the moral stress they suffer when having to decide which patients are to be intubated and placed on a ventilator to save their lives and which are not. The fateful decision is prompted by life sustaining equipment scarcity. In more extreme scenarios, the life sustaining equipment must be removed from the older patient, who will also be provided pain control and comfort measures to be used in the younger one. Many of the accounts attempt to explicate the moral anguish on having to “play God” and probably, unwittingly, promote its acceptance as standard ethical medical care. The role of ideologies foreign to medical practice and failed state or government health policy is not emphasized. Several moral agents could be complicit in this scheme – the physician, the hospital, the state and others.

The physician is faced, first with a quality of life decision – what is the morally good and technically right thing to do now, for this particular patient to save her life. For both of the above patients the answer is: intubation and mechanical ventilation. Explains Keown (1) in “distinguishing from ‘quality of life to Quality of Life’...to avoid any misunderstanding here, quality of life” will be used to refer to an assessment of the patient’s condition as a preliminary to gauging the worthwhileness of a proposed treatment and Quality of Life to refer to an assessment of the worthwhileness of the patient’s life.”

It seems that medical device scarcity allows physicians to seamlessly forfeit quality of life decisions for Quality of Life (2) decisions, that is euthanasia as “intentional or foreseen life shortening.” For there to be euthanasia there must be a shortening of life or in Keown’s words: “… a decision to shortens a patient’s life by a doctor and that death is thought to benefit the patient (1).” This shortening of life can be accomplished in medical settings by removing life sustaining care (expert personnel and medical equipment) or by failing to provide life sustaining care. Beauchamp and Childress assert (3); “We conclude that the distinction between withdrawing and withholding is morally untenable and can be morally dangerous…The felt importance of the distinction between not starting and stopping procedures undoubtedly accounts for, but does not justify, the speed and ease with which hospitals and health care professionals accepted no code or DNR orders and formed hospital policies regarding cardiopulmonary resuscitation (CPR).”

Regarding the moral obligation of both physician and hospital Pellegrino explains, “The physician is the final common pathway whose assent is required for whatever is done for the patient. The physician's covenant is with the patient. It is the patient’s interest that should be primary, not societal interests. The physician is primarily the advocate for his or her patient and not an instrument of social, institutional or fiscal policy. There will be times when physicians may have to refuse to comply with law or public policy (4).”

The hospital (5) must carry the moral obligations it incurs by virtue of its own declaration as a “Hospital” – a setting, a place for the sick to be healed (6). It must provide the setting in which medicine can be practiced safely and competently: a building, trained personnel, facilities, medical devices and personal protection equipment (PPE). The hospital has the moral obligation to inform the public, all who work within it walls, future patients and their families or caretakers if it lacks any or all of the above so as to ease “… free and rational choice well beyond informed consent” and stakeholders be able to avoid unsafe and life threatening environments.

Raul Perez, MD, is Professor of Ophthalmology and Medical Ethics at the University of Puerto Rico School of Medicine.

References
1. Euthanasia, Ethics and Public Policy 2nd ed. Keown John Cambridge University Press 2018 pp. 37-49
2. “Patients who have the best chance of getting better are our first priority.” Kasie @
“Patients who have ventilator or ICU care withdrawn, will receive pain control and comfort measures.” @Nicholas _bag_ “Letter was in preparation for worst case scenario, but has not been enacted as policy.”
3. Principles 7th Ed pp. 161, 2013 Oxford UP
4. Mayo Alumni, ethics at the bedside Pellegrino Ed.
5. Physician and Philosopher
6. Physician & Philosopher Pellegrino Ed. (Hospital as moral agent)

Provider burnout and physician suicide had already been a well-documented public health crisis before COVID-19. Now, as hospitals are stretched beyond normal space and employee usage patterns, as resources and PPE are inadequate or inaccessible, as neighbors, patients, families and colleagues are threatened nationwide, the impact on provider health is amplified. Recent COVID-19 studies out of China report that a considerable proportion of frontline health care workers experienced symptoms of depression (50.4 percent), anxiety (44.6 percent), insomnia (34 percent) and distress (71.5 percent). We are seeing these same symptoms roll out across the United States in our providers. On an unprecedented level, they are and will be exposed to high levels of horror, anguish, vulnerability, sorrow, moral distress, self-doubt and even helplessness. In my own specialized practice, physicians from around the country are telling me that they are resolved to be courageous and responsive, but they are already fatigued, hurting and strained by unrelenting moral triage.

Society has been focused on the PPE of masks and gowns, but providing EMOTIONAL PPE is critical to managing burnout, demoralization, moral distress, and both direct and secondary trauma.

The wave of trauma is beyond the typical training and preparation of healthcare teams and providers, despite their preparation for courage, excellence and professionalism under duress. As society asks for and applauds providers for being heroically sacrificial, the providers are quietly experiencing shame and guilt when they reach their own limits as human beings. Healthcare providers are drafting wills, self-quarantining from their families, video-recording messages for their children in case they die, watching others succumb to devastating respiratory distress and trying to decide whether to rush to the epicenters and help their colleagues, or to hold the line in their own communities. The terrible risks of this distress must be addressed immediately to fortify the critical resource of our healthcare providers. There is no doubt that we will find the impact of this traumatic stress on our healthcare professionals will last far beyond the immediate circumstances. We need them. They need us.

A Call to Arms: I encourage our APHC members and colleagues to creatively design empirically supported interventions for healthcare providers and first responders to foster responsive and adaptive resilience. This is critical to a lasting and steady professionalism during and following crisis.

These are our hard questions:
What does just-right courage look like in the battlefield ethics of medical crisis? Are the military-war metaphors the right ones for this time, or do they miss something important?
Is there any possibility of peace (let alone sleep) when no matter how hard we try, our limitations result in others’ possible or actual suffering? What do we do when we can’t help but imagine the harms coming from tasks undone?
How do we triage emotional labor when the whole world needs care? Is there any cure to compassion fatigue?
How do we cope with this terrible grief? In all of this direct and secondary trauma, how can we think about and nurture a semblance of post-traumatic growth, or at least prevent trauma disorders?

How do we cope with all the righteous anger we are feeling about everything that has gone wrong? Who is our “neighbor” when our many communities are all at risk simultaneously?
How do we map a path through this sense of overwhelming futility? What do we do when being smart and well-educated doesn't actually bring us the guidance we really need for what to do NOW?

My faculty and I are working on tackling these hard questions directly and honestly in a Resilience Mini-Bootcamp that will begin by livestreaming on Sunday evenings, April 19, and will also be recorded and posted for 24/7 availability. This empirically supported intervention invites healthcare providers and first responders from every sector across the country to stop, breathe and implement immediate practices for resilience. In a moving act of solidarity, I am seeing my local departments sponsor their residents and fellows out of professional funds. I will offer aggressive discounts to help any program access this for their teams.

I am offering APHC Members and their friends/colleagues to immediately receive $125 off the Resilience Mini-Bootcamp by using the coupon: APHCFRIEND
https://virtuemedicine.com/resilience/

At Virtue Medicine, we have also pulled together a Doctors for Doctors Program of interdisciplinary providers, all senior and experienced Mind-Body specialists who are working as a team on rapid-response care to activate the Defiant Power of the Human Spirit in healthcare professionals, to use Viktor Frankl’s term. My team is completely on a telehealth platform offering care across the entire country. In my call to arms, I am asking APHC members and colleagues to support and offer similar services. If your providers need our services, contact us. We have opened up 100+ hours including evenings and weekends. https://virtuemedicine.com/doctors-for-doctors/

You can reach me at jtansey@virtuemedicine.com. Or use our 24/7 inquiry and new client portal at www.virtuemedicine.com to get a question to us.

Godspeed, friends.
Janeta

Janeta F. Tansey, MD, PhD is a Psychiatrist, Bioethicist, Specialist in Physician Care and Secondary Trauma; Principal, Virtue Medicine PC; Adjunct Clinical Associate Professor, University of Iowa

Professionalism is a word that has synonyms like expertise and adeptness. The art of professionalism can be overlooked until an overt unpleasant circumstance presents itself. In education, there is much effort placed on applied skills and tiers of knowledge that integrate into achieving goals and establishing learning objectives for students. Medical education is not any different in today’s complex societal norms. Medical educators face challenges in translating the art of professionalism into taking a history and performing a physical examination.

At times, there is an awkwardness that is observed when a first-year medical student, who has had no prior clinical experience, begins to translate details from learning objectives to documenting a history and performing a physical examination during standardized patient encounters. On occasion, a medical student is encouraged to put the cellphone away; and to modify, to a degree, some personal grooming towards an attire that is polished and well-primed in order to meet the standard that is incumbent upon medical professionals.

After an observed encounter is completed, medical educators coach to give feedback to medical students. The coaching approach is a conceptual framework that defines measurable constructs using tools, such as an assessment form. A medical student can tangibly learn from these transitional encounters which may lead to improved outcomes.

The challenge from a coaching perspective is how to communicate effectively the notion that professionalism is integrated into the art of history taking as well as the quality of performance during a physical examination. After receiving feedback, it is hoped that the medical student’s perceptive is one that is appreciative. Retrospectively, medical students have purported that coaching should be a part of medical education, because they feel that it is a natural precursor to coaching patients.

The transference from an awkward approach to an adept one is subtle. Principles reminiscent of par excellence are ingrained in the thinking of the medical educator who fosters ethical standards and confidentiality. Medical students can be steeply enwrapped in emotional constraint that inhibits collecting historical data and/or completing a physical examination. Under timed and stressful conditions, the medical student may disengage from the standardized patient who demonstrates perceived maladies in a portrayal of a clinical presentation. The interaction between the two can be intense during an encounter. Under such conditions, a medical student may become somewhat uncomfortable and lose focus which may create deficiencies in the history or physical examination. The coaching approach is one that is conducted with a thoughtful assessment so that there is time to reflect, make adjustments, implement a goal plan, address the deficiency, manage time/stress and personal energy as it relates to a feeling of optimism for the next encounter. Overall, the coaching experience augments the formal rigor of medical education in comparison to traditional practices at so early a juncture in the curriculum.

The art of coaching is a dynamic one between the medical educator and the medical student. It incorporates aspects that engage qualities of trust, reliability, emotional engagement and acceptable professional behavioral standards. The medical student becomes adept at the practice. The process is a trans-formative rite of passage from pre-clinical to clinical practicum. History and physical examination skills evolve so that the medical student can create a list of assessments/differential diagnoses to then move on to contemplate assessments that are ruled in or ruled out through formulating a well-developed plan. A constructive plan is configured through medication(s), lab workup, imaging, osteopathic manipulative treatment, counseling, referrals, admission or a follow-up visit that represents tiers of knowledge building.

The impact of coaching early in medical education in a longitudinal curriculum opens portals to establishing ground work for self-improvement. There evolves an indelible influence between medical educator and medical student through coaching. The coaching approach can raise the level of confidence and a renewed sense of what expertise is expected as the medical student prepares to embark upon the dynamic relationship with clinical preceptors in the subsequent years ahead.

Teresa Hunter-Pettersen, MD, is Associate Professor of Medical Education at Lake Erie College of Osteopathic Medicine in Bradenton, Florida

Resources
1. Cameron, D., Dromerick, L., Ahn, Jaeil, & Dromerick, A.W. (2019). “Executive/life coaching for first year medical students: a prospective study, BMC Medical Education, (2019) 19:163; Retrieve from: https://doi.org/10.1186/s12909-019-1564-4.
2. Deiorio, N., Carney, P., Kahl, L.E., Bonura, E.M., & Juve, A. M. (2016), Coaching: a new model for academic and career achievement, Medical Education Online, 2016, 21:33480, Retrieve from: https://dx.doi.org/10.3402/meo.v21.33480.
3. Sim, J. H., Aziz, Y.F.A., Mansor, A., Vijayananthan, A., Foong, C.C., & Vadivelu, J. (2015), Students’ performance in the different clinical skills assessed in OSCE: what does it reveal? Medical Education Online, 2015, 20:26185- Retrieve fro: https://dx.doi.org/10.3402/meo.v20.26185.
4. Polak, R., Finkelstein, A., Axelrod, T., Dacey, M., Cohen, M., Muscato, D., Shariv, A., Constantini, N. W., & Brezis, M. (2017), Medical students as health coaches: Implementation of a student-initiated Lifestyle Medicine curriculum; Israel Journal of Health Policy Research (2017) 6:42; DOI 10.1186/s13584-017-0167-y.

As a pharmacy practitioner, I must confess I have been known to make more than a few ridiculous public acknowledgments. In teaching clinicians, I have, at least once or twice, recommended health care professionals work on recognizing their implicit biases in order to miraculously erase them.

Implicit bias has to do with the subconscious judgments we make that are often based on stereotypes (1). Using the example of tobacco use, implicit bias exhibited by clinicians can negatively affect implementing proper screening or supporting adequate quit attempts. Research now demonstrates that clinicians offer tobacco cessation treatments more often to sicker patients and to patients of higher socioeconomic status. Nicotine dependence and tobacco abuse disproportionately impact disaffected populations. And implicit bias has been shown to contribute additively to the issue of health disparities, potentially creating more negative circumstances for patients to overcome.

Part of my practice is working as a tobacco treatment practitioner; as such, it is impossible not to deal with patients with social and health disparities. Medicaid recipients, the impoverished, the mentally ill, HIV patients, those who self-identify as LGBTQ, those with lower socioeconomic status, pregnant women under the age of 20 and numerous other special interest groups are associated with higher incidence of tobacco use disorder.

But other medical conditions are affected by implicit bias as well. Twenty-five percent of all Americans with diabetes do not know they have it. Sadly, the rate among Asian-Americans is even higher, with approximately 50 percent of diabetic Asian-Americans not aware of their diagnosis. They are two times more likely than whites to develop diabetes, despite lower obesity rates (1). Elizabeth Tung, MD, internist at University of Chicago, recently studied the disparities in diabetes screening between Asian Americans and other adults. Her group found that Asian Americans had 34 percent lower odds of receiving diabetes screening than whites (1), explained only by unconscious bias parameters.

The National Academy of Medicine reported that racial and ethnic minorities receive lower-quality health care than white people, even when insurance status, income, age, and severity of conditions are comparable (2). Where are you on this and other issues in the unconscious bias paradigm? What can each of us do to identify where we stand on perceptions that may have been embedded over a lifetime of experience and learning?
Concrete suggestions to evaluate one’s specific biases are available using several recent resources (3). First, implicit bias cannot be measured with standard survey type, self-report questions (3). One instrument designed specifically to measure one’s implicit bias is the IMPLICIT ASSOCIATION TEST (IAT). Examples of this format are available at https://implicit.harvard.edu (3).

Considerations for clinicians, researchers, policymakers and patients are included in Irene Blair’s research in The Permanente Journal, 2011 (3). For clinicians, these include: considering “gut” reactions to specific individuals/groups as potential indicators of implicit bias, assessing how these might affect your work (4), looking at the situation from the patient’s perspective (5), acknowledge and reappraise (6,7) rather than suppress uncomfortable feelings and thoughts (8). These and many other suggestions have been confirmed to add value to eliminating and reducing biases. The Institute for Health Care Improvement at www.IHI.org also has numerous recommendations for minimizing bias.
Neglecting someone’s medical needs or giving them less than the best care is reality when clinicians ignore the role of implicit bias in the patient’s care. If the clinician harbors deep seated negative feelings about the way the patient appears or some aspect of their background, it characterizes unconscious actions in response to bias within their patient base.

What can you do about the baggage you may carry into an examination room? How about what you bring into a conversation with a family in crisis? I urge you to investigate your own feelings more. We can all improve on how we carry out our life’s experience as we work with patients.

C.S. Solomon, RPh, FASCP, CTTS, NCTTP, Assistant Clinical Professor, Department of Internal Medicine and Neurology, Wright State University-Boonshoft School of Medicine, Dayton, Ohio

References
1. Quinn, C. ‘Implicit bias’ may account for glaring disparity in health care screening. THE WORLD. https://www.pri.org/stories/2017-02-09/implicit-bias-may-account-glaring-disparity-health-care-screening accessed 01-25-2020.
2. Bridges,KM. Implicit Bias and Racial Disparities in Health Care. https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the_state_of_healthcare_in_the_united_states?racial_disparities accessed 01/25/2020.
3. Blair,IV, et al. Unconscious Bias and Health Disparities: Where Do We Go From Here?. PERM J. 2011 Spring; 15(2):71-78.
4. Ranganath KA, et al. Distinguishing automatic and controlled components of attitudes from direct and indirect measurement methods. J EXP SOC PSYCHOL 2008 Mar;44(2):386-96.
5. Todd AR, et al. Perspective Taking Combats Automatic Expressions of Racial Bias. J PERS SOC PSYCHOL 2011. Mar 7[epub ahead of print].
6. Monteith MJ, et al. Putting the brakes on Prejudice on the development and operation of cues for control. J PERS SOC PSYCHOL 2002. Nov;83(5):1029-50.
7. Murphy MC, et al. Leveraging motivational mindsets to foster positive interracial interactions. SOC PER PSYCHOL COMPASS 2011 Feb;5(2):118-31.
8. Macrae CN, et al. Out of mind but in sight: Stereotypes on the rebound. J PERS SOC PSYCHOL 1994;67:808-817.

In the past eight years, I have had the good fortune to participate in two particularly rewarding projects. The first was to serve on a University of Texas Task Force that sought to define Professional Identity Formation and propose curricular strategies for implementing such a formation in medical education. In a 2015 Academic Medicine article, our team described the work we accomplished (1). My second project was to serve on the founding faculty of the University of the Incarnate Word School of Osteopathic Medicine. This role afforded me the opportunity to implement some of the strategies that our UT Task Force had proposed, and to do so in the building of a curriculum from the ground up.

One of the challenges I have encountered in implementing the formative dimension in the curriculum is clarifying the difference between Professional Identity Formation and Professionalism. The latter, as it is often conceived and addressed, relates to behaviors deemed appropriate in the eyes of traditional wisdom. The former is a process devoted to cultivating those virtues and elements of character that result in the behaviors associated with Professionalism. For the purposes of helping to develop the medical curriculum at my institution, I adopted the definition of Professional Identity Formation that our Task Force derived, though I did provide my colleagues with this “elevator speech” abridgment: Professional Identity Formation is the transformative journey through which one cultivates those virtues and elements of character necessary to becoming a fulfilled, humanistic physician of excellence.

Our Task Force distinguished six Domains and 38 Sub-Domains of virtues and elements of character we hoped to find in a fully-formed physician, then suggested broad educational experiences that could foster longitudinal development in each dimension. One of the Domains, for example, is Habits: in a fully-formed physician, we would expect to see certain acquired habits, and these would include (Sub-Domains) Self-Directed Learning, Critical Thinking, Self-Care, Empathic Labor, Reflection of the Meaning of Experience, Self-Awareness, Regard for the Human as an integration of Mind-Body-Spirit, and Aesthetic and Spiritual Experience (2). How might we foster longitudinal development in each of these dimensions? (3) At my present institution, I have sought to incorporate specific educational experiences that do just this. Of note is that we regarded the formation as a “curricular thread” that is woven into and throughout the curriculum, not something to be addressed as a Friday afternoon add-on. A basic scientist, a clinician, and a medical humanist team-teach whole-class sessions and integrate formation concerns in the lesson. This doesn’t take extraordinary amounts of time, and it enhances the quality of the educational experience.

In addition, one should recognize that a particular educational experience may address development in multiple Sub-Domains. Say I was team-teaching a large group session (Socratic, not lectures) related to breast cancer. I might show students the photo of a woman’s torso, post-mastectomy, from a medical textbook, then show an illustration depicting the same circumstance, then show a self-portrait of an artist who had undergone a mastectomy. I would ask students to reflect, in writing, upon what they thought was being communicated in each representation.

Obviously, there is a “reflection on the meaning of experience” occurring here, as well as an “engagement in aesthetic experience.” As students meditate on that artist’s work, though, they engage themselves in a labor of empathy that attunes itself to the feeling of what it is to lose a breast, and they learn something about the integration of a spirit with body and mind that is absent in the textbook illustration and the photograph. In broaching the emotions that empathy brings about, they develop self-awareness, and they deepen such awareness, as well, in experiencing the different kinds of knowing brought about by the different representations. They learn something about non-verbal communication. Because the faculty has included the artist’s/patient’s representation, the students receive a role-modeling that valorizes the patient’s perspective and insists that compassionate, truly ethical care—rooted in a regard for the Human Other as sacred—demands our understanding of it. All of this in an educational experience that runs maybe 30 minutes: an experience not deemed some form of intellectual recess or decorative add-on, but as something essential in the evolution of achieving an identity of professional and moral excellence.

Mark Clark, PhD, is an Associate Professor of Medical Humanities at the University of the Incarnate Word School of Osteopathic Medicine.

References
1. Holden, MD, et al. (June 2015) “Professional Identity Formation: Creating a Longitudinal Framework Through TIME (Transformation in Medical Education).” Academic Medicine 90, 6: 1-7.
2. I added the Sub-Domains “Regard for the Human as an Integration of Mind-Body-Spirit” and “Spiritual Experience,” which do not appear in the Task Force document. These elements reflect dimensions of the identity sought at a school of osteopathic medicine and a Catholic university. The additions suggest an important point: an institution has a role in the shaping of professional identity and ought to address this through the development of Sub-Domains unique to the program.
3. As our Task Force had noted and which I have sought to address in depth, the full scope of the challenge becomes (1) to determine what is called for in promoting development, longitudinally, with respect to each of the Sub-Domains; (2) to design and deliver educational experiences that promote such development; and (3) to design and implement modes of assessment that track development. A suitable discussion of addressing this challenge is beyond the scope of this article.

Background and aim: Nursing students form a professional identity from their core values, role models, and past experiences, and these factors contribute to the development of their professional identity. The hidden curriculum, a set of ethics and values learned within a clinical setting, may be part of developing a professional identity. Nursing students will develop a professional identity throughout school; however, their identity might be challenged as they attempt to balance their core values with behaviors learned through the hidden curriculum. The purpose of this project was to educate students on the hidden curriculum in the development of their professional identity.

Materials and methods: A sample of 112 senior nursing students was recruited from a northeastern university in the United States for this study. Pre–post survey design was used, and an educational session was administered prior to the post-survey. Descriptive statistics and a valid percentage were used to describe the data within the surveys.

Ethical consideration: Study was approved by the author’s University Institutional Review Board.

Findings: A significant finding was for advocacy as students would speak up if witnessing inappropriate behavior toward patients or families with a mean score increase from 2.50 (pre-survey) to 1.45 (postsurvey). Also, over 95% (n ¼ 106) found the educational session beneficial as they learned they had the ability to advocate and speak up for their patients.

Conclusion: Students were able to use their core values and advocate for their patients and families which allows for safer patient care.

Published in Nursing Ethics.

Companies of all sizes and from all industry sectors are working to create and strengthen their Compliance Programs. Compliance is adhering to the sundry of external laws, rules and regulations; internal policies and procedures; and standards and best practices of the “business you are in.”

Employees have varying reactions to an organization’s compliance requirements. At times the response can be the perfunctory getting the boxes checked off, so someone from the HR or Compliance Department will stop sending you reminders. Compliance obligations today are probably on the list of what keeps senior management and board members up at night.

The expectations of companies today can be dizzying. As healthcare professionals, we think of compliance as things we need to consider for the health and safety of people we treat and work with. However, there are many other areas of compliance that an organization must consider, such as employee relations and accountability, the environment and the many financial aspects of the company. One overall way to think about compliance is simply to “Do the right thing.” (1)

Compliance needs to be managed, and companies give the detailed oversight to a particular department and key employees from other departments. They work from a framework of Seven Pillars to plan, execute and monitor their compliance program (2).

A major component of any compliance program is a company Code of Conduct. These are becoming more robust. Within the Seven Pillars of an effective compliance program and within the company code of conduct, the elements of “professionalism” may not be apparent. This potential gap is an opportunity for those working to build professionalism among healthcare employees to work with their compliance officer.

The compliance officer may not realize that much synergy can come from approaching compliance from a professionalism angle. Certainly professionalism is part and parcel to a company’s code of conduct, but it may not be explicit. We could point out to compliance officers that by abiding by our respective professional codes of conduct, we help build an overall culture of compliance for the company (1). It is similar to herd immunity.

In a chapter in a recently published book on managing nonprofit health organizations, I explained how professionalism is one of the guards that helps companies avoid “Mismanagement, Misdemeanors and Crimes” (3). Emphasizing professionalism, along with board member oversight, developing a code of conduct, keeping an eye toward best practice, employee staffing, legal advice, and quality assurance checks from outside entities, are areas management should consider to avoid bad acts from taking place in a company.

Compliance officers look for creative ways to implement their strategies and tactics to meet their compliance goals and objectives (4). Consider reaching out to compliance officers to see how the professionalism initiatives in healthcare can support company compliance goals.

Stephen Gambescia, PhD, is professor of health services administration at Drexel University, College of Nursing and Health Professions in Philadelphia.

References
1. Singh, N. & Bussen, T.J. (2015). Compliance management: A how-to guide for executives, lawyers, and other compliance professionals. Santa Barbara, CA: Prager, p. 3.
2. Compliance 360 (n.d.). White Paper: The seven elements of an effective compliance and ethics program. Alpharetta, Georgia: Author.
3. Gambescia, S. F. “Chapter 17: Mismanagement, Misdemeanors, and Crimes” in S.F. Gambescia, S. Bastani & B. Melgary (Eds.). (2019). The healthcare nonprofit: Keys to effective management. Chicago, IL: Health Administration Press.
4. Jacobus, L. (2019). Module 11 Discussion Board: Creative Ideas to Remind Employees of Company Code and Policies. Retrieved from Blackboard LSTU 501S: Compliance skills: Auditing, investigations & Reporting. Kline School of Law, Drexel University.

Practitioners are being urged these days to a kind of “resource stewardship” as a way to combat healthcare costs (1). This may include encouraging discussions of the cost of proposed treatments with the patient (2) or, separately, making treatment decisions based on costs to the healthcare system itself (3).

The former is necessitated by the bankrupting cost of care and treatment in the U.S. (4) where more than 28 million citizens have no health insurance and millions more have, at best, limited care coverage. Related to this is the perceived need to curb the rising national costs of care currently estimated in the United States at 18 percent of the U.S. Gross Domestic Product. This results in a triage economy in which there will be, at best, minimal care for less wealthy patients whose aggressive treatment is sacrificed to the common good (5).

All this ignores the central issue, the inequities of the U.S. healthcare system itself. Practitioners are asked to be “stewards” (6) of, by far, the most expensive, least efficient, least equitable healthcare system in the multi-nation Organization for Economic Cooperation and Development (OECD).

If the problem is systemic then so, too, it must be the corrective. And yet, nowhere in the literature on resource stewardship do authors call for a reformation of the U.S. healthcare system. The reason may be in the rise of “professionalism” as a standard of professional behaviour. Professionalism presents as a given metaphorical, non-negotiated contract between government, business, and the health practitioner (7). The contract is assumed to be sealed; its contents never critiqued. The necessity of its renegotiation is never discussed.

The result is an ethic that increasingly denies the primacy of the practitioner’s traditional, vocational focus on individual care (8) for one that urges practitioners to think first, as bioethicist Daniel Callahan urged, "The common good and collective health of society." (9)

But “good stewardship” is more than triage of a distressed, over-extended system. It is about the ordering and then maintenance of one that is once viable and sustainable. Good stewards are active in that system’s design, not quiescent in the face of its failings. It is, therefore, perhaps time for organizations like the Academy of Professionalism in Health Care to actively engage the health debate, arguing publicly for systemic improvements.

We can and, I argue, are obliged—as citizens and as practitioners--to advocate for a system that better serves all persons (10). Other OECD countries, where care is universal and costs relative to GDP are less (10.8 percent in Canada), provide convenient examples of what could be. Certainly, it is incumbent on individual practitioners distressed by current realities to insist upon reforms to the system-at-large in a manner that will assure comprehensive care for all without encouraging the penury of the many we are engaged to treat.

Professor Tom Koch is an ethicist and consultant in chronic and palliative care. He is the author of Ethics in Everyday Places: Mapping Moral Stress, Distress, and Injury.

References
1. Centers for Medicaid and Medicare Services, 2018; cited in Apple R. the Professionalism in Suing Patients.” Professional Formation 2019.
2. Perez SL, Weissman A, Read S. et al. U.S. Internists' Perspectives on Discussing Cost of Care With Patients: Structured Interviews and a Survey. Annals of Internal Medicine. May 2019. https://annals.org/aim/fullarticle/2732821/u-s-internists-perspectives-discussing-cost-care-patients-structured-interviews.
3. Thomasma DC. The Asbury Draft Policy on ethical use of resources. Cambridge Quarterly of Healthcare Ethics 1997; 8 (2): 249.
4. Dbokin C, Finkelstein A, Kluender R. Notowidigdo MJ. Myth and Measurement — The Case of Medical Bankruptcies. N.E. J. of Medicine 2018; 378:1076-1078 DOI: 10.1056/NEJMp1716604.
5. Callahan D. Individual good and common good: A Communitarian Approach to Bioethics. Perspectives in Biology and Medicine 2001; 46 (4): 496-507.
6. Seuli Bose Brill SB, Moss KO Prater L. Transformation of the Doctor–Patient Relationship: Big Data, Accountable Care, and Predictive Health Analytics. HEC Forum 2019; 31: 261-282. https://doi.org/10.1007/s10730-019-09377-5.
7. Cruess RL., Cruess SR. Expectations and obligations: professionalism and medicine’s social contract with society. Perspectives in Biology and Medicine 2008;51:579–98. doi: 10.1353/pbm.0.0045.
8. Koch. T. Professionalism: An Archeology. HEC Forum 2019; 31:219-232
9. Rothman D. 1992. Rationing life. New York Review of Books. March 5, 1992: 33.
10. Willson P.D. The Importance of Lobbying to Advance Health and Science Policy.
Academic Medicine 2019. Doi: 10.1097/ACM.0000000000003036.

Since its inception, the term professionalism in its sensu stricto (4) included those human activities that had categorical import as providers or keepers of essential or basic human goods required for human flourishing.

Pellegrino emphasized four features that are fundamental for a human activity to be a true profession: First, is the nature of the human needs it addresses. Those essentials to our fulfillment as human persons. When unsatisfied, our humanity itself is wounded. Second, consider the vulnerable state of those it serves-- a state of necessity and vulnerability. Third, the expectation of trust it generates; the character of the professional and her or his willingness to work for the benefit of the patient is absolutely essential. Fourth the social contract that allows, either for training, curing or healing, access to intimacy and privacy coerced by disease (5). The practice of medicine: preserving life and health, law preserving life, liberty and other goods, and men and women of the cloth referring to life thereafter seem to fulfill the previous criteria.

In its sensu latu (6) profession may describe any gainful lifelong activity in sports or other trade/craft choices. As a noun: competence or skill is expected of a profession – practicing of an activity, especially a sport by professional rather than amateur players (7).

Professionalism: “the conduct aims or qualities that characterize or mark a profession or a professional person (8). From a philosophical (9) or a more inclusive perspective, the key features of profession are important and exclusive expertise, internal and external recognition, autonomy in matters of expert practice and the obligations of professions and professionals towards their clients. “Clients” seems to be a less restrictive or more inclusive term.

Thus, we can affirm that professions, at least in the strict sense as “good moral communities” of physicians cognizant of and “willing to honor the ethical commitments for the best interest of the patient as a primary consideration and to always do what is in the patient’s best interest to the best of his/her ability (10,11), when adherent to their principles would be beyond behavior that could harm the consumer or hinder fair competition. Relman (12) stated that when physicians start seeing themselves as businesspeople selling high tech services, it is the beginning of the end for the profession.

Then professions should not be subject to Federal Trade Commission’s regulations and or surveillance, since as professions in themselves (self-regulation) they would not wield, even if they could, market power or monopoly power (13) in a way that could harm consumers by such activities as price fixing or restriction of trade.

But lo and behold in a landmark case in 1975, Goldfarb vs. Virginia State Bar it is judged that “…professions are not exempt from antitrust laws. Against… price fixing and… restraints of trade…” In this instance, professionals (lawyers) were behaving or acting, the court thought, as traders or in such a way that their activities fell under the jurisdiction of the Federal Trade Commission. When self-regulation lags, leaving a vacuum, external constraints will fill the void.

Professionalism is then, a term with multiple meanings and inclusive, which in common usage recognizes superior performance and some obligations to others. It should be the aspiration of every member of morally good communities to ease human flourishing of both self and others by “professionalizing” his or her work or endeavors.

Raul Perez, MD, is Professor of Ophthalmology and Medical Ethics at the University of Puerto Rico School of Medicine.

References
1. Commentary on a Text by Scribonius Largus, Edmund & Alice Pellegrino, Literature and Medicine Vol 7, 1988 pp.
22-38.
2. The Future of Medical Practice, Arnold S. Relman MD, Health Affairs Vol 2, No 2, Summer 1983
3. (conference call)
4. “Narrow or strict sense”: in the restricted sense. Oxforddictionares.com
5. Pellegrino’s approach also lays the foundation for a philosophy of medicine.
6. In the broad sense, more inclusive vs. original description or definition. Researchgate.net
7. Oxforddictionares.com
8. Merriam Webster0nline
9. Encyclopedia of Bioethics 2004, David T. Ozar, PhD, pp.2158
10. Ibid 2
11. Ibid 1 “Nothing is more important than the skill as a whole.”
12. The Future of Medical Practice, Arnold S. Relman MD, Health Affairs Vol 2, No 2, Summer 1983
13. Market power: “is the ability to raise prices above those that would be charged in a competing market.” “Monopoly power is substantial market power.” Document 180-1 Section Five of the FTC Act

APHC Members' Scholarship
Here are recent books authored by APCH Members.

Medical Professionalism Across Cultures: A Literature Review by Gerald Stapleton
This review aims to identify the cultural perspectives of medical professionalism by identifying relevant literature from the Middle East, East/South Asia and the Western world that discuss definitions. A literature search was conducted using the "Summon" search engine, and 200 articles sorted by relevancy were manually reviewed. Based on the surveys and documents gathered from each of the regions, the definitions seem to be fairly consistent in their recognition of characteristics important to the concept of medical professionalism. These include several characteristics, with some of the most common being personal character, respect for patient autonomy, responsibility and social obligations; the main difference lies in emphasis with the West focusing on societal issues and patient rights, the Middle East focusing on morality and personal character, and East Asia focusing on respect, responsibility and other duties. These differences are reviewed, and the cultural sources are further expanded upon.

Yasin, L., Stapleton, G. R., & Sandlow, L. J. (2019). Medical Professionalism Across Cultures: A Literature Review. MedEdPublish, 8(3). doi: 10.15694/mep.2019.000191.1

Remember Evil: Remaining Assumptions In Autonomy-based Accounts Of Conscience Protection by Bryan Pilkington
Discussions of the proper role of conscience and practitioner judgement within medicine have increased of late and with good reason. The cost of allowing practitioners the space to exercise their best judgement and act according to their conscience is significant. Misuse of such protections carve out societal space in which abuse, discrimination, abandonment of patients and simple malpractice might occur. These concerns are offered amid a backdrop of increased societal polarization and are about a profession (or set of professions) which has historically fought for such privileged space. There is a great deal that has been and might yet be said about these topics, but in this paper author Bryan Pilkington addresses one recent thread in this discussion: the justification of conscience protection rooted in autonomy.

Pilkington, B. C. (2019). Remember Evil: Remaining Assumptions In Autonomy-based Accounts Of Conscience Protection. Journal of Bioethical Inquiry, 1-6. DOI: 10.1007/s11673-019-09949-7
https://link.springer.com/article/10.1007/s11673-019-09949-7

The following interview took place at the Gold Humanism Summit 2019 in Orlando, Florida.

Dr. David Doukas, founder and first president of the Academy for Professionalism in Health Care (APHC) was interviewed regarding the journey to developing the APHC. Dr. David J. Doukas, is also the James A. Knight Professor of Humanities and Ethics in Medicine, Department of Family and Community Medicine, Tulane University.

Dr. Doukas, undertook a Post-Doctoral Fellowship in Bioethics at the Joseph and Rose Kennedy Institute of Ethics at Georgetown University with Dr. Edward Pellegrino in 1986-7 in which his studies examined end-of-life care ethics and the ethical basis of medical practice within the context of virtue ethics. Subsequently in 1999, Dr. Doukas, as the American Society for Bioethics and Humanities (ASBH) representative to the Association of American Medical Colleges’ (AAMC) Council of Academic Sciences (CAS), was curious about the lack of a moral framework for the newly introduced Accreditation Council of Graduate Medical Education (ACGME) General Competencies which included Professionalism and had ethics obviously woven throughout the numerous competencies. To address this non-attributed ethical underpinning of the General Competencies, he wrote, “Where is the virtue in professionalism?” (1) and advocated that the ACGME General Competencies could catalyse ethics education and nurture virtue ethics to support the flourishing of trainees’ character as they become physicians.

In 2010, Dr. Doukas, collaborated with Drs. Laurence McCullough and Stephen Wear in an examination of Abraham Flexner’s 1910 report in medical schools (2) and found that Flexner considered medical ethics and humanities central to medical education, predicated on pre-medical education in humanities. The authors subsequently led the Project to Rebalance and Integrate Medical Education (PRIME) from 2010 through 2012.

PRIME I brought together a panel of American expert educators in history, visual arts, ethics and literature, who concurred that teaching in medical ethics and the humanities in medical school is necessary to train humanistic physicians and supports development of the critical appraisal skills necessary for medical professionalism (3). PRIME II included the original participants as well as representatives of three accreditation bodies, which included leaders from LCME, ACGME and AAMC. Recommendations from PRIME II (4) were that: A) “professionalism requires transformational change whereby medical ethics and humanities educators would make explicit the centrality of professionalism to the formation of physicians, B) the flourishing of professionalism must be based on first addressing the dysfunction now affects the current system of healthcare delivery and financing that undermines the goals of medical education and C) ethics and humanities educators must have unity of vision and purpose in order to collaborate and identify how there disciplines advance professionalism.”

PRIME III (also called the Keystone Conference) was the 2012 national conference serving as the culmination of the PRIME project in which educational accreditation leaders and national scholars and educators articulated a framework on how to implement curricula based on medical ethics and humanities to catalyze professionalism formation. The PRIME III meeting was held in Chicago and speakers included: Dr. Rita Charon speaking on narrative medicine and Dr. Daniel Kirsch, the AAMC’s then president.

Attendance far exceeded the goal with 167 U.S. and international registrants. It was abundantly evident after this successful conference that the efforts toward building professionalism pedagogy could not end in 2012. Dr. Doukas envisioned an entirely new academic organization with its roots based upon the gathering of a critical mass of interested scholars and educators from the PRIME project and reaching out broadly to all facets of healthcare. Collectively between the Flexner and PRIME projects, 11 new, major peer–reviewed publications have been added to the literature in the last decade, serving as a foundation for APHC and professionalism scholarship in the future.

The Academy for Professionalism in Health Care (APHC) was founded on June 4, 2012, as a natural outgrowth of PRIME, with the aim of developing an academic community for ethics and humanities scholars and educators in all facets of healthcare who wished to discuss professionalism education for all healthcare learners. The APHC’s second aim was to contribute to advanced learning in professionalism for scholars and educators by creating a higher level of educational development within APHC of “Fellows of the Academy” based upon meaningful contributions in both scholarly and organizational work. One attempt in this regard was the establishment of "Romanell Fellows," sponsored by the Edna and Patrick Romanell Fund for Bioethics Pedagogy, Stephen Wear, Trustee, where several educators/scholars were brought together for our annual meetings with a scholarship to promote their attendance.

Dr. Doukas authored the first bylaws and 501(3)(c) documents and ensured the APHC organization was given tax-exempt status. During the first several years, Dr. Doukas in his role as President orchestrated board meetings, set board agendas, worked with consulting accountants on organizational finances, facilitated negotiation of hotel contracts for annual meetings, authored the webpage and publicity flyers for the organization and worked with program chairs to solicit and review annual meeting abstracts submissions. Early board members included: Drs. J. Carrese, C. Braddock, J. Malek, H. Brody, S. Wear, S. Lederer, L. Lehman, L. Nixon, J. Katz, M. Green, and J. Shapiro.

Dr. Doukas strived to build relationships with not only the accreditation organizations of AAMC, ACGME and LCME, but also facilitated strategic partnerships that exist to this day with the American Society for Bioethics and Humanities (ASBH), and the Academy of Communication in Healthcare (ACH) – which resulted in APHC’s strategic alliance with ProfessionalFormation.org. He also pursued ongoing, strengthened relationships with the Arnold P. Gold Foundation, the American Board of Internal Medicine Professionalism Round Table and the American College of Dentists. Dr. Doukas has worked to promote APHC to all healthcare educators and to solicit contributions and invite their membership to APHC.

Dr. Doukas’ diligence in striving for excellence has insured that the annual conferences and continued membership in the organization would allow for APHC to flourish as an autonomous academic society devoted to professionalism education and pedagogical scholarship. These efforts culminated with the extraordinarily successful 2019 APHC meeting in New Orleans (with over 200 attendees), which helped to firmly establish the organizational foundation for a future of growth and success.

Janet de Groot, MD, FRCPC, MMedSc, Staff Psychiatrist, Tom Baker Cancer Centre and Foothills Medical Centre, Associate Professor, Psychiatry, Oncology and Community Health Sciences, Cumming School of Medicine, University of Calgary

References
1. Doukas DJ. Where is the virtue in professionalism? Cambridge Quarterly of Healthcare Ethics 2003; 12(2): 147-154.
2. Doukas DJ, McCullough LB, Wear S. Reforming medical education in ethics and humanities by finding common ground with Abraham Flexner. Acad Med. 2010;85:318 –323
3. Doukas DJ, McCollough LB, Wear S for the project to rebalance and integrate medical education investigators. Perspective: Medical education in medical ethics and humanities as the foundation for medical professionalism. Acad Med 2012; 87(3): 334-341
4. Doukas DJ, McCollough LB, Wear S, et al. The challenge of promoting professionalism through medical ethics and humanities education. Acad Med 2013; 88: 1624-1629.
Additional Publications
Articles, Peer Reviewed
Doukas DJ, McCullough LB, Wear S, “Re-visioning Flexner: Educating Physicians
to be Clinical Scientists and Humanists,” American Journal of Medicine, 123(12):
1155-1156, 2010.

Fins JJ, Pohl B, Doukas DJ, “In Praise of the Humanities in Academic Medicine: Values, Metrics and Ethics in Uncertain Times.” Cambridge Quarterly of Healthcare Ethics, Aug 12:1-10, 2013.

Brody HA, Doukas DJ, “Professionalism: A Framework to Guide Medical Education.” Medical Education, 48, 980-987, 2014.

Doukas DJ, Kirch DG, Brigham TP Barzansky BM, Wear S, Carrese JA, Fins JJ, Lederer LL, “Perspective: Transforming Educational Accountability in Medical Ethics and Humanities Education Toward Professionalism.” Academic Medicine, 90 (6):738-743, 2015.

Carrese JA, Malek J, Watson K, Lehmann LS, Green MJ, McCullough LB, Geller G, Braddock CH, Doukas DJ, “The Romanell Report: The Essential Role of Medical Ethics Education in Achieving Professionalism.” Academic Medicine, 90 (6):744-752, 2015.

Shapiro J, Nixon LL, Wear SE and Doukas DJ, “Medical Professionalism: What the Study of Literature Can Contribute to the Conversation.” Philosophy, Ethics, and Humanities in Medicine, 10:10, 2015.

Doukas DJ, Volpe RL, “Why Pull the Arrow When You Cannot See the Target? Framing Professionalism Goals?” Academic Medicine, 93(11):1610-1612, 2018.

Open Commentaries, Peer Reviewed by Journal Editorial Board

Doukas DJ, “Promoting Professionalism Through Virtue Ethics,” American Journal of Bioethics, 19(1): 37-39, 2019.

If you Google empathy in healthcare, the articles, blog posts, book reviews, etc., detail the necessity for healthcare professionals to be empathetic toward their patients. Many hospitals and healthcare providers provide training to their healthcare professionals to facilitate empathy toward patients and their families. But what about empathy between colleagues in healthcare?

Adam Waytz, in his article, “The Limits of Empathy” published in the Harvard Business Review, notes that being empathetic is exhausting, “…empathy depletes our mental resources. So, jobs that require constant empathy can lead to ‘compassion fatigue,’ an acute inability to empathize that’s driven by stress and burnout, a more gradual and chronic version of this phenomenon.” He goes on to specifically note that healthcare workers such as doctors, nurses and social workers are especially susceptible to this type of fatigue. And this makes sense, especially given the obvious fact – healthcare professionals are dealing with life and death situations. They are dealing with patients and their families who are afraid, sad, angry, worried and confused on a daily basis, which can be draining over time.

But we know that empathy in the workplace is necessary for an organization to function effectively. Empathy fosters communication, collaboration, diversity and inclusion, and is necessary for successful leadership. According to the Businessolver’s 2019 State of Workplace Empathy, empathy is a human need and it is also “…a business imperative that leads to tangible bottom line impact.” And while there has been progress in valuing empathy in the workplace, this report has identified the widening “Empathy Gap,” which they define as “the difference between employees and employers in their perception of empathy in the workplace.” This year, 58 percent of CEOs report having difficulty in exhibiting empathy on a consistent basis. If leadership is struggling to show empathy toward their employees, then how are those same employees supposed to show empathy toward one another? And to further complicate this question, how can healthcare professionals who are at risk of empathy burnout with their patients, find that emotional space for their colleagues?

Barring life and death decisions that need to be made immediately, where there is little space for pleasantries or give and take, here are four ways colleagues in healthcare can be empathetic toward one another, even when their empathy tank is close to empty.

1. Listen – take a step back from the face-paced conditions of healthcare for a moment to listen to your colleagues. Listening is one of the most important aspects of empathy. When a colleague feels they have been heard, they are more able to accept an unanticipated outcome. Conversely, when you don’t listen, you come across as either disinterested or arrogant – neither of which will serve you well over time.
2. Ask Questions – when you don’t agree with a colleague, begin by asking a few questions to gain a better understanding of their viewpoint. When you give your colleague the opportunity to explain their point of view, you may learn something about a process or policy or situation you had not previously considered.
3. Avoid Assumptions – the old adage about making assumptions remains true. When you make an assumption about another colleague, about their ideas or about their work, you set yourself up to be wrong. Perhaps more important, you are contributing to a toxic work culture.
4. Interactions with your Colleagues – when you can spend a minute or two on a daily basis learning about one another, whether it is one’s love of chocolate, Lifetime movies, football, concerts or even cat videos, you learn about someone else’s interests and thus their life, which tends to make you more empathetic, because Joe is not just Joe who works on the peds floor – Joe is a person whose mother recently passed away, who is also a huge Eagles fan, and he loves cats.

These four pathways to being more empathetic are cornerstones of good communication, which is essential to a productive work environment. Good communication tamps down conflict, which often stems from misunderstandings, refusal to see someone else’s point of view and arrogance. However, there is no doubt that empathy in the workplace filters down from the top. Senior leadership in healthcare must acknowledge empathy cannot be reserved for medical and professional staff and their patients and patient families only, it must also be encouraged and fostered between colleagues. This is a huge commitment that will require effort, resources and patience. But, this cannot rest solely in the hands of leadership; each employee should commit to being empathetic with one another. And it starts with you.

The time you invest in being more empathetic will not be wasted. In fact, according to Brian Robinson, a Professor Emeritus at UNC-Charlotte and an author who has studied workplace issues says, “Empathy gives you control over challenging work situations that you cannot control. It keeps you calm, cool and collected, holding your integrity intact. Stress-free, empathetic relationships between management and employees and among coworkers are mutual [and] flow freely.” He then outlines the five qualities of these empathetic relationships beginning with open communication, avoiding harsh criticism and judgment, striving to see another’s viewpoint, episodes of appreciation and the application of a win-win strategy versus the I win, you lose approach.

Think about your work environment and ask yourself how you can be more empathetic: how can you listen more often and listen more actively? Can you ask more questions and be open to the responses? Do you make assumptions about your colleagues, why they didn’t do their job or how they did it, why they’re late and so forth? And finally, can you take a few minutes to get to know your colleagues, ask them questions about their lives outside of the hospital, the clinic, etc. Actively being empathetic not only improves your daily work experience, it improves it for your colleagues as well.


Anne Converse Willkomm is Assistant Professor and Department Head of Graduate Studies in the Goodwin College of Professional Studies at Drexel University in Philadelphia

References
Waytz, A. (2016). “The Limits of Empathy” Harvard Business Review. January-February Issue,
(pp. 68-73). https://hbr.org/2016/01/the-limits-of-empathy

Robinson, B. (2019, July 3). Workplace Empathy Packs A Powerful Punch: Discover The Jaw- dropping Results. Forbes. Retrieved from http:
https://www.forbes.com/sites/bryanrobinson/2019/07/03/workplace-empathy-packs-a-powerful-punch-increasing-job-satisfaction-motivation-and-productivity/#77bab8892b60

Shanahan, R. (2019, March 28). The 2019 State of Workplace Empathy Study: The Competitive
Edge Leaders are Missing. Businessolver Blog. Retrieved from: https://blog.businessolver.com/author/rae-shanahan

Looking back at recent postings on social media and in the news during the month of September, there was an increase in attention towards suicide awareness. As future physicians, medical students must be better equipped to converse with patients experiencing active suicidal ideations. In 2017, the CDC reported that 47,173 people committed suicide in the United States (1), and there are about 420,000 emergency room visits for intentional self-harm per year (2). Unfortunately, rates of suicide have been increasing over time and seem to be linked with multiple factors including location (3), race (4) and age (5).

When caring for a patient with suicidal ideations, a student cannot easily tell by looking at their vitals and laboratory values whether a patient is a danger to themselves or to others. The management of suicidal patients involves experience from practicing the “art” of medicine whereas most students who are starting on their clerkships are experienced in the “science” of disease processes. As with physicians, medical students also have an ethical duty to provide the best patient care possible; failing to address the needs of those with mental health issues in various clinical settings highlights the tension between beneficence and nonmaleficence.

Students are in a unique position on the medical team, because they are directly responsible for a smaller number of patients and can commit more time to interacting with each of their patients by obtaining extensive histories. I believe there are a few ways in which medical schools can teach students how to more comfortably approach conversations and develop trust with patients who have expressed suicidal ideations.

First, as more medical schools are running expanded orientation periods for students prior to clerkship training (6), a portion of these orientations should be set aside to address how to communicate with patients presenting with suicidal ideations or other psychiatric complaints. Medical schools frequently utilize standardized patients for teaching students how to discuss bad news about poor prognoses and also how to do genitourinary and breast examinations in supervised clinical educational settings. Schools could use a similar approach for students to practice interacting with patients with suicidal ideations in a safe space with the support of faculty and peers before going on to the wards.

Additionally, students in their psychiatry and other hospital-based rotations should be given the opportunity to rehearse a suicidal risk assessment with a designated attending physician before being observed while administering it to a patient in real time. Completion of such learning outcomes can be documented through patient logs to ensure adequate exposure, training, and formative feedback.

Finally, while multiple choice subject examinations should play a role in assessing a student’s fund of knowledge, the importance of assessing a student’s clinical skills is absolutely crucial to ensure that medical schools are graduating future physicians who can excel in real-life clinical settings. Competency-based assessments such as Objective Structured Clinical Examinations (OSCEs) would provide valuable feedback not only on student performance and preparedness but also on how effective the clinical curriculum is for the training of students which is important information to psychiatry clerkship directors.

Advocating for such changes in medical education is meant to benefit our patients, and it is also a professional obligation to highlight and attend to areas of need within our profession. It is an important responsibility, and a moral conundrum, to have the least senior member of the medical team be put in the position of relaying a patient’s mood and feelings to the rest of the team. Therefore, it is imperative for schools to educate students before embarking on their clinical years and throughout their schooling on how to approach conversations regarding suicide as these encounters can occur in any clinical setting.

Steven M. Henick is a third-year medical student at the Albert Einstein College of Medicine.

References
1. National Center for Injury Prevention and Control, CDC. Suicide Injury Deaths and Rates per 100,000 in 2017, United States. https://webappa.cdc.gov/cgi-bin/broker.exe. August 2019.
2. Miller IW, Camargo CA, Arias SA, et al. Suicide Prevention in an Emergency Department Population: The ED-SAFE Study. JAMA Psychiatry. 2017;74(6):563–570. doi:10.1001/jamapsychiatry.2017.0678
3. Rodrick, S. All-American Despair, Rolling Stone, May 30, 2019. URL: https://www.rollingstone.com/culture/culture-features/suicide-rate-america-white-men-841576/
4. Lindsey MA, Sheftall AH, Xiao Y, Joe S. Trends of Suicidal Behaviors Among High School Students in the United States: 1991-2017. Pediatrics. 2019.
5. Conejero I, Olié E, Courtet P, Calati R. Suicide in older adults: current perspectives. Clin Interv Aging. 2018;13:691–699.Published 2018 Apr 20. doi:10.2147/CIA.S130670
6. Ryan MS, Feldman M, Bodamer C, Browning J, Brock E, Grossman C. Closing the Gap Between Preclinical and Clinical Training: Impact of a Transition-to-Clerkship Course on Medical Students' Clerkship Performance. Acad Med. 2019.

CBD (cannabidiol) is the source of more than 6.4 million hits on the internet monthly. A 2019 Gallup poll demonstrates use at 17percent of adults in the U.S. Currently, CBD in its three basic forms is the talk of the town, the state, the country and the world. CBD, the acronym for cannabidiol, is, in one of its forms, a major ingredient in medical marijuana, along with delta-9-tetrahydrocannabinol (THC). It is the THC content that determines marijuana potency. Currently, this is the only way we have of comparing the physiologic effects and side effects of each strain of the Cannabis sativa plant. In comparison with the psycho-active effects including euphoria created by THC, CBD theoretically is responsible for immune-modulating, anti-inflammatory and anti-psychotic properties. CBD is showcased as a rock-star in miraculous wellness benefits, few of which have shown positive human clinical efficacy.

The second form of CBD is a FDA approved drug, reproducible as a single agent product, EPIDIOLEX, (0.1 percent or less THC). It is currently indicated as add-on treatment for two childhood epileptic syndromes, Dravet’s and Lennox-Gastaut. This product, costing some $32,000 per year, is the source of much hope for indications to come. Numerous drug interactions may limit its use. For future clinical benefits, multiple companies are studying various uses of CBD, in its refined pharmaceutical form.

The third source of CBD is for hemp-derived CBD, recently considered in new federal legislation. The Agriculture Improvement Act of 2018, re-categorized hemp, a genetic cousin to marijuana, as separate from marijuana. The legislation removes hemp from controlled drug status, removing its DEA scheduling from that of schedule 1, as marijuana is considered an illegal drug. This legislative change allows hemp to be transported in interstate commerce for utilization in paper, clothing, building and other industries. And, generally, hemp has little THC content, making the definition of hemp-derived CBD, containing 0.3 percent or less of THC. The FDA has kept its authority over hemp-derived CBD, still considering any products associated with it to be schedule 1, in following with DEA regulations. This makes the movement of hemp-derived CBD illegal in interstate commerce. Online purchasing, mailing or moving hemp-derived CBD between states is federally illegal.

Of the three forms of CBD listed herein, CBD derived from hemp has been and is the source of most patient concerns, hopes and dreams. While patients may not recognize the difference between CBD types, this is the source of CBD that may be promoted for some legal use in all 50 states. Various state laws now, much like medical marijuana state laws, allow the sale of locally produced hemp-derived CBD (0.3 percent or less of THC), in lotions, oils, edibles, beverages, pet products, animal feeds, etc.

Patients want access to CBD, wondering if it will allay their ills. The promotion of CBD for sometimes miracle producing, disease curing, symptom-relieving phenomena for almost every known malady is not allowed. And, it was recently shown in a sample of over 80 different CBD products for sale, approximately two-thirds of the products were mislabeled, adulterated, counterfeit, indeed, not containing hemp-derived CBD as labeled. Yet, understandably confused patients, interested in learning, are wondering if these products might change their lives in a positive way.

One would hope patients would come to their clinicians to discuss and learn about options. This means clinicians need to be in the know about the facts and myths about this category of products. As clinicians, we must be cognizant of the importance of patient preferences in treatment. Legally, these products are not to be promoted for prevention, treatment or cure of diseases. Just this past month, CBD manufacturers have been the subject of FDA warning letters and actions to stop them from recommending CBD for Parkinson’s disease, ADHD, Alzheimer’s, anxiety, depression and many other disorders for which there is no concrete evidence of efficacy.

The expectation and hope that patients will be involved in treatment decisions is a positive in the world’s amazingly prolific availability of information about therapies and possible treatments. But, CBD products, in all forms except for the one available FDA product, have virtually no evidence of benefit. Scientifically speaking, they have many risks, such as significant drug interactions, including those with opiates, anti-depressants, anti-anxiety agents and anti-convulsants. Also significant is the reality of liver enzyme abnormalities and potential liver toxicity associated with its use.

Patients have unique knowledge of their own health preferences with final decisions about their care, self-care or otherwise, becoming their own. Partnerships with clinicians take time to develop. Trust, fairness and non-judgmental approaches make the development of that partnership worthwhile and comforting. Patient preferences may differ from those of their health care professional. And, it has been shown that when the physician is viewed as more powerful and knowledgeable than they are, the patient is reluctant to share preferences. Research has shown that some clinicians may not have proper skill sets to communicate with patients to elicit patient preferences. It has been said that a patient must be given technical info in an unbiased format to ensure preferences are based on fact and not misconception.

And, so it goes, with CBD. As a clinician and/or ethicist, are you ready to assist your patients in learning more about the issues associated with CBD? What are the resources you will use? How will you lead in your community to support and encourage discussions of these products, the regulations associated with them, or the safety factors? How can you effectively partner with your patients to help them determine if the benefits outweigh the risks of use?

Check with state authorities, such as Boards of Pharmacy and Agriculture for specifics on your state’s status with CBD regulations.

Here are resources for a CBD toolkit:
1. National Academies of Sciences, Engineering, and Medicine. 2017. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press.
2. Guidance for the use of medical cannabis in Australia. Overview. Dec. 2017.
3. Simplified Guideline for Prescribing of Medical Cannabinoids in Primary Care. Canadian Fam Phys. Feb 2018.169:5,
4. Keyhani, S, et al. Risks and Benefits of Marijuana Use: A National Survey of US Adults. ANN IM. Sept 2018. 169:4, 282-290.
5. Marijuana as Medicine, National Institute of Drug Abuse,https://www.drugabuse.gov/publications/drugfacts/marijuana-medicine
6. Hall, Render: FDA clarifies Position on CBD, After Passage of 2018 Farm Bill, posted January 18, 2019, in HR Insights for Health Care.
7. Devinsky, O, et al. Effect of Cannabidiol on Drop Seizures in the Lennox-Gastaut Syndrome. NEJM, May 2018; 378: 1888-97.
8. Americans Views on CBD Products and Marijuana for Recreational Use< Harvard TH Chan School of Public Health, November, 2019.
9. Solowij, N, et al. A protocol for the delivery of cannabidiol (CBD) and combined CBD and delta-9-tetrahydrocannabinol (THC) by vaporization. BMC Pharmacology and Toxicology 2014, 15:58.
10. Say, RE, et al, The Importance of Patient Preferences in Treatment Decisions-Challenges for Doctors. BMJ 2003; Sep 6; 327 (7414): 542-545.

Cynthia Sheppard Solomon, BSPharm, RPh, FASCP CTTS, NCTTP, is a Clinical Assistant Professor in the Department of IM and Neurology at Wright State University-Boonshoft School of Medicine in Dayton, Ohio.

One of neuro-ethics most valued and expected contributions to medical practice would be a comprehensive definition of death and precise structural and physiologic correlations. For trial lawyers and judges, it would be an anatomy-pathology correlation amenable to probing and assessment by neuro-ethics tools so as to be able “to supply credible evidence of guilt in criminal cases and (blame) responsibility in civil ones.” Therein lies the huge difficulty to be able to “impute the badness of the fleeting act to the enduring agent” (2) from neuro physiologic evidence.

David Hume, (3) a Scottish philosopher, affirmed that human actions do not arise from reason alone but from the passions – those emotions, feelings and desires that humans have. He further enumerated desire, aversion, hope and fear as direct passions. Direct passions are those which arise immediately from encounters with good or evil, pain or pleasure and are the origin of intentional action that “immediately exciting us to action,” he explained.

Julian Hutcheson, (4) also Scottish, argued: “Desires arise in our Mind, from the Frame of our Nature, upon the Apprehension of Good or Evil in objects…” Hutcheson believed that in addition to the external senses, humans have internal senses: among those a “moral sense.” (5)
Hume (6) asserted, that to hold an agent morally responsible for a bad action, it is not enough that the action be morally reprehensible. We must impute the badness of the fleeting act to the enduring agent. Not all harmful or forbidden actions incur blame for the agent. Those done by accident, for example, do not. It is only when and because the action’s cause is some enduring passion or trait of character in the agent.

We could assume that the function of Hume’s passions in human beings would be to initiate, sustain, direct and stop actions or behaviors and provide the corresponding feelings throughout those motions. The medical equivalent would be motivation. “Motivation refers to the characteristic and determinants of goal directed behavior. Theories on motivation are intended to account for the direction, vigor and persistence of an individual’s action, that is, for how behavior gets started, is energized, is sustained, is directed, is stopped and what kind of subjective reaction is present in the organism when all of this is going on.” (7) Maybe the passions are just the philosophical equivalent and/or the source of motivation. Through the disorders of diminished motivation, (8) the anatomic substrate of the passions construct can be found, explored and analyzed. It seems to reside in the cingulate (9) gyrus, its neuronal web and circuitry. And there could be found, perhaps, a legible neuro chemical footprint of “the fleeting act of the enduring agent” that could provide credible evidence for the administration of justice.

Raul Perez, MD, is Professor of Ophthalmology and Medical Ethics at the University of Puerto Rico School of Medicine.

References
1.The Value of Passions in Plato and Aristotle, Stephen Leighton, Southwest Philosophy Review 1995. “In view of this, true virtue can’t be seen as intellect over passion, but involving passions rightly developed.”
2. Cogen, Rachel, “Hume’s Moral Philosophy”, The Stanford Encyclopedia of Philosophy (Fall 218 edition) Edward N. Zalta (ed.), URL=.
3. Hume’s Passions: Direct and Indirect, Jane L. McIntyre, Hume Studies Volume XXVI, Number 1 (April, 2000) 77-86.
4. Ibid 4
5. The passions move agents into action after an encounter in which the “moral sense” determines good or evil, and perhaps other senses assess pain or pleasure.
6. Cogen, Rachel, “Hume’s Moral Philosophy”, The Stanford Encyclopedia of Philosophy (Fall 218 edition) Edward N. Zalta (ed.), URL=.
7. Disorders of Diminished Motivation, Robert S. Marin et al, J Head Trauma Rehabil Vol 20, No. 4, pp. 377-388, 2005 Lippincott Williams & Wilkins, Inc.
8. ICD-10; R 47, R47.01, R 45.3, R 45.84… & neurocognitive disorders due to traumatic brain injury DSM-5 294.11 (FO2.8)
9. Ibid 8 “a cortico-striatal-pallidal-thalamic circuit”

Now and again, I see a professional development course, workshop or short session offering healthcare and other professionals to improve their “soft skills.” I wince when I see professionalism listed among the “soft skills,” because in reality these are not easy to develop and are often more challenging to assess.

Anne Converse Willkomm, Assistant Professor and Department Head of Graduate Studies in the Goodwin College of Professional Studies at Drexel University, Philadelphia, writes about these social skills: “It might seem obvious that these skills are essential to success in the workplace; however, few schools or companies expressly teach these skills because they have long been considered part of the repertoire of skills known as “soft skills,” and thus not as important or valuable as hard or technical skills.” (1)

Having worked in Professional Studies type colleges or programs at several colleges, I can say that when talking with hiring managers, they find these ostensibly “softer skills” the more challenging to find in employees. And professionalism is at the top! To demonstrate, let me offer a common scenario I found when working in this area of continuing professional education. Units within these colleges often go “off sight” and outreach to the business and industry community to provide “tailored training” for their employees. When asking a room full of hiring managers what they want from our graduates, they will list a sundry of industry specific skills, mostly found in the major.

However, when speaking one-to- one to a hiring manager at their place of work, the response shifts dramatically! They tell us: “Listen, we know your graduates will come out ‘educated’ and will know some stuff about this business, but we can really teach them the business of the business in our own way here. What we really need and what is harder to train them on, are good communication, teamwork, professionalism, strong sense of self, being aware of others and just all around being in good form skills.”

Leaders at the Association of American Colleges and Universities who are working on “Advocacy for Liberal Education” are on to the misnomer of referring to these social type skills as “soft skills.” (2) We are perpetuating both the tacit devaluation of the skills and, not so recognized, the challenge to teaching and instilling these skills by calling them “soft.”

As more companies of any type become more circumspect about compliance, they depend on a workforce that can self-monitor behavior and develop an acute sense of what is “the right thing to do.” (3) One approach is to couch these social skills as part-and-parcel to professionalism. While in the realm of behavioral standards, we can move out of the personal sphere to the public sphere to meet the objectives of being professional, thus making the changes to behavior more palatable, as opposed to subjecting people to some type of social engineering. (4)

Instilling the principles and character of professionalism among students and practitioners is not soft or easy; it is hard work!

Stephen Gambescia is professor of health services administration at Drexel University, College of Nursing and Health Professions in Philadelphia.

References
1. Willkomm A. C. Social Skills are Essential Skills. Drexel University, Goodwin College of Professional Studies. 25 Sept. 2019 Retrieved from https://drexel.edu/goodwin/professional-studies-blog/overview/2019/September/Social-skills-are-essential-skills/
2. Association for Colleges and Universities. Advocacy for Liberal Education. 17 October 2019. Retrieved from https://www.aacu.org/advocacy-liberal-education
3. Singh, N, Bussen, T, J. Compliance Management: A How to Guide for Executives, Lawyers, and Other Compliance Professionals. 2016. Santa Barbara, CA: Prager.
4. Gambescia, S, F. A briefing on student civility. Drexel University, College of Nursing and Health Professionals. 7 Nov. 2016. Unpublished student handout.

Case 1. The man enters the emergency department with chest pain, and we can see the death in his eyes. He cannot fix the gaze, and the deep black of his pupils is open to the final act of human life. The despair of the father is mirrored by the endless movement of the mother and grownup children in the waiting room. We do not know anything about him; only that death is coming. Without hesitation, the orchestra of medicine takes over, and the different professionals, with complementary expertise, refill the coronary arteries with blood like the ballerinas fill the music with beauty. The father will come back home.

During the process, this coordinated team was not able to explain to the patient what was going on, and the patient and family were in a kind of wormhole, where space and time were indissociable. We can excuse the team by believing that the time was scarce, and immediate action was needed. OK, but and if the patient had died? Would his last words had been listened to? Would his family have had the opportunity to digest the process? How would the mourning process have been?

Case 2. The woman enters the office at 5 P.M. Her cancer colonized her body, but her mind is still free to be reborn from the sadness and misery. She is feeling the wisdom pouring from the pain and wants to share this knowledge about life - a knowledge that comes from intimacy with death. Her family cannot benefit from her new wisdom, because they still believe death is avoidable, and every time she starts talking about it, they change the subject. For her, sharing this wisdom would be the last act of love, and she chooses you to make it concrete. But you are running out of time, still have a patient to see in the hospital, and end the consultation after the clinical stuff is done. She leaves the office to die in the next week.

We all believe that empathy is essential to achieve patient-centered care and guarantee shared-decision making. We are all terrified of the possibility that medical schools are failing to preserve and nurture the empathy of medical students and residents. Maybe it is time to understand that empathy is not only a concept and a value but also a virtue and a praxis. Understanding empathy as a concept is vital for developing empathy as a praxis.

Compassion, pity or empathy? Compassion is a unique type of solidarity that is born from love. We see; we feel; we act. Compassion is not always conscious. The urge to help takes control of our mind, and suddenly we know the right thing to do. Because compassion is born from love, it is not always possible. I believe that interacting with a compassionate doctor is a blessing, but what should we do when the love is not there?

And my other concern is: to help can be challenging, because often the way we want to help is not the way the patient wants to be helped, and we need to make a conscious effort to adapt our action to the needs as perceived by the patient. This conscious effort is not clearly related to the concept of compassion.

Pity is also a manifestation of love, but a love that comes from a higher position. Thus, pity seems to be a paternalistic feeling that, when perceived by the patient, can increase the sense of impotence and solitude. Pity can also put the patient in a passive position. Although I believe that there is space for pity in specific circumstances, particularly when approaching patients in extremely vulnerable situations, when being active is not an immediate option, I still find it challenging to combine pity with giving equal voice to patients.

The concept of empathy encompasses the cognitive, emotional and volitional aspects of understanding the suffering of another human being. This wholeness clarifies that being empathic is to understand, feel and act aligned with patients’ perceived needs. Although it is challenging to be wholly and always empathetic, the concept of empathy offers health professionals guidance and purpose when interacting with patients.

Thus, I advocate for health professionals to have compassion when possible and pity when necessary, but, above all, health professionals should always aim for empathy. But what does it mean to aim for empathy?

Empathy as a praxis. Aiming for empathy implies that it is an effort to act empathetically. If it is an effort, it demands energy, focus and benefits from the supportive elements of the context. So, to act empathetically, we need to accept and embrace the concept, develop a repertoire of cognitive strategies to communicate with and understand patients and mobilize psychological resources to regulate and align our emotional responses with patients’ needs. However, this internal arousal is not enough; our working environment should provide us with structural assets to facilitate empathetic attitudes. I believe that the discussion about empathy should enlarge its focus by looking beyond the individual to enlighten the relevance of the structure of the healthcare system to nurture empathetic relationships between health professionals and patients.

One of the most valuable assets is time. The clinical encounter should not be narrowed down to reaching a diagnosis and choosing a drug or procedure. We need time to listen to patients and construct a shared understanding of the problem. We need time to build trust, acknowledge patients’ emotions and their legitimacy. We need time to recognize how patients are influencing our perception of the world and react to it positively. We need time to be empathetic and feel happy about it.

Another valuable asset is team support. Resilience is not only an individual trait but also a characteristic of social groups. Social groups can modulate resilience in different ways. Group members can emotionally support each other when one of the members is facing a challenge. In Brazil, we say that a “shared blue is already half of the joy.” Groups can also adopt strategies of resistance to take advantage of the characteristics of its members. In the healthcare setting, members who are good communicators can actively create communication channels that function as thermometers of the group dynamic. For instance, if one knows that one of the members is in a difficult moment, tasks can be reorganized to protect this individual. If one member feels that the group is taking care of her, she will feel compelled to take care of the others. Kindness generates kindness, a cycle that culminates in a culture of caring — a culture with empathy in its core. Functional teams that embrace empathy as a need and a duty can change the way we provide care.

Coming back to case 1, what would be the effect of designating a health professional to share all the procedural steps in real-time with the family? A health professional who could be part of the decision process without necessarily being part of the execution of the plan. A health professional who could go in and out of the operational theater but whose primary responsibility would be to guarantee that patients and families actively engage in the caring process. A professional with support of the team, a specific place on the process of care and the backing of the institution committed to using empathy to advocate for the patient.

In case 2, what would be the effect of giving time to the doctor? Different patients with different needs demand different consultations with different durations. In several healthcare systems, consultations are being scheduled every 10 to15 minutes. Twenty minutes is considered a luxury. Do we believe that it is enough time? What if we developed a system where consultations will have the time they need to guarantee empathetic encounters? What would this system look like? Are we brave enough to ask these questions and deal with the consequences?

I hope we are.

Marco Antonio de Carvalho-Filho, MD, PhD, is Associate Professor of Emergency Medicine - School of Medical Sciences - State University of Campinas - Brazil and Research Fellow in Medical Education - Center for Education Development and Research in Health Professions (CEDAR) - University Medical Center Groningen - The Netherlands

As the cost of healthcare in the United States perches at nearly 18 percent of the GDP and continues to climb, physicians are encouraged to consider resource stewardship at the bedside (Centers for Medicaid and Medicare Services, 2018). The Choosing Wisely initiative advocates patients discuss necessity and costs with physicians, but particularly in the in-patient setting, this is not always an option (“Physicians and Cost Conversations,” 2019). Indications that high costs of medical care contribute to the American erosion of trust in physicians was documented by Sweeney in 2018, who noted “Healthcare systems … have been accused of acting out of self-interest, rather than in the best interest of patients” (Sweeney, 2018, para. 6). Much attention has been paid to overused imaging and diagnostic testing, as provision of these services increased by 85 percent during 2000 and 2009 (Feldman et al., 2013). Physicians are often unaware of the costs associated with such testing, and it does not appear as though providing such information promises more than a modest decrease in orders. A trial at the Johns Hopkins Hospital indicated that knowledge of costs reduced “from 3.72 tests per patient-day … to 3.40 tests per patient-day” (Feldman et al., 2013, p. 903).

Targeting unnecessary testing and determining a method to combat the practice is a worthy goal. In the meantime, though, unpaid medical bills – for myriad services – have created a nation where 20 percent of the population has been sent to collections (Bruhn et al., 2019). While exploring the charitable responsibility of tax-exempt hospitals, Kane (2007) noted that “in ancient Greece, taking money in exchange for providing life-saving services was grounds for electrocution by the gods” (p. 459); mythology states that Zeus smote medicine’s founder as a result of accepting gold in exchange for healing people.

Today, cost-conscious, value-based care complicates reimbursement and patients with outstanding bills exist beneath the sword of Damocles. These individuals may be under- or uninsured, or have incomes prohibiting their ability to take on another bill. They might be unable to work due to illness or live below poverty level. Regardless of hardship, such patients can find themselves not only referred to collection agencies but being sued and having their wages garnished.

Decisions about hospital collections activity are administrative, and while physician behavioral shifts offer cost-cutting potential, another trend deserves attention: non-clinical hospital employee wages. Reinhardt (2019, p. 165) wrote, “… we talk about evidence-based clinical practice, but not ever about evidence-based administration.” Compensation of hospital executives “frequently exceeds that of most physicians” (Du, Rascoe, & Marcus, 2018, p. 1911), and Kocher (2013) noted that for each practicing physician in the American healthcare system, there are 16 non-physician workers, 10 of which are either administrative and/or management.

The Internal Revenue Service established rules prohibiting “extraordinary collection actions” (Fuse Brown, 2015, p. 764), and fair pricing legislation in some states seeks to protect certain patient populations such as the uninsured from paying full billed amounts. But in Virginia, wage garnishing “was conducted by 48 of 135 hospitals … the most common employers of those having wages garnished were Walmart, Wells Fargo, Amazon and Lowe’s” (Bruhn et al., 2019, p 692). If healthcare professionals seek to re-establish trustworthiness with the public, it is worth considering where incoming funds are going, rather than applying ruthless tactics toward those least able to pay.

Rebekah Apple, MA, DHSc, is Director of Medical Management at Carnegie Mellon University.

References
1. Bruhn, W. E., Rutkow, L., Wang, P., Tinker, S. E., Fahim, C., Overton, H. N., & Makary, M. A. (2019). Prevalence and characteristics of Virginia hospitals suing patients and garnishing wages for unpaid medical bills. JAMA, 322(7), 691. doi:10.1001/jama.2019.9144
2. Centers for Medicaid and Medicare Services (2018, November 11). Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html
3. Du, J. Y., Rascoe, A. S., & Marcus, R. E. (2018). The growing executive-physician wage gap in major US nonprofit hospitals and burden of nonclinical workers on the US healthcare system. Clinical Ornhopaedics and Related Research, 476(10), 1910–1919. doi:10.1097/corr.0000000000000394
4. Feldman, L. S., Shihab, H. M., Thiemann, D., Yeh, H.-C., Ardolino, M., Mandell, S., & Brotman, D. J. (2013). Impact of providing fee data on laboratory test ordering. JAMA Internal Medicine, 173(10), 903. doi:10.1001/jamainternmed.2013.232
5. Fuse Brown, E. (2015). IRS rules will not stop unfair hospital billing and collection practices. AMA Journal of Ethics, 17(8), 763–769. doi:10.1001/journalofethics.2015.17.8.hlaw3-1508
6. Kane, N. M. (2007). Tax-exempt hospitals: What is their charitable responsibility and how should it be defined and reported? Saint Louis University Law Journal, 51(2), 459-474.
7. Kocher, R. (2013, September 23). The downside of healthcare job growth. Harvard Business Review. Retrieved from https://hbr.org/2013/09/the-downside-of-health-care-job-growth
8. American Board of Internal Medicine (ABIM). (2019, May 22). Physicians and cost conversations. Retrieved from https://www.choosingwisely.org/resources/updates-from-the-field/physicians-and-cost-conversations/
9. Reinhardt, U. E. (2019) Priced out: The economic and ethical costs of American health care. Princeton, NJ: Princeton University Press.
10. Sweeney, J. F. (2018, April 10). The eroding trust between patients and physicians. Medical Economics. Retrieved from https://www.medicaleconomics.com/medical-economics-blog/eroding-trust-between-patients-and-physicians

Have you heard the story of the Michigan pharmacist delivering life-sustaining medicine on her snowmobile during a terrible winter storm? What about the physician caring for patients in a small Tennessee town where there is no other physician within 50 miles and no local hospital? And who has not heard a story of a compassionate nurse who went over and above the call of duty to care for an acutely ill patient? Dedication – professional, personal sacrifice and caring all around.

Remarkably, we can focus so intensely on getting the job done, that we may miss opportunities to enhance working relationships with other key members of the healthcare team: the pharmacist, other physicians, various therapists, the dentist, a psychologist or any number of nurses in our community. These colleagues can help alert us to a subtle sign, assisting with a unique perspective on another piece of the puzzle before we make a challenging call regarding a patient’s condition. We all seek better outcomes for our patients.

Let’s address how to add synergy to these professional relationships – ultimately adding energy and value to interactions we have with patients we share. This does not mean we have to know and love every single healthcare colleague in our geographic area. But, what about working together to develop trust? Reaching out on community projects? How about introducing ourselves when we are in each other’s vicinities, sharing toolkit resources to build on the power of a key partnership?

Contemplate these ideas, or create some of your own:
1. The afternoon before, call to book 10 minutes of your colleague’s time the next morning – go in a bit early – today is a new day! Bring juice – fruit – yourself and say hi. Introduce yourself – ask them what some of their work challenges are.
2. Follow up a good deed with a personal note of thanks when your colleague has gone over and above to help one of your patients. Yes, a real note to a colleague – you always know someone in this category. Go ahead, make their day!
3. Tobacco abuse-secondhand smoke, the opioid epidemic, healthy eating to prevent diabetes, skin cancer checks….whatever the cause – there are toolkits, community education opportunities to advocate – ask your colleague to join you at the local PTO-PTA meeting, whether a drug prevention discussion or local marathon. Together you can bring attention to the cause.
4. When you see one another in the cafeteria or a local lunch spot, ask to join his or her table if appropriate. Help your colleague recognize your interest in his or her professional world –by asking how their day is going—discuss their work, their challenges.

What can you do to reach a colleague to thank them for their efforts? Let them know you would like to better understand what they do, how they feel, what their perspective is. The next time you have a challenging patient situation, can you reflect more about how to include the other team member into that creative solution? Can you turn the challenge into a trusting powerful bond? Maximize your impact.

Cynthia Sheppard Solomon, BSPharm, RPh, FASCP, CTTS, NCTTP, is nationally certified in tobacco treatment practice and currently chairs the medical marijuana task force in Wright State University’s Department of Internal Medicine and Neurology, in Dayton, Ohio.

In the early 1970s, an aha! insight gave birth to a new science[4] with the aim of saving humanity from overpopulation and the environment from destruction. Bioethics:[5] bio, the life sciences and ethics, and human values. Knowledge to be gathered in the philosophical sense of knowledge as a good in itself.

In the 1980s it is the law,[6] through the courts, in the person of Judge C.J. Utter that asks moral philosophy to help evaluate the practical applications of the neurosciences concept of death in the determination of death in human beings. Also, to discriminate between human beings with latent life and those humans, who having suffered irreversible destruction of the brain including the brain stem, would be dead in the eyes of the law.

The case that led to the decision was regarding William Mathew Bowman, age five, admitted on September 30, 1979 to St. Stevens Memorial Hospital after suffering massive physical injuries inflicted by a nonfamily member caretaker. In a hearing held on October 17, 1979, the attending physicians testified that on that day Mathew showed no brain activity as per a flat electroencephalogram and a radionuclide scan evidencing total absence of brain blood flow. Mathew’s pupils were fixed and dilated, did not respond to any stimulus, and he lacked a corneal reflex. Deep tendon reflexes or other signs of brain stem actions could not be elicited. Signs of spontaneous breathing or response to deep pain stimuli were absent. Drug intake and body temperature had been normalized. Mathew’s heart was beating. If blood was flowing in his retinal vessels, is not known. He was felt to satisfy the stringent Harvard Criteria[7] for brain death, which predicted that despite mechanical ventilation, loss of function as a physiological unit would occur in 14 to 60 days. The courts relented allowing for Mathew to be removed from the ventilator and/or all life support systems with his mother’s consent, but not before October 27, 1979. Mathew died, that is, “all of his bodily functions ceased on October 23, 1979[8] despite the maintenance of the life support system.”

Nonetheless, there are many issues to be resolved: Is it the state or medicine that declares a human dead? Who chooses the criteria to make such a determination? Is death loss of the “passions”?[9]

Capron and Kass[10] emphasize the need for well-informed public debate, so that the voice of the public, which has both the right and a legitimate role to play in the conceptual formulation of death and the adoption of its standards, is heard. From the human rights perspective, perhaps, the adequate tools would be never ending “Interactive dialogues.”[11] In the Socratic sense, “elucidate truth by questioning the logic of different points of view… better views about what needs to be done.”[12]

Raul Perez, MD, is Professor of Ophthalmology and Medical Ethics at the University of Puerto Rico School of Medicine.

References
[1] Roskies, Adina, “Neuroethics” The Stanford Encyclopedia of Philosophy (Spring 2016 edition) Edward N. Zalta (ed.), URL= First use of the term “neuroethics” credited to William Safire who defined it as “the examination of what is right or wrong, good and bad about the treatment of, perfection of, or unwelcomed invasion of and worrisome manipulation of the human brain. (Marcus 2002: 5)”
[2] “1. [Determination of Death]. An individual who has sustained either (1) irreversible cessation of circulatory and respiratory function, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accord with medical standards.” Uniform Determination of Death Act, National Conference of Commissioners of Uniform State Laws, July 26-August 01, 1980
[3] Cohen, Rachel, “Hume’s Moral Philosophy. “The Stanford Encyclopedia of Philosophy”
[4] Ciccone L. Bioethics: History, Principles, Issues. Madrid, Palabra, 2005: 13-23.
[5] Fritz Jahr’s 1927 Concept of Bioethics, Hans-Martin Sass, KIBEJ, J. Hopkins University Press Volume 17, Number 4, December 2007 pp.279-295 Von Rensselaer Potter in 1970 was the first to use the term in a North American Publication. Later, in 2007, it was reported, by the KIEJ to have been used by Fritz Jarh in a Cosmos article as early as 1927 with a similar “care for nature” theme.
[6] In the Matter of the Welfare of William Mathew Bowman, 94 Wn.2d 407 (1980) 617 P.2d 731 No 46582 The Supreme Court of the State of Washington, October 02, 1980, 409 Utter C.J.
[7] Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death, A definition of irreversible Coma, 205 J.A.M.A. 337 (1968)
[8] Ibid. 2
[9] Ibid 3
[10] A Statutory Definition of the Standards for Determining Human Death: An Appraisal and a Proposal, Alexander Morgan Capron, Leon R. Kass, U. of Penn. Law Review [Vol. 121:87, pp. 87-118, 1972]
[11] Interactive Dialogue as a Tool for Change, Michael Maccaby, RTM Vol. 39, Wo. 5. September-October 1996.
pp. 57-59.
[12] Ibid 11

Most people become physicians and nurses and pursue careers in the health professions to help people to alleviate at least a small portion of the suffering seen in the world around them. It is a defining feature of professionalism among all healthcare providers. The opioid crisis stems, in part, from this call to action. In the 1990s, when the American Pain Society brought the phrase “pain as the 5th vital sign” to the forefront of patient care, it was an attempt to reduce suffering by addressing inadequacies in pain management. With pain then being one of the most salient characteristics in patient care and subsequently “consumer” satisfaction,
physicians began looking for the most effective method to address the issue. When pharmaceutical companies started aggressively disseminating reassurance that opioids had low addictive risk, it played on the pressure physicians felt to maintain patient satisfaction in care through aggressive pain management and also the general physician desire to reduce suffering. Here was a way for physicians to honor their commitment to care for patients, ease their pain and support them. In terms of beneficence, physicians acted in a way they believed benefited their patients with little risk.

However, we see the truth of the story unfold in the present day, as the risks to patient health due to opioid use and misuse become apparent. Pain and suffering are not exactly synonymous anymore, as the multitudes of suffering caused by the use of opioids sometimes far surpasses the physical pain that it was initially meant to address. So now what does it look like for physicians to alleviate suffering? And do we cause some forms of suffering in the course of preventing others?

We can’t stop prescribing opioids completely, as we leave those who truly require the potency of opioids for pain management and those already in the trenches of addiction in a possible place of vulnerability and desperation. “Total avoidance of prescription opioids is not an ethical option. If a patient is in chronic pain, then the patient may need a prescription opioid and whatever the physician thinks is best for the patient.” (1) We may feel that ceasing opioid prescription is a form of beneficence in that we benefit patients in preventing the foreseen harm of addiction, but then we come into the issue of non-maleficence and trying to avoid patient harm, in that “if taken off the medication, it is highly likely that these patients will seek out illicit sources and are at risk of getting into real problems with opiate overuse and overdose.” (1)

Physicians and patients alike need to reevaluate the definitions and boundaries of suffering and pain. The desire to dissipate pain lay in the “unrealistic expectation that pain can be relieved significantly.” (1) We need a medical and cultural shift of acceptance that pain management may not have an immediate, simple or complete solution. “The concentration of pain treatment should be successfully teaching people how to live well with pain and how to minimize it using various strategies…engagement in the process of healing and lifestyle changes of patients themselves.” (1)

Not only do we need to reevaluate our cultural perception of pain management in order to prevent future opioid abuse, but we must also reevaluate our perception of opioid abuse itself in order to help individuals suffering with addiction. The long-standing belief that addiction is a “moral failing” prevents people from seeking treatment and prevents resources from supporting systems for addiction treatment. Alternatively, the “medicalized view of addiction leaves intact the dignity of people seeking drug treatment,” destigmatizes it and makes it more accessible. (2)

Changing our societal perspective on addiction is essential, but perhaps even more pressing is the need for healthcare professionals to be given more support and education in addiction medicine, and to begin recognizing and addressing (to the best of their abilities) the social, systemic and structural causes that ultimately precipitate the medical issue of addiction.

Opioid abuse is the “intersection of social disadvantage, isolation and pain—requiring meaningful clinical attention that is difficult to deliver in high-throughput primary care.” (2) However, instead of receiving such attention and care, “patients suspected of drug-seeking behavior are fired.” (2) If clinicians aren’t given the time they need, then there should be non-clinician supports to give that time and care to patients. These supports should extend from the clinical setting into the community, to “integrate clinical care with efforts to improve patients’ structural environment.” (2)

The health professional’s role in reducing suffering now looks much different from easing physical pain with an opioid prescription. It’s an issue of justice in addressing the social inequities that have led to the suffering due to addiction, as “it is our duty to lend credence to these root causes and to advocate social change.” (2) The question remains how to best rally our fellow health professionals to this call to action.

Samantha George is a third-year medical student enrolled at Albert Einstein College of Medicine. This essay was written in response to a request for students to reflect on ethical and societal concerns regarding Harm Reduction strategies to address support for patients with substance use disorders.

References
1. Chen, A. F., Ballantyne, J. C., & Patel, M. (2017). Point/Counterpoint: Opioid Abuse in the United
States. Healthcare Transformation,2(1), 9-19. doi:10.1089/heat.2017.29038.pcp
2. Dasgupta, Nabarun, et al. “Opioid Crisis: No Easy Fix to Its Social and Economic Determinants.” American Journal of Public Health, vol. 108, no. 2, Feb. 2018, pp. 182–186., doi:10.2105/AJPH.2017.304187.

Nowhere in the literature on "professionalism" in medicine is there mention of the practitioner's primary responsibility as a citizen. The so-called "social contract" of medicine, business and officialdom ignores its primacy and at least implicitly discourages practitioners who would challenge programs or policies advanced by contract partners.

From its inception, professionalism in medical education has been a pragmatic response to and an embrace of "the pressures of the marketplace" (1) with a perspective defining "all human relationships... as business arrangements" (2). In that environment, acceptance of the system and its edicts is assumed.

Thus, we encourage students to embrace principles of social equality, justice and care of the person without questioning - or confronting - an economic and bureaucratic environment that makes their implementation difficult where not impossible. Organizations like our own, or the American Society for Bioethics and the Humanities (ASBH), do not condemn the economies of Big Pharma or the inequitable limits of corporate, for-profit healthcare. We are, after all, "professionals" and not activists.

The result is that some - for example Savulesqu and Schucklenk, insist physicians perform whatever procedure is legally allowed whether or not they believe it ethically appropriate or clinically necessary (3). In the social contract, we promote the practitioner's right to demure, let alone argue for change, increasingly becomes "unprofessional" behavior in a system where official dictates are not to be questioned.

We may support "whistleblowers" but only in a limited context (4). We do not condemn the politically supported, corporate structure that make such events almost inevitable. Thus, in the famous case of Dr. Nancy Olivieri, the focus was a specific drug being tested and not the greater business model that financially requires hospitals to partner with pharmaceutical companies for an "income stream" (5).

In 1997 Cleveland State University bioethics professor Dr. Mary Ellen Waithe brought to a local prosecutor's attention the Cleveland Clinic's embrace of the "Pittsburgh Protocol" in which death was to be hastened in gravely ill, potential donors (6). When asked why she didn't simply discuss this with clinic authorities, she said that, as a citizen, when one sees a possible crime the duty is to the law and not ones "colleagues." She was criticized for this by a CCF ethicist who argued the "greater good" of increased organs transplantation - a profitable enterprise (the current cost of a heart transplant is estimated at about $1 million in the US) - justified CCF policies (7). Waithe lost her career in bioethics for that "unprofessional" approach.

There are many other examples of systemic failures we are socialized to ignore and not protest (8). Until we insist - as practitioners and as an organization - on both rights of conscience for practitioners and as citizens for the obligation to address structural problems in healthcare, the business of medicine will dominate practice and whatever we believe, as practitioners or as citizens, will be easily ignored or, where advanced, dismissed. Teaching high ideals like social justice will be just spitting into the wind.

Tom Koch is a Canadian-based ethicist and gerontologist consulting in chronic and palliative care. http://kochworks.com.

References
1. Hendelman W., Byszewski A. Formation of medical student professional identity: categorizing lapses of professionalism, and the learning environment. BMC Medical Education 2014: 14 (139) http://www.biomedcentral.com/1472-6920/14/139.
2. Brody H., Doukas D. "Professionalism: a framework to guide medical education," Medical Education 2014: 48: 980–987 doi: 10.1111/medu.12520.
3. Savulesqu J., Schüklenk U. Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception. Bioethics 2016; 31 (3). doi.org/10.1111/bioe.12288.
4. Fauce T., Bolsin S., Chan W-P. Supporting whistleblowers in academic medicine: Training and respecting the courage of professional conscience. Journal of Medical Ethics 2004; 30(1):40-3
5. Shuchman M. The Drug Trial: Dr. Nancy Olivieri and the Science Scandal that Rocked the Hospital for Sick Children. Toronto: Random House Canada, 2005.
6. Koch T. Scarce Goods: Justice, Fairness, and Organ Transplantation. Westport, Ct., and London. Praeger Books, 2001: 152-3.
7. Aggich G. J. From Pittsburgh to Cleveland: NHBD Controversies and Bioethics. Cambridge Quarterly of Healthcare Ethics 1999; 8 (3): 269-274.
8. Koch T. Thieves of Virtue: When Bioethics Stole Medicine. Cambridge, MA. MIT Press: 2012.

National and International Curricular Guidelines value the teaching of communication in the healthcare field. The 1910 Flexner report guided curricular changes in medical schools in the United States and Canada during the last century. Formation was divided into two cycles: basics and clinical, thus separating medical and social sciences. This model is still present in many graduate curricula, which constitutes a paradox with respect to the World Health Organization’s definition of health as not only the absence of disease, but as a mental, social and physical condition. Therefore, in order to adapt the curricular guidelines so that they correspond to the concept of health that is perpetuated and accepted today, it is necessary to implement new methodologies, namely active methodologies, that allow for early professional engagement of students and greater dedication to the people receiving care.

Objective: To share the educational experience of ludic class projects in the subject Communication in Health Care and to describe the active methodology used in these activities.

Experience report: The subject Communication in Health Care exercises knowledge, abilities and professional attitudes. It uses content from an online platform developed in the United States, which was translated into Portuguese as DocCom Brasil, with many topics regarding communication between healthcare professionals and patients, conversation circles, questions for reflection, categorization into word nuclei, researching of articles, integrative dynamics, presentation of content from DocCom Brasil, presentation of videos, dramatization and conclusion with arts. The students who participated were able to criticize and evaluate the work, in addition to learning and interacting with facilitator students during every step of the execution, representing a dynamic, reflective, critical and creative way of learning. Furthermore, it is also worthwhile to highlight the interdisciplinarity that emerged from the interaction between students from different courses in the context of the elective subject, such as medicine, nursing, psychology and pharmacy.

Conclusion: The set of active methodologies in Communication in Health Care allows for the formation of professionals engaged with people’s health and endowed with social commitment to patients and multiprofessional staff. The ludic class projects strengthen the humanistic axis of professional formation in Health Care and promote empathy and reflective action towards practicing medicine with social justice.

Fernanda Patrícia Soares S. Novaes, Physician, PhD(c), Institute of Integral Medicine Professor Fernando Figueira (IMIP), and National Institute of Social Security (INSS) – Brazil

DocCom Brasil has been translated from DocCom, an online communication skills learning program, comprised of 42 modules and over 400 videos for hospitals, residency programs and medical schools. For a free 30-day trial subscription, contact Barbara Lewis at BLewis@DocCom.org.

Summer, opportunities for wellness and reflection often intersect. Professionalism includes health provider wellness and resilience. A leader in physician health recently mentioned that physician health has become a science. In this regard, physician wellness influences the performance of healthcare systems (1). Jane Lemaire and colleagues have also shown that patients form judgements about physicians’ wellbeing that influences the patient-doctor relationship (2).

Certainly, there is a strong evidence base for various forms of preventive health. In this regard, a recent Nature article emphasizes the value of being in nature to support good health and well-being (3). Although many would give anecdotal agreement with this evidence, it great to see the evidence!

Following some well-deserved rest and relaxation, reflection on an academic year may support insight and goals for moving forward in the upcoming year. For example, how was a new or revised course that one offered received and evaluated? What elements of the evaluations were useful? What could be continued or changed? Often courses on professionalism and wellness are challenging to make useful to medical students prior to their clinical experience. Wendy Lowe’s (4) useful reflective article provides a compassionate perspective on negative feedback from students in relation to a Social Determinants of Health course that often seemed abstract.

Louise Aronson’s (5) 12 tips on reflection distinguishes reflection and critical reflection. Critical reflection supports transformative learning through analysis, questioning and reframing. In this regard, in reviewing a new course or changes to a course, one could ask how were decisions made, what assumptions were part of the decision? What were the underlying beliefs and values of the people providing the course and the institution that supported the new or changed course? What could literature provide or colleagues who provide alternative perspectives contribute to one’s choices about the course? With this critical reflection, which takes time, effort and an openness to change, more transformative changes are possible.

Reflecting on this month’s newsletter, it is tremendous to see the numerous faculty development opportunities offered by the APHC! Please read on for details!

Janet de Groot, MD, FRCPC, MMedSc - Founding Editor, APHC-PFO Newsletter

1. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009; 374:1714-1721.
2. Lemaire LB, Ewashina D, Polachek AJ, Dixit Yui V. Understanding how patients perceive physician wellness and its links to patient care. PLoS One 2018; 13(5): e0196888.
3. White MP, Alcock I, Grellier J, et al. Spending 120 minutes a week in nature is good for health and well-being. Nature, 2019; 9: 7730
4. Lowe W. Reflecting with compassion on student feedback: Social sciences in medicine. Journal of Perspectives in Applied Academic Practice 2018; 6(3): 30 – 41.
5. Aronson L. Twelve tips for teaching reflection at all levels of medical education. Medical Teacher 2011; 33: 200-205.

Suffering is an unavoidable reality in healthcare. Not only are patients and families suffering, but more and more the clinicians who care for them are also experiencing distress. Moral distress, as this suffering is known, arises in clinicians as they struggle to reconcile their competing ethical values and commitments with integrity when constraints make it impossible to act in accordance with them.

“Clinicians in healthcare are constantly confronted with ethical questions. In many ways, ethical issues are embedded in everything we do,” says Cynda Hylton Rushton, PhD, RN, FAAN, the Anne and George L. Bunting Professor of Clinical Ethics in the John Hopkins Berman Institute of Bioethics and School of Nursing. “In every moment, we’re making decisions about how we allocate our talent, our competence, our attention.”

“Clinicians in our current healthcare environment are feeling a lot of pressure externally from the organizations where they’re practicing that often reflect a mindset of being expected to do more with less. Couple with throughput pressures, there is also distress about whether we are actually benefiting our patients, and potentially harming them, because we’re not able to provide safe, quality care. Clinicians end up feeling their integrity is compromised. How can be I a good doctor, or nurse, if I can’t practice in a way that reflects the values that are central to my profession?”

To help provide a pathway to transform the effects of moral suffering in healthcare, Rushton spearheaded publication of Moral Resilience: Transforming Moral Suffering in Healthcare (Oxford University Press, 2018), serving as its editor and author of several chapters. In the book, she and her colleagues offer new approaches to addressing moral suffering, devising strategies for individuals and systems alike that leverage practical skills and tools to support healthcare professionals in practicing with integrity, competence and wholeheartedness.

Rushton is particularly well-qualified to provide such guidance for ethical clinical practice. An international leader in nursing ethics, she co-chairs the Johns Hopkins Hospital’s Ethics Consultation Service. In 2014, she co-led the first National Nursing Ethics Summit, convened by the Berman Institute and the School of Nursing, and her seminal work on nurse suffering and moral distress was selected for inclusion in the U.S. Nursing Ethics History project.

“It’s important to document the existence of moral distress, and there’s been a lot of excellent scholarship that has informed our understanding of the experience, contributing factors and consequences. But it’s also true that we need to move toward solutions. One of the distinctions of the book is that we’re shifting from focusing exclusively on the distress to the possibility we might be able to restore integrity in the midst of moral adversity,” says Rushton. “We can offer clinicians a vision of hope, rather than reinforce the sense of victimization and powerlessness that is very prevalent in our healthcare environment right now.”

Rushton’s book is the first to explore moral resilience from a variety of perspectives, including not only bioethics and nursing, but also philosophy, psychology, neuroscience, and contemplative practice. It offers tangible solutions for individuals and systems alike to reduce the ever-increasing prevalence of moral suffering.

“One very important way for clinicians to cultivate their own moral resilience is reorienting themselves to why they’re doing the work in the first place, and their core values,” says Rushton. “We often lose track of that in the midst of all the complexity and pressure that clinicians experience. If organizations are really committed to an environment for clinicians to thrive in, there has to be concurrent attention to how do we create a culture that helps them focus on our core mission, our patients and their families. Otherwise, it’s putting a band aid on a gaping wound. And that has not worked.”

Johns Hopkins Berman Institute of Bioethics graciously sponsored the APHC 8th Annual Meeting in May. Cynda Hylton Rushton was a keynote speaker at the 7th Annual Meeting

When I started medical school, I imagined that social inequality would be part of my daily life as a medical student and doctor. My own experiences prior to medical school observing patients and families in the waiting room of the University Hospital comes to mind. People were worried about their employment and worried about their children at home in addition to the health problems that they had. Very early on, I could see the social context was clearly exposed.

Pardos*, blacks and some whites were among the patients at the University Hospital. I mention this because it was quite different than what I had known as a patient or accompanying someone in my family, which I would describe as mostly white. But were these differences only on the “outside”? I knew the “inside” part soon afterwards when I started medical school.

Inequalities were evident inside and outside and not only the hospital, but in the classrooms, as well. It was common to hear prejudicial comments about skin color, gender, sometimes clothing attire, hygiene or any other characteristic. To understand the nature of these comments, you would need to speak with the persons in greater detail. I remember feeling that they sounded aggressive to me and wondered what choices were made and whether cognitively deliberate or driven by emotion. The way patients are sometimes treated, judged and "predestined" brings a lot of suffering. We still have lower survival and higher mortality in various conditions due to skin color, gender and economic situation (among other social conditions). But we have seen that they are separate factors. It is unreal to speak of the white or black race in a context that we are 99.9 percent similar and facing the various discoveries of epigenetics (and other areas).

Having spent a week reflecting on and discussing the role of social justice at the APHC conference with friends and professors brought me back more than 20 years ago. I saw myself in those benches in the waiting room in a mixture of feelings. There was a certain guilt for not doing more at that time, but at the same time being grateful to be part of one (among many) groups that discuss and can propose strategies to improve social inequities now. There is still much to do in the academic environment and health care. Perhaps this is why one of the roles of healthcare professionals should include talking about social justice, promoting a fairer, more accessible environment and building a society where everyone can have better greater opportunities.

* Pardo is a Portuguese word used in Brazil referring to Brazilians of mixed ethnic ancestries. Pardo Brazilians represent a wide range of skin colors and backgrounds. They are typically a mixture of white Brazilian, Afro-Brazilian and Native Brazilian

Renato Soleiman Franco, MD, PhD Student - Faculty of Medicine - University of Porto, Portugal
Assistant Professor - School of Medicine - Pontifical Catholic University of Paraná, Brazil
Director of the Psychiatry Residency Program SMS/FEAES - Curitiba, Brazil

Annual Meeting Keynotes

My Journey to Discover Why Disparities Exist…And What To Do About It
Film Screening: The Skin You’re In
by Janet de Groot
We were privileged to have two occasions to learn from and be inspired by Dr. Thomas LaViest, Professor and Dean, School of Public Health and Tropical Medicine, Tulane University. He also holds the Weatherhead Presidential Chair in Health Equity. Fortunately, his office is just across the street from the Jung Hotel. On Wednesday, we viewed his evocative documentary film, “The Skin You’re in.” The viewing was generously sponsored by The Arnold P. Gold Foundation. The film evocatively explores how African Americans 'live sicker and die younger' than other ethnic groups in the United States. The film portrays persons of various generations who spoke movingly of their commitment to their community and families within the New York neighbourhood of Brownsville, which has environmental hazards of crime and poverty. High stress levels are associated with adverse health outcomes.

Dr. LaViest’s powerful keynote address addressed health disparities based on his peer-reviewed and funded research. He used the example of the Titanic to illustrate how those with higher income were more likely to access a lifeboat and survive than those in steerage. He also dispelled a myth to show that black men are more likely to go to college than go to prison. We also heard about how sub-communities only transit stops apart can vary by almost a decade in longevity. Further, Dr. LaViest vividly conveyed how mixed race and mixed ethnic communities result in better health.

Teaching for Social Justice: Privilege, Power and Voice
by Janet de Groot
We successfully utilized live streaming for our final keynote address of the conference to support Dr. Ayelet Kuper’s social justice commitment. Dr. Kuper, Associate Director (Fellowship) of the Wilson Centre for Research in Medical Education at the University of Toronto, thanked the APHC for allowing her to present through live streaming given that she is standing with her colleagues who cannot travel to the U.S. Our decision and her choice was made carefully, recognizing that we miss networking and dialoguing with one another. However, some colleagues who wish to travel to the U.S. from other countries do not have a choice.

Dr. Kuper then described her perspective on the concept of privilege. With privilege, it may be more difficult to fully appreciate the experiences of those who in intersectional ways have less privilege. That is, binaries tend to portray privilege on one side and its lack on the other. Whereas, a focus on intersectionality, recognizing how various aspects of identity are associated with privilege whereas others are not. We heard about her medical education focus where, by giving voice to those who do not always have a voice without ‘othering,’ we flatten or disrupt hierarchies. In addition, in a teacher-led approach, Dr. Kuper encouraged dialogue that focuses on subjective experience.

Imperatives of Social and Structural Justice
through Action and Compassion
by Janet de Groot
Dr. Camille Burnett’s very well received presentation “Imperatives of Social and Structural Justice through Action and Compassion” ended with a standing ovation. Her talk was also widely tweeted via @TheAPHC.

At the University of Virginia in Charlottesville, Dr. Burnett, Academic Director, Community Engagement and Partnerships has worked closely with the nursing school to incorporate social justice teaching into nursing education. A powerful example, conveyed in words and pictures, revealed how some beginning nursing students began their academic year by visiting a site where counter-protesters of Charlottesville’s August 11 and 12th 2017 Unite the Right rally were violently struck down that resulted in multiple injuries and a fatality. Recognition of community tensions, historical trauma and subsequent healthcare needs through a nursing school without walls provided a rich introduction to nursing students entry into their chosen healthcare field. A conference participant, Dr. Jill Konkin @djillk1 wrote, “Dr. Burnett role modelled how racism and oppression must be named and addressed.”

In this regard, Dr. Burnett also provided a very helpful description of Structural Justice that includes a demand for action, based on her scholarly work with colleagues. “Structural justice acknowledges the oppressing and re-victimizing inherent nature of structures as unacceptable and requires purposeful rectification. It demands that primacy and privilege be extended to the most vulnerable, through sustainable structural processes that attend to equity, power and human dignity.”(1)

Finally, we heard about Dr. Burnett’s collaborative work towards developing an Equity Institute at UVA. We look forward to hearing more about the work that will be implemented at the UVA Equity Institute in the future.

(1) Burnett C et al. Structural justice: A critical feminist framework exploring the intersection of justice, equity and structural reconciliation. Journal of Health Disparities, Research and Practice 2018; 11(4): 52-68.
The State of the State Address
by Tyler Gibb
Rebecca Gee, MD, MPH, has served as the Secretary of Louisiana Department of Health since 2016. Appointed by Governor John Bel Edwards, Dr. Gee oversees the state’s largest agency with a budget of $14 billion dollars. Her oversight responsibilities include areas full of social justice issues, including, public health and other direct service programs for citizens in need such as behavioral health, developmental disabilities, aging and adult services, emergency preparedness and the Medicaid program.

Dr. Gee has been working on issues surrounding social justice for many years, not only in medical practice but in public service. During her speech, she discussed how she first encountered social justice issues. Access to healthcare resources has been a major focus of Dr. Gee’s tenure in Louisiana state government, a state, she noted, which is ranked as second most unhealthy state in the country. Dr. Gee emphasized that in Louisiana, like many other states, a person’s zip code has more influence of health outcomes than their genetic code.

Under Dr. Gee’s leadership, over 500,000 Louisianans are newly insured under Louisiana’s Medicaid expansion, and for the first time, many are receiving much needed primary and preventive healthcare. Her Medicaid expansion work also resulted in the launch of a dashboard to measure access to healthcare services, which has become a national model used in other states. She has been a national leader in tackling pharmaceutical pricing, including spearheading an innovative effort to eliminate hepatitis C in Louisiana by negotiating with manufacturers on a subscription model for drug access.

Prior to her role as Secretary, Dr. Gee served as the director for the Birth Outcomes Initiative where she led the charge to decrease infant mortality and prematurity statewide – an effort that in part led to a 25 percent reduction in infant mortality, an 85 percent drop in elective deliveries before 39 weeks and a 10 percent drop in NICU admissions statewide.

Fostering a Virtual Community of Practice
By Patrick D. Herron
At this year’s APHC Annual Meeting, my colleagues and long-term collaborators, Dr. Macey Henderson and Dr. Jennifer Chevinsky and I offered a workshop titled, "Breaking Interprofessional Silos and Fostering Collaboration through the use of Social Media in Academic and Clinical Medicine for Students and Health Professionals." The workshop was based in part on our interprofessional partnership and friendships with one another over the past five years. Having first interacted with one another through Twitter and then soon after in person, we each were early on in our professional career tracks of medicine, public health and bioethics. While we had very different backgrounds, we all shared an interest and enthusiasm for the use of social media as a tool for education, engagement and advancement of our professional aspirations.

Over the years, we have presented and published together and with other mentors and colleagues forming a supportive and nurturing community of practice that existed spanned both in-person and virtual worlds. As we have matured into our respective careers, we recognize the importance of sustaining the professional relationships we have established. We also know how valuable it is to be supportive of others and to share our own experiences with colleagues and trainees. In designing our workshop, we pondered how to help others achieve what we were able to do with one another? Could we use our own expertise and familiarity with social media to help facilitate new communities of practice through the Academy for Professionalism in Health Care?

Starting with our first cohort of participants, we are embarking on an exciting initiative for this coming year. Using an online registration process and in-person invitation through the workshop, we will be helping to curate and disseminate recommendations for social media tools and platforms that will support participant’s scholarly pursuits and provide recommendations for thought leaders and experts on social media with whom they might connect with virtually. We also will attempt to help match participants with one another and colleagues we have worked with for possible professional collaborations. In the months to follow, we will be checking in with participants to field questions on social media usage and offer support and guidance on how to overcome barriers and facilitating the achievement of their scholarly goals. There is still time to join us and our virtual community of practice, you can sign up online: https://forms.gle/Lp9ZieHVhqiDphVC9 until June 30th.

Patrick D. Herron, DBe, Associate Professor of Family & Social Medicine and Epidemiology & Population Health at Albert Einstein College of Medicine

Taking Our Talents Elsewhere - Utilizing the Ethical Skill Set of Healthcare Professionals to Work for Social Justice in Our Communities
by Donald Platthoff, DDS
Valerie Harris Weber, DMD, MA, and Alma Ljaljevic-Tucakovic, DMD, sparked a lively discussion in their session. Valerie and Alma are associate professors at the University Of Louisville School Of Dentistry and were colleagues in their department who became close friends in their community. Valerie with her Baptist faith claim spoke first about her experience in bringing the bio-ethical frameworks she uses to help engage her dental students in dental ethics deliberations to help her church members discuss and deliberate how they accept and interact with people of other faith claims in their own church and their larger community. A survey of the members about the sessions showed that they were unfamiliar with the process and that almost all the participants gave it high worth. Alma with her Muslim faith claim also gave a handout on how she saw the principles of bioethics being reflected in the Quran. She then pictured her experiences as a child during the Bosnian War, then what life was like as a refugee. She shared the beauty of her country and people despite the destructions of war and how that shaped and gave her resilience. Both also shared some of their differences and variations within their own faith traditions and why some of their family and personal traditions are not always common with others of their faith or at all times in their own lives. Both emphasized their celebration of the same loving God and that openly talking about their faith was important to their friendship. Their open faith sharing has also shaped their interactions with other students of various faiths and, similarly, with their joint efforts in larger community dental health interventions that deal with the just use of dental resources.

Charlene Galarneau, MAR, PhD, is Core Faculty at the Harvard Medical School, Center for Bioethics. She started by saying her doctorate was in religious social ethics and health policy and that her presentation would continue the deliberations of Valerie and Alma by offering a way to frame what communities mean, how they make meaning and how they interact on multiple and almost uncountable levels and sublevels. Charlene pulled from her 2016 book, Communities of Health Care, that presents a concept of community justice to help understand that multiple and diverse communities are critical moral participants in determining the nature of justice in U.S. healthcare. One conceptual tool she offered to deepen the deliberations was to ask the audience to start thinking about communities as any group or gathering that was larger than a family but smaller than Society. Another idea was to ask groups to think about a good and what might be a community good such as healthcare and justice. In this light, healthcare is family based, community based and societally based. There are community benefits of healthcare and also stresses created by community healthcare; thus, making healthcare a community good made by people who become healthy and sick in a community. Justice like health also comes in many forms that is seen as a vision of not yet and a given from traditions; both notions - and the communities and people in them - need and want respect. This lead to clarifications of what respect is and how those clarifications must cross geographical lines, whole person care when sick and well, and a participatory voice in democratic deliberations about all these issues - a process which requires humility rather than hubris.

Oral Presentations

Relationship Centered Care:
Designing a Successful Fourth-Year Medical Student Clerkship that Emphasizes Social Justice, Ethics and Professionalism
by Janet de Groot
Dr. Fernandes’ inspiring presentation conveyed how he had successfully implemented a two-month medical student professionalism training block at Ohio State University. Many of us are challenged to make professionalism tangible and useful to medical students. Dr. Fernandes described how he integrated professionalism education into an ambulatory care training block. Clinical hours so that student can complete modules on ethics and professionalism, including self-care. The innovative program has increased student ratings from 2.9 (out of 5) to 4.3 (out of 5) from 2014 to 2018! Dr. Ashley Fernandes, MD, PhD; Assistant Professor, Ohio State University

Social Justice in Practice Creating an Inclusive and Welcoming Classroom
by Janet de Groot
Dr. Solis provided a fascinating oral presentation outlining a course on ethics for Masters students, several of whom subsequently entered medical school. She describes how students are familiarized with the Human Rights code and its beginnings. Subsequently, they grapple with concepts of not killing and yet perhaps being confronted with requests for medical assistance in dying. She finds that students subsequently return to her for informal discussions about ethical challenges in medicine. Linda Solis, PhD; Assistant Professor, Applied Humanities, University of the Incarnate Word School of Osteopathic Medicine

PROFIS Change My Life: Affirmative Policies and the Struggle of Low-Income Medical Students to Fit in the Medical Culture
by Janet de Groot
Dr. Carvalho de Filho’s very interesting presentation began with describing PROFIS, a program in Brazil that promotes entry into medicine for Brazilians of African descent and for indigenous Brazilians. This group is typically of lower socio-economic status than most university students. Their proportion in medical schools has increased from almost 0 percent to almost 30 percent at the University of Campinas. The audience was fascinated by his qualitative study that included rich pictures drawn by PROFIS students of what it meant to be in medicine. The pictures were paired with brief narratives. The students’ experiences varied to include gratefulness to have the opportunity, as well as the challenges of getting up very early to travel to the University. Marco Antonio Carvalho de Filho, MD, PhD; Professor of Clinical Medicine, University of Campinas

Beyond Care Providers: A Leap into a Leadership Course with Professionalism as the Overarching Ethos
by Janet de Groot
Dr. Patricia Gerber outlined an innovative Leadership Experience tied to Pharmacy (LEAP) course implemented for third year entry to practice Doctor of Pharmacy students at the University of British Columbia in Canada. Each class session begins with a game or jolt to re-orient students to the course which differs substantially from standard pharmacy courses, such as medications and chemistry. The jolt includes a question related to leadership and team work and re-orients the class to the course goals.

Dr. Gerber also spoke passionately about nature vs. nurture aspects of leadership, concluding that both contribute to leadership, and that an interactive curriculum is necessary for effective leadership. Students involved gained enhanced self-awareness, as well as greater capacity to work with others. Alumni’s enthusiasm for the course was evident in that many chose to become mentors for graduate students in subsequent LEAP courses.

Conscientious Practice: Where Professionalism and Social Justice Meet
by Tom Harter
Dr. Bryan Pilkington, Associate Professor at Seaton Hall University, gave a more traditional talk exploring the ethical bounds of conscientious objections by healthcare professionals at the intersection of medical professionalism and social justice. This session made sparse use of technology, thereby nicely challenging participants to engage in active listening of the core arguments. Dr. Pilkington’s topical question was simple enough: Do acts of conscientious objections by healthcare professions stand morally opposed to the goals of professional identity formation and social justice? The answer, of course, is nuanced and depends on what the conscientious objection is and the effects of the objection on patients. While, as Dr. Pilkington argues, healthcare professions should have the ability to practice conscientiously as a function of professional identity formation, the extent to which they may engage in conscientious objections is rightly limited when such acts conflict with social justice concerns. Participants at this talk came away with the reinforced lesson that in the realm ethics and conscientious objection in healthcare, context matters – moral development and exercise by healthcare professionals is good but not at the expense of patient welfare.

Workshops

Developing Leaders: Fostering Social Justice through Professional Identity Formation Growth Employing Teamwork
by Janet de Groot
Drs. Audrea Burns, Satid Thammasitboon of the Baylor College of Medicine and Gia Merlo, Director of the Medical Professionalism Program at Rice University effectively engaged their audience in a one-hour workshop. They invited audience members to engage in case discussions and to role play scenarios. The case discussion usefully introduced the concept of reverse culture shock that healthcare students may face. In their setting, they provide pre-departure training that includes the history of the country students are going to. Through role play in one scenario, a participant was the medical student and the other a patient’s father. In this way, overlapping religious and cultural beliefs were explored and educational immersion in the conflictual experience was supported along with debriefing. Finally, Drs. Burns, Thammasitboon and Merlo generously provided a workbook entitled, “Cultivating Cultural Praxis for Social Justice within Professional Identity Formation” to support sharing educational practices.

Skills for Social Justice in Practice
by Tom Harter
One highlight of the 2019 APHC meeting in New Orleans was the “Skills for Social Justice in Practice” workshop the opening afternoon. The first session was about the role of behavioral health mentoring and counseling for medical students at the Penn State University College of Medicine. Of note, Dr. Martha Peaslee Levine – a psychiatrist – and Drs. Kelly D. Darby Holder and Carly Parnitzke Smith – both psychologists – spoke of students at risk for suffering circumstantial and existential burnout and distress, as well as the role of the institution in addressing these problems.

The second session taught about helping LGBTQ+ patients through identifying inequities they regularly face interacting with healthcare systems and ways for healthcare providers to provide safe, effective care. Participants in this session practiced taking a sexual history with a fictitious LGBTQ+ patient who presented to the hospital with his partner after experiencing symptoms indicative of HIV/AIDS. Both sessions offered new and important content to their subject areas and had good opportunities for participants to actively learn by engaging with the presenters. After a fantastic plenary session to open the conference, this session nicely built on the growing momentum.

Flash Presentations
by Darcy Reed
The Flash Presentation Session included nine unique innovations presented in an engaging ‘rapid fire’ fashion over the course of an hour. Presenters had approximately five minutes to convey their main points and then field questions from the audience. This format seemed to really engage both presenters and session attendees, who participated in a thought provoking exchange of new ideas, hypotheses and next steps.

Topics included a social justice lens on transportation challenges to healthcare and suicide tourism, the impact of racism on birth satisfaction and an analysis of declarations of diversity and social justice in medical school mission statements. Other studies focused on remediating professionalism among medical students, benefits of peer tutoring of professionalism for students and tutors, and promoting reflection and reflective communication using a community-wide current events and dialogue forum. An analysis of students’ responses to the hidden curriculum question on the AAMC’s Year 2 and Graduation questionnaires was also presented and results highlighted the important impact of the hidden curriculum in the clinical learning environment.

This week a PhD student forwarded an inspiring video entitled “The Only Psychiatric hospital in Sierra Leone” (1). What stood out for me was both how psychiatry is often underserviced throughout the world and the value of well-planned partnerships for community engagement and global health.

The video also highlights how access to medications and basic therapy supports many with mental illnesses to return to work and engagement in their families and their communities. However, return to work typically also requires community resources, including family support programs, community psychiatrists and therapists, support groups and funding to support quality of life and social wellbeing (2). Unfortunately, the stigma of mental illness often affects public and private funding. In this regard, a 229 country survey of attitudes to mental illness found those in developed countries more likely than those in developing countries to believe that mental and physical illness to similar, but less likely, to believe mental illness could be overcome (3).
Regarding partnerships for health, there is advocacy for ethical criteria to be used in global health. The importance of bi-directional participation and longitudinal engagement is essential to community benefit and global health learner training experiences (4). As well, suggested ethical criteria for public-private partnerships in public health include: assessing for active allegations in relation to partners and that the partner products or services not be counterproductive to public health goals. Finally, transparent agreements are needed (5).

Janet de Groot, MD, FRCPC, MMedSc - Founding Editor, APHC-PFO Newslette r

1. https://www.youtube.com/watch?v=Xk_SfS5UTVs
2. Costillo EG, Ijadhi-Mahgsoodi R, Shadravan S et al. Community interventions to support mental health and social equity. Current Psychiatry Reports 2019; 35.
3. Seeman N, Tang S, Brown AD, Ing A. World survey of mental illness stigma. Journal of Affective Disorders 2016; 190: 115-121.
4. Melby MK, Loh LC, Evert J et al. Beyond medical “missions” to impact driven short term experiences in global health: Ethical principles to optimize community benefit and learner experience. Acad Med 2016; 91: 633 – 638.
5. Iliff AR, Jha AK. Public-private partnerships in global health – driving health improvements without compromising values. NEJM 2019; 380 (12): 1097-1099.

Minority Populations and Health: An introduction to Health Disparities in the United States by Thomas LaVeist, PhD, an APHC Conference keynoter in 2019. He describes the key issues and suggests theoretical frameworks that could be used to develop policy to address and rectify health disparities among racial and ethnic groups in the United States. The text is divided into 14 chapters with two appendices. An introductory chapter describes how war, disease and forced displacement led to future health disparities for both African Americans and American Indians.

The text opens with a discussion on the conceptual issues with describing race. Dr. LaVeist expresses his concern and lack of comfort with labeling races and ethnic groups. This difficulty with defining the term “race” makes studying health disparities even more challenging. LaVeist carefully describes his study methods and the efforts he made to precisely define and categorize the racial and ethnic groups he would be discussing in the text. The historical facts and references he uses in the discussion provide a solid platform for understanding the issues. Subsequently, he introduces the concept of demography and the tools that are used to study epidemiology. This text was written for undergraduates but is so complete and written in such a compelling manner that it would behoove anyone in the healthcare industry to read it.

In the second section of the textbook, Dr. LaVeist compares and contrasts each of the racial/ethnic groups studied in the US in terms of both morbidity and mortality rates. He compares morbidity/mortality indices to comparative international groups providing readers with a complete epidemiological profile of each racial/ethnic group. He demonstrates, using studies and statistics, that racial/ethnic minorities have significant disparities in health outcomes compared to non-minorities and that the disease profile of minorities compared to non-minorities differs both in-group and between-group. Some of the factors contributing to this may be reduced access to care, lack of insurance, access to lower quality care, and psychosocial and behavioral stresses.

Dr. LaVeist presents and explains several theories that have been put forth to explain health disparities. Socioenvironmental theories including racial/ethnic segregation, risk exposure theory and resource deprivation theory show the relationship between segregation, food deserts, socioeconomic status and health disparities. Psychosocial theories include weathering hypothesis, John Henryism and racial discrimination discuss how chronic stress, hypertension and disease factors are intertwined. Biopsychosocial theories such as a true genetic difference between races and the slave hypertension theory were discussed. Dr. LaVeist provides ample evidence to show that genetic differences between races are not significant and cannot be the sole explanatory factor for disease. He then explores whether it is socioeconomic status that is the major factor contributing to health disparities. His conclusion is that though there are differences in socioeconomic status between different race/ethnic groups, health disparities are not a direct consequence of social economic status alone.

In the final chapter, Dr. LaVeist describes the barriers to access and use of services, mediators and cultural competencies that are needed to address disparities in healthcare. In addition, he says that community-based participatory research, cultural tailoring and community health workers are necessary keys to success. Several models for addressing health disparities in the United States are presented and discussed. The book concludes with case studies for discussion and a robust list of resources for further reading.

Minority Populations and Health: An Introduction to Health Disparities in the United States. Jossey-Bass 2005. 4 ISBN 0-7879-6413-1 368 pages

Leann Poston, MD, is a pediatrician and an instructional designer/educational consultant at LTP Creative Design, LLC, which she founded in Dayton, Ohio.

The Legacy of The Crossing, Life, Death and Triumph Among Descendants of The World’s Greatest Forced Migration is a compilation of research and teaching, edited by Thomas A. LaVeist PhD, who is a keynote speaker at the APHC Annual Meeting in May. The book came about as a product of the International Conference on Health in the African Diaspora (ICHAD). The purpose of this conference was to bring together scholars, health workers and community activists to build a body of knowledge that is presented on both a web-based platform as well as this book.

Each chapter, written by a conference attendee, has a different focus both in terms of country of study and premise followed by a well-developed bibliography. In the first section of the book, Kwasi Konadu and Michael Hanchard discuss the origins of the Transatlantic Slave System and the use of color to categorize races. Both authors write in a concise, informative style. They both write from multiple perspectives on their given theme and as researchers are careful to present the data supporting the pros and cons of each perspective. Key points from this section include: the importance of correct usage of terminology and that genetic differences between races are unable to explain the health disparities that are seen. First, because these genetic differences account for less than one percent of the genetic code and secondly, because the genetic difference between members of the same racial group are greater than between groups. leading to their conclusion that it is racism that is the risk factor for a poor health outcome, not race.

The second section of the book looks at comparative studies in Latin America, the Caribbean and the United States. The first comparative study was the Survey on Health, Well-Being and Aging in Latin America and the Caribbean. Key findings were that the Afro- descendants had fewer opportunities for education which had long-term employment and financial outcomes and that European descendants had significantly more disease symptoms, problems with physical function and disability and early childhood diseases that Afro-descendants. The authors note that this second finding may be due to a greater willingness to report health issues in the European descendants as well as access to health care. The age of the surveyed participants may also be past the age point where the greatest health disparities may have been seen. Other studies presented and discussed the social determinants of health in multiple regions and considered possible explanations for the range of chronic diseases present, areas of research, and preventative measures which may have the greatest impact. Several chapters of this section were devoted to diet and its effect on the descendants of the African diaspora as well as the marked overrepresentation of HIV/AID in the Afro population. Possibilities for this increased risk include: servitude, poor diet, economics and lack of access to health care.

Racial, cultural and gender dimensions of health were examined as well. After a review of the usage of genetic single nucleotide polymorphisms to look at both country of origin, race and disease. Rick Kittles concluded, “At the individual level, the response to racism and discrimination is a complex social determinant of health and is mediated by skin color.” He also said that the present health disparities in the Americas are likely due to a complex interaction of genetics, environmental factors and health-related behaviors. In addition, the discriminatory factors, income and education are strong predictors of health outcomes.

The author’s recommendations included: a better definition of terms to make sure the research and results were properly communicated, populations must be clearly defined instead of lumping together all minority populations, research and recommendations must be focused on inequities that are found between populations, and results must be reported in terms of percent gain or improvement.

Leann Poston, MD, is a pediatrician in Dayton, Ohio.

An emerging literature describes explicit education for professionalism competencies across residency training programs, including psychiatry resident training (1). In Canada, the CanMEDs Framework includes Professional Role competencies that include the concepts of commitment to patients, society, the profession and self (2).

At the University of Calgary, Cumming School of Medicine, three psychiatrists, with content expertise spanning emergency psychiatry, outpatient consultation-liaison psychiatry, psychodynamic therapy, group therapy and professionalism created an academic half day curriculum to manage relationships in regard to Adverse Events and Difficult Conversations. The curriculum maps well onto the CanMEDs Professional role concepts.

Seminar topics included:
1) responding to a patient’s death to recognize the unique consideration of confidentiality and addressing one’s own grief, to support the self, self-awareness and resilience;
2) setting limits in emergency and therapy settings to support patient responsibility and recognize finite health care resources; and
3) communicating with colleagues about professionalism lapses as part of a self-regulating profession.

Educational strategies to foster resident learning of these content areas include: large group discussion of narratives about authentic psychiatrist – patient interactions, evidence-based strategies for communication challenges, experiential exercises to practice communication with colleagues about professionalism lapses and resident reflection on their own similar clinical challenges. Resident generated cases were included to ensure relevance for trainees.

Second and third year psychiatry residents valued discovering their peers’ varied and non-judgmental perspectives on challenging clinical situations and anticipation of empathic support from peers when adverse events occur. Further academic half days are planned to foster additional professionalism competencies.

Rachel Grimminck, MD, FRCPC, DABPN, Clinical Lecturer, University of Calgary, Consultant Psychiatrist, Psychiatric Emergency Services, Foothills Medical Centre

Janet de Groot, MD, FRCPC, MMedSc, Staff Psychiatrist, Tom Baker Cancer Centre and Foothills Medical Centre, Associate Professor, Psychiatry, Oncology and Community Health Sciences,
Cumming School of Medicine, University of Calgary

Elizabeth Wallace, MD, FRCPC Clinical Associate Professor, Psychiatry, Cumming School of Medicine, University of Calgary; Training Psychoanalyst, Canadian Psychoanalytic Society

References
1. Freudenreich O, Kontos N. “Professionalism, Physicianhood and Psychiatric Practice”. Conceptualizing and implementing a senior psychiatry resident seminar in reflective and inspired doctoring. Psychosomatics 2018; 1-9. doi: 10.1016/j.psym.2018.12.005
2. Snell L, Flynn L, Pauls M, Kearney R, Warren A, Sternuszus R, Cruess R, Cruess S, Hatala R, Dupre M, Bukowskyj M, Edwards S, Cohen J, Chakravati A, Nickell L, Wright J. Professional In Frank J, Snell L, Sherbino J editors. CanMEDS 2015 Physician Competency Framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015.

We are honored to have the leaders in professional formation, Richard Cruess, MD, Professor of Surgery and a Core Faculty Member of the Centre for Medical Education of McGill University, and Sylvia Cruess, MD, Professor of Medicine and a Core Faculty Member of the Centre for Medical Education of McGill University, leading a conference pre-course workshop, From Teaching Professionalism to Supporting Professional Identity Formation: Transforming a Curriculum.

The Cruesses and others have proposed that the teaching of professionalism is a means to an end, with the end and the educational objective, being to assist learners to develop their professional identities. If medical educators are to design a curriculum that supports professional identity formation and socialization, through which it is formed, they must understand both processes. This workshop will be based on experience gained in transforming a curriculum devoted to teaching professionalism to one whose educational objective is to support the development of professional identities of learners.

Learning Objectives:
1. Describe the nature of professional identity formation in medicine.
2. Articulate the role of socialization in the formation of professional identity and the factors which impact upon the process.
3. Develop a plan to support professional identity formation in their own milieu.

Format:
This pre-course will include didactic presentations by the Cruesses with interactive sessions in small groups with faculty facilitators, who include leaders of professionalism education at health profession schools around the country. Participants will receive a bound set of articles and workshop materials for use at their institutions. The discussion on professional formation will be relevant for learners at various levels of training including residents and fellows.

Register for the Pre-Conference Workshop on Wednesday, May 15 from 9 to 12 p.m.

P. Preston Reynolds, MD, PhD, MACP, is Chair of the APHC Board of Directors and Professor of Medicine and Nursing at the University of Virginia.

The appropriate professional formation promotes understanding and engagement among people. The best doctor-patient communication is based on empathy, respect and social justice. This is the meaning of health care. National and international curricular guidelines value the teaching of communication in the health care are (1).

The 1910 Flexner report guided curricular changes in medical schools in the United States and Canada during the last century (2). The medical formation was divided into two cycles: basics and clinical, thus separating doctors of the social sciences.

In this context, it becomes necessary to develop communication teaching tools associated to active methodologies in order to engage students in the doctor-patient relationship. Art is considered a powerful tool to develop the humanist axis in professional formation (3).
The objective is to share the educational experience of ludic class projects in the subject Communication in Health Care and to describe the active methodology - 10 steps used in these activities.

The subject Communication in Health Care exercises knowledge, abilities and professional attitudes. It uses content from an online platform developed in the United States, which was translated into Portuguese, called DocCom Brasil, with many topics regarding communication between health care professionals and patients. It was built by professors from Drexel University in Philadelphia and 10 modules were translated to Portuguese by professors from Santa Catarina University in Brazil (4).
The 60 students enrolled in this class formed 10 groups of six participants in the debate and reflection. The students from 2017.1, 2017.2, 2018.1 e 2018.2 classes produced ludic projects improving the teaching-learning of health communication. The subject looks to improve interprofessionalism in healthcare, bringing together students of medicine, nursing, pharmacy and psychology.

The method used is didactic choreography, which combines active methodologies in order to standardize an educational process that respects creativity and values every participant’s individual contribution.

Fernanda Patrícia Soares Souto Novaes, MD, Master, Communication in Health Care Professor, PhD candidate Professional Formation in Health Care, IMIP, Recife, Pernambuco Brazil.
Suelleen Thaisa Henrique de Souza, Communication in Health Care Student, 2018.2, Federal University of São Francisco Valley (UNIVASF), Petrolina, Pernambuco, Brazil.

References
1. Liberali R, Novack D, Duke P, Grosseman S. Communication skills teaching in Brazilian medical schools: What lessons can be learned? Patient Educ Couns. 2018. DOI: https://doi.org/10.1016/j.pec.2017.12.021
2. Cooke M, Irby, DM, Sullivan W, Ludmerer KM. American Education 100 years after the Flexner Report. New Engl J Med. 2006 Sep 28;355:1339-44. DOI: 10.1056/NEJMra055445.
3. Haidet P at al. A guiding framework to maximise the power of the arts in medical education: a systematic review and metasynthesis. Med Educ. 2016;50:320–331.
4. Novaes FPSS, et al. Implicações do Método Qualitativo no Ensino-Aprendizado Ativo do Profissionalismo Humanista. Relato de Experiência Educacional. REVASF 2016;6(10):159-172.

The Knowing-Doing Gap: How Smart Companies Turn Knowledge into Action by Jeffrey Pfeffer and Robert Sutton is a very interesting read. The main premise is that most managers know what to do to maximize the success of their organizations, but are not doing it. They say that many organizations, including hospitals and physician practices have sought the advice of consultants again and again, but are not implementing the advice they are given. Managers know that providing feedback and including their employees in decision making for the organization are important, but they are not doing it.

Hospitals and hospital workers are considered knowledge workers. They are in the business of collecting information and then using this information. The authors say that knowledge has become a commodity that is collected, but not utilized. As you sit in a physician’s office for an appointment, the focus has shifted from the patient to filling in all of the boxes on the computerized form. At a recent appointment, I witnessed a physician interrupting a patient because he needed to fill in a particular answer on the medical record before he forgot. All of the information has been collected, but how is it utilized? How much mental energy was spent on filling in the boxes instead of carefully listening to the patient and evaluating non-verbal clues?

Pfeffer and Sutton say that 70 percent of knowledge transfer is informal and that frequently the people transferring the knowledge are not the ones actually doing the job. The people who designed the EMRs and who require completion of the forms are not the people who sit in the patient rooms caring for patients. How do we know this? The focus is not on the customer. The patient is the customer for both the hospital and the physician and they have been relegated to a role of supplying data to “fill in the blanks.” Is this a new problem? No. Pfeffer and Sutton state that most problems in organizations are well known and if they are not, multiple consultants have been available to provide input. It is the approach to solving the problem that is the issue. Instead of going to patient rooms and observing the disconnect and poor patient service, meetings are held, PowerPoints are prepared and endless discussions ensue.
Why don’t organizations change? Why do they keep repeating the same mistakes? Pfeffer and Sutton say that past actions and behaviors set such a strong precedent that few managers are willing to question them or attempt change. New hires are assimilated into the organization with the explanation that this is the way we have always done it. People have implicit theories about why things are the way they are, and they may not even be consciously aware of these theories. This makes it impossible to change them. In addition, suggesting an improvement implies that there is something wrong. Fear makes most people unwilling to take a chance on suggesting a better way. This causes everyone to focus on the short-term instead of the long-term.

So, what are we to do? Pfeffer and Sutton say that you need to know why you are doing something before you determine how. Those designing the system should be in the patient room teaching the new hires how to use the medical record system with actual patients sitting there. Since action counts for more than words, disband the committees and have everyone involved in the decision-making process witness how it affects the customers. Allow mistakes to happen so we can learn from them and allow employees to suggest improvements without fear. Identify the metrics and collect the data that actually matters. Finally, look at the leaders in your organization and see where they spend their time and how they allocate their resources.

Pfeffer, J., & Sutton, R. (2000). The Knowing-Doing Gap: How Smart Companies Turn Knowledge into Action. Boston: Harvard Business School Press. 314 pages

Leann Poston, MD, is a pediatrician in Dayton, Ohio.

I have a New Year’s resolution – read books that inspire me to live the values I hold dearly in my daily walk as a physician, as a scholar and as an activist.

Your Heart is the Size of Your Fist by Dr. Martina Scholtens is a must read for anyone who is committed to social justice. Dr. Scholtens is a family physician and clinical instructor at the University of British Columbia. She shares her journey caring for refugees for more than 10 years at the province’s only refugee clinic.

This beautiful narrative account of refugee medicine demonstrates the profound art of connecting with people with backgrounds and stories so different from our own and the importance of treating everyone with respect and dignity. Dr. Scholtens shares her patients’ struggles to integrate into Canadian society and to establish lives far from their homes and any loved ones they may have left behind as they fled situations that put their lives at risk.

As a member of Canadian Doctors for Refugee Care, she walks us into advocacy when she decides to protest against cuts in funding for refugee medicine. All physicians working in refugee medicine know that this funding is critical to our ability to provide comprehensive care to these vulnerable and marginalized persons.

A colleague, also working in refugee medicine wrote this review with which I concur completely.

"With her decade of experience with refugees in Canada, Martina brings heart and determination to her patients, as revealed in this book. Sharing the joys and challenges of being a clinician to people whose life experiences differ so much from her own, she writes about dealing with doubts and uncertainty, and cherishing the gifts, concrete and abstract, exchanged between doctor and patient. Skillfully weaving her own story with that of her patients – describing personal loss, challenges to the values of her Dutch Christian upbringing and professional norm – Martina reflects on how she balances her personal life with the demands of her vocation, the need for flexibility in boundaries and the importance of advocacy when working with marginalized populations. Martina draws us in with vivid stories of doctor–patient exchanges and leaves the reader with a deep appreciation of how humility, curiosity, humour and good faith can compensate for any deficits in knowledge in cross-cultural interactions." ―Dr. Neil Arya, founder of the Kitchener Waterloo Centre for Family Medicine Refugee Health Clinic

Another way to do social justice as a physician is to conduct asylum evaluations for persons with a history of torture. I have been doing this work for 25 years and find it meaningful, personally and professionally. With our on-going crisis at the border between Mexico and the U.S., and with increasing numbers of persons fleeing violence and torture in their home countries around the world, we have a role to play in helping these individuals find shelter and create new lives that are safe and secure. We have so many opportunities to use the knowledge and skills we acquire during years of training to profoundly impact individuals in our immediate environment. As the articles below co-authored with colleagues discuss, with professionalism and personal commitment, just a little more training can go a long, long way.

P. Preston Reynolds, MD, PhD, MACP, is Chair of the APHC Board of Directors and Professor of Medicine and Nursing at the University of Virginia.

Martina Scholtens. Your Heart is the Size of Your Fist: A Doctor Reflects on Ten Years at a Refugee Clinic. (Brindle and Glass, 2017)

KC McKenzie, J Bauer, PP Reynolds. Asylum seekers in a time of record forced global displacement: the role of physicians. Jou Gen’l Intern Med. 2019;34:137-143.

KE Roth. Internists support global human rights, one patient at a time. J Gen’l Intern Med 2019:34:3-4.

One of the claims resulting in devaluation or erosion of the moral aspect of the medical enterprise is regarding medical ethics and professionalism as non-cognitive endeavors. This deprives the medical act; that special kind of human relationship (1) that binds physician and patient, both in search for what is morally good and technically right, of some of its constitutive cognitive elements such as remembering, thinking and reasoning. In years past, Non-Cognitive Academic Factors Evaluation Forms bundled a variegated assortment of descriptive and action terms that seemed to challenge the understanding of most faculty members, under the heading of three criteria: Professionalism and Ethics, Interpersonal and Communication Skills, and Patient Care. Humble acceptance of the not quite coherent terms and definitions, as not to be questioned curricular dogmas, prevailed.

Cognitive is as relating to cognition (2), involving conscious intellectual activity, such as remembering, thinking and reasoning, and cognitive mental processes and their products. Non-Cognitive attributes, such as temperament, virtue and attitude are those supposedly not related to conscious intellectual activity, such as remembering, thinking and reasoning. If the moral act is subject to strict scrutiny, we may find that the difference lies more in the temporal immediacy of the rational process to actions rather than in its absence. It may be where psychology and virtue ought to meet.

Possibly, the cognitive deprivation of the moral act, in the best-case scenario, saw ethical judgement as ingrained natural order prescriptions beyond rational inquest and a direct intuitive access to moral truths. On the other hand, as irrational beliefs not worth taking into consideration or just plain expressions of emotions. Some of the ancients considered being as the formal object of intelligence, truth as the formal object of reason and good as the formal object of the will. Moral pluralism has ushered an era of truth avoidance, distortion of being and irrationality, depriving “the one medical reality that does not change with time” of those of its cognitive elements that lent it standing to “define some set of moral commitments” (1) that can transcend the deep philosophical differences that divide the medical profession.

Raul Perez, MD, is Professor of Ophthalmology and Medical Ethics at the University of Puerto Rico School of Medicine.

1. Humanism and Ethics in Roman Medicine: Translation and Commentary on a text of Scribonius Largus. Edmund D. Pellegrino, Alice A. Pellegrino. Literature and Medicine, Volume 7, 1988, pp. 22-38 (Article). Published by The johns Hopkins University Press
DOI:10.1353/lm.2011.0164 http://muse.jhu.edu/journals/lm/summary/v007/7.pellegrino.html
2. www.Merrian-Webster.com

As an educator and bioethicist, I am frequently asked to discuss issues concerning professionalism and ethical concerns with the use of social media. Depending on the audience, I have found there to be a wide variety of perspectives, misconceptions and no shortage of opinions. When thinking about an upcoming talk or teaching session, I need not worry about finding recent examples of health professionals who have demonstrated lapses in professionalism as revealed through social media posts. Frequently, these behaviors reveal disturbing statements reflecting prejudicial attitudes towards others and often patients, sexist rhetoric and sometimes hate speech.

This is not a problem unique to health professionals. The presence of toxicity witnessed throughout social media has grown with intensity in recent years due to political and ideological polarization. While I believe civility is a quality we should all aspire to as individuals, I hold myself and colleagues to a higher standard of behavior because of the extraordinary privilege afforded to health professionals and educators. Communities look to their health professionals to reflect the qualities of compassion, truthfulness and confidence in an increasingly uncertain and complex world. Integrity and trustworthiness in our interactions with others both offline and online is essential.

Professionalism is also about belonging to a wider community – whether the community we live and work in or the community of colleagues we represent. Our behavior as individuals affects multiple stakeholders and part of our professional duty includes our responsibility to others who may be affected by our actions. The American Medical Association’s Code of Medical Ethics states, “Physicians must recognize that actions online and content posted may negatively affect their reputations among patients and colleagues, may have consequences for their medical careers (particularly for physicians-in-training and medical students) and can undermine public trust in the medical profession.” (1)

We, as individuals, cannot control the behavior of others nor should we be tasked with changing those behaviors in others to conform to our own worldview. Nevertheless, there is an ethical obligation to recognize and call attention to these behaviors when witnessed or shared with us in confidence by colleagues and especially by trainees seeking guidance and support from those of us with protected status and a dual role of having responsibility for their contributing to their professional development. Addressing these behaviors is a moral choice that each of us must make knowing the implications of taking action or inaction on our patients, colleagues, institutions, communities and profession, but also the effect on our own well-being. Silence as a bystander in the face of prejudice, misogyny, intolerance and all forms of social injustice is not taking a neutral stance. As professionals, we must commit to either stand up to such detrimental behavior or sit back in complicit indifference.

Patrick D. Herron, DBe, is Director of Bioethics Education at Albert Einstein College of Medicine.

1. American Medical Association. Professionalism in the Use of Social Media. Code of Medical Ethics Opinion 2.3.2. Available at: https://www.ama-assn.org/delivering-care/ethics/professionalism-use-social-media Last accessed 1/18/19.

The enculturation process is at once exciting and arduous to most medical students. Moving from didactic to clinical settings introduces a host of challenges, including self-doubt and fear. Stone, Charette, McPhalen and Temple-Oberle (2015, p. 751) identified four “domains of concern” for students, including uncertainty regarding expectations, insufficient knowledge, technical skills and anticipated negative experiences. Being afraid to speak up may be one of the most profoundly negative experiences for a medical student. They may experience confusion by a decision made or action taken by someone in authority. Worse still, they may disagree with such decisions or actions, without feeling able to speak up about it. The hierarchy naturally creates intimidation, leaving students feeling as though they cannot or should not speak up.

A new text by Ira Bedzow, PhD, Giving Voice to Values as a Professional Physician: An Introduction to Medical Ethics (2018), seeks to provide students with the tools to address such situations without fear of damaging important relationships.

Bedzow, assistant professor of medicine at New York Medical College and director of the Biomedical Ethics and Humanities Program, wrote the book for students to use as a framework to act upon ethical principles while forming their professional identities. According to Bedzow, it is reasonable for medical students to feel apprehensive about speaking up. “Many times, the fear of misspeaking creates a self-fulfilling prophecy of not being able to speak up,” says Bedzow. “Yet students can learn how to communicate their values and ask questions effectively. It just takes appropriate practice and proper guidance by faculty and peers.” He believes learning how to act ethically in clinical and interprofessional settings mirrors clinical training: the more they practice, the better they will become. In his classes at New York Medical College, Bedzow delivers more than ethics content; he works with students on communication, anticipating situations, and creatively addressing dilemmas.

The approach used in his book is based on a methodology created by Mary Gentile, professor of practice at the University of Virginia Darden School of Business and senior advisor at the Aspen Institute Business and Society Program. Giving Voice to Values is a values-driven leadership curriculum designed to equip professionals with tools to positively impact their environments through ethical behavior. “I saw its value for new initiates in healthcare,” explains Bedzow. Noting the importance for medical students to balance the expectations others have of them with those they have of themselves, Bedzow’s book is intended to guide students as they develop realistic strategies and action plans. As in his classes, the book calls upon students to examine decisions and then explore techniques for offering alternatives. In discussing how to improve students’ skills for ethical action, the key, he says, for effective peer and faculty guidance is to shift from critiquing the person to critiquing his or her strategy of action.

Bedzow feels traditional approaches to ethics education miss the mark, focusing extensively on what should be done in a particular situation, without including what students would actually do if they were faced with an ethical challenge themselves. “What I love about the Giving Voice to Values methodology is that it reinforces students’ desire to advocate for their own beliefs and for their own growth, (and) forces them to consider how to do so … by thinking about their own capabilities and limitations as well as the opportunities and potential hindrances they may encounter from others.”
The text covers topics including bias, patient autonomy, rationalizations, and addressing patient complaints, among others. “Even though in traditional medical ethics courses students learn about what should be done, they often leave class at a loss about what actual steps to take,” says Bedzow. This book aims to change that, moving students from examining moral theory exclusively to include learning what it takes to act on one’s moral decisions in practice. This is a skill that must be honed, states Bedzow, as opposed to “shooting from the hip. The hardest thing in ethics education in medical school is getting people to realize that improvement is possible. If they don’t think it’s possible, then they are going to be afraid to make mistakes rather than being willing to make mistakes in order to grow.”

The book is published by Routledge/Greenleaf Publishing and has received positive reviews from faculty at institutions including Harvard Medical School, Johns Hopkins Berman Institute of Bioethics, and the University of Colorado.

Rebekah Apple, MA, DHSc, is the Director of Medical Management at Carnegie Mellon University.

References
1.Stone, J.P., Charette, J.H., McPhalen, D.F., & Temple-Oberle, C. (2015). Under the knife: medical student perceptions of intimidation and mistreatment. Journal of Surgical Education, 72(4), 749-753. http://dx.doi.org/10.1016/j.jsurg.2015.02.003 7

2 am. Emergency Department. After seeing more than 50 patients in 7 hours, I am tired. The intern comes to me with another case to discuss. He is a bright young man, 22 years old, also tired, and fails to provide me with organized data so that I can reason about the woman who supposedly is fighting to breathe. My eyebrows blow with frustration; I let the anger step in and eat my words in silence. Next second, with the file in my hands, I go to the office to interview the patient by myself. The intern comes along and, inside the examination room, he looks to the ground; his soul is not there anymore. I crushed him. I try to forgive myself, after all, it is 2 am.

Role modeling is a tough job. We need to deal with the patient, the team, the environment, the students and the residents while guaranteeing patient safety and the learning outcomes. We need to solve conflicts, make decisions, balance values, inspire and remediate. We need to smile, be moral and bring hope. Do you already feel the pressure? And I did not mention the emotions involved. Paraphrasing the great Stan Lee: “With great power, comes great responsibility, and a runaway truck loaded with all sort of emotions.”

Let’s be honest: within those complex tasks, mistakes and lapses are commonplace. Considering that patients well-being and safety are our primary concern, neglecting students’ and residents’ needs is a real risk. Recently, Telio et all (1) offered the concept of the educational alliance as a strategy to ground learning encounters in the real clinical scenario and improve feedback acceptance by students and residents. The educational alliance concept encourages teachers to establish a relationship with students based on trust and credibility. Building a relationship depends on teachers acknowledging the presence and the needs of the students while exploring their worldviews, opinions and ideas. Trust requires teachers to commit first and foremost with students’ development explicitly, putting aside any hidden agenda. Credibility is related to teachers’ expertise and beneficence towards students. Admittedly, a relationship based on respect, as demanded by the educational alliance principle, needs time to grow and is easier to establish during longitudinal programs.

Does the educational alliance principle work for short clinical rotations? We can compare a learning encounter in a short clinical rotation with a clinical consultation in the emergency department. It is always challenging to build trust during brief clinical relationships. As an emergency physician, I had to develop a strategy to establish trust in the middle of a complex, sometimes chaotic and uncontrollable environment. It goes without saying that time is a rare commodity in the Emergency Department. My secret is to be honest, always explicit, as objective as possible and empathic. Above all, I had to learn to say, “I am sorry,” with my soul, with the message coming directly from my heart. If during a consultation, we say or accidentally do something improper, the person in front of us will communicate with their eyebrows, clearly showing that we made a mistake. We need to be ready to read the message. We need to be ready to apologize and to restart. We can do the same with students.

In a short clinical rotation, clinical teachers can start with an open conversation to set the “rules of engagement.” At the beginning of the day, clinical teachers may invite students to share their particular learning goals. Then, teachers can be explicit about their methods, feedback style, learning goals, and commitment to students’ development. Teachers can also share the characteristics of the clinical activities that were planned, and how the clinical activities may influence the learning activities and outcomes. We should not forget that medical students want to become doctors; they also know that patients’ needs come first. At the end of the clinical activities, we can provide a “wrap up” session to address issues that were not solved or were misunderstood. Eventual tensions can be relaxed by a debriefing session in which the teacher ‘steps down’ or reduces the traditional hierarchy to communicate with students as colleagues. We should not be afraid of sharing our difficulties; even the challenges related to role modeling.
Mistakes are universal. Maybe we should look for the bright side of being imperfect. Mistakes and lapses offer opportunities to share with students our strategy to deal with the ultimate challenge of being alive: we are all vulnerable. Clinical teachers able to acknowledge, share, reflect on, apologize and remediate their mistakes show students our commitment to a human value or trait that Rousseau called perfectibility. After all, being wrong is the first step towards being right.

I would like to go back in time and apologize to the intern in my story. I would like to share with him my frustration with failures of Brazil’s healthcare system and how health professionals feel obligated to compensate for the lack of structure with their sweat. I would like to invite him to interview the patient again, with my support, gathering the correct piece of information and sharing the enlightening moment of insight related to getting to the final diagnosis and therapeutic plan. After completing our care of the patient, we would have a cup of coffee together, both chilling as partners and getting ready for the next patient.
Marco Antonio de Carvalho-Filho, MD, PhD, is Associate Professor of Emergency Medicine - School of Medical Sciences - State University of Campinas - Brazil and Research Fellow in Medical Education - Center for Education Development and Research in Health Professions (CEDAR) - University Medical Center Groningen - The Netherlands

References:
The "educational alliance" as a framework for reconceptualizing feedback in medical education. Telio S, Ajjawi R, Regehr G. Acad Med. 2015 May;90(5):609-14. doi: 10.1097/ACM.0000000000000560.

Dr. Levine began the workshop talking about Individual Development Plans (IDPs), which are powerful tools for learning. Learners take an active role in setting goals, identifying strengths, practicing self-assessment and reflection, all of which demystifies learning and growth. Dr. Novack followed up with definitions of professionalism: a trust-generating promise and an application of virtue to practice. He briefly described ProfessionalFormation.org, an online platform of 12 modules, currently in development, to help leaners with professional formation.

Dr. Wright shared seven tips for professional growth:
1. Fully understand who you are (self-assessment and personal inventory e.g. Myers Briggs, DISC, etc.).
2. Giving translates to growth (recommended books - Give and Take and Servant Leadership).
3. Strive for excellence tenaciously (recommended books – Outliers and Mindset and Grit).
4. Failures are necessary on the road to success (recommended book – Creativity, Inc.).
5. Be fully present and engaged (recommended books – The Power of Now and Visual Intelligence).
6. Take good care of yourself.
7. Read more (recommended books – biographies and fiction).

Dr. Preston concluded with a description of the learning environment, which when right, professionalism is enhanced. The Charter of Professionalism for Health Care Organizations is an important document that includes patient partnerships, organizational culture, community partnership and operations and business practices.

The session included interactive exercises.

Dennis Novack and colleagues created ProfessionalFormation.org (PFO), funded by a generous grant from the Arthur Vining Davis Foundations. PFO is an online resource for professionalism education, assessment, remediation and research, originally designed for learners in medical, nurse practitioner and physician assistant programs. The Macy Foundation has recently provided funding to revise PFO to be useful for professionalism and inter-professional education in all allied health professions. This grant will also enable pilot testing, expanding and enhancing programs in 13 institutions and over 30 affiliated programs, including nursing, pharmacy, social work, physical therapy, law and others.

Principal Investigators Dennis Novack, Professor of Medicine and Associate Dean of Medical Education, and Kym Montgomery, Chair of the Nurse Practitioner and Doctor of Nursing Practice Department, at Drexel University welcomed nearly 50 participants, who will work for the next three years on revising, incorporating and pilot testing PFO in professionalism and interdisciplinary programs at their institutions.
Assessments Review

Dennis Novack and Kym Montgomery are incorporating user assessments into the 12 PFO modules under development. At the Macy Grant kick off meeting in July 2017, Deborah Danoff, MD, Adjunct Faculty at McGill University discussed her research with Mary Catherine Beach, MD on over 50 assessments that PFO could potentially use.

The assessments that may be used:

1. Interpersonal Reactivity Index (IRI): perspective-taking (7 items) and empathic concern (7 items) subscales
2. Cohen Perceived Stress (4 or 10 items)
3. Values/behavior concordance (100 mm lines)
4. Groningen Reflective Scale (23 items)

Other assessments being considered:

1. Mindful Attention Awareness Scale (MAAS, 14 items)
2. Paul Haidet’s C3 measure (variable # items) measures the professionalism climate
3. Readiness for Inter-Professional Learning

ProfessionalFormation.org/Content has 13 modules that Macy grant participants are in the process of reviewing.

1. Overview of Professionalism & Professional Formation
2. Professionalism, Bioethics & Codes of Conduct
3. Professional Formation: Empathy, Compassion & Hidden Curriculum
4. The Clinicians’ Role in Regulating Peers and the Profession
5. Social Justice
6. Error, Disclosure & Honesty
7. Interdisciplinary Team Relations
8. Professional-Personal Boundaries
9. Moral Distress and Moral Courage
10. Burnout, Compassion Fatigue & Transformative Growth
11. Confidentiality
12. Promoting Institutional Culture Change

February 2018 Update

Dennis Novack and Kym Montgomery, the PIs on the Macy Grant, have completed their review of most of the 12 modules.

Four modules - 1,3, 7 and 11 will be available for Macy Grant participants to use in their curricula within the month.

When the pilot program ends, modules will be available for all institutions to incorporate into their curricula.

The modules include text, learning goals, assessments, exercises and references. After the pilot program, the PFO modules will be available for other institutions.

March 2018 Update
Several of the 13 participating institutions have begun incorporating PFO modules (see sidebar on right) into their curricula. A number of schools will be meeting with curricula committees this spring to finalize PFO incorporation.

If your institution is using videos, either that you produced or you found on the internet, please let us know. We have shot over 80 videos, but we are particularly interested in interdisciplinary videos.

We are finalizing the module assessments and adding many innovative features to the modules.

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Participants in the APHC 2018 conference will be encouraged to consider the quality of resilience, and to explore its connections to the development and demonstration of professionalism in clinicians. While there are many definitions of the term, we understand resilience to be the process of adapting well in the face of adversity, trauma, tragedy or significant workplace stress — all common components of a healthcare environment. The values of professionalism may benefit from clinician commitment to resilience, but it is unclear how or even if this attribute can be cultivated.

Keynote Speakers

Timothy P. Brigham, MDiv, PhD, is the Chief of Staff and Senior Vice President for Education at the Accreditation Council for Graduate Medical Education (ACGME). He is also Co-Chair of the ACGME Physician Well-Being Task Force.

Tyler Cymet, DO, is Chief of Clinical Education at the American Association of Colleges of Osteopathic Medicine and Urgent Care Physician at the University of Maryland School of Medicine. He developed a national program on resilience and does research on mental health in medical students.

Steve Rosenzweig, MD, directs the Program in Professionalism, Bioethics and Humanities at Drexel University College of Medicine where he is Clinical Associate Professor of Emergency Medicine (Hospice and Palliative Medicine) and teaches self-regulation and resiliency skills to medical students and residents.

Cynda Rushton, PhD, RN, is the Anne and George L. Bunting Professor of Clinical Ethics in the Johns Hopkins Berman Institute of Bioethics and the School of Nursing, with a joint appointment in the School of Medicine's Department of Pediatrics. She is currently designing, implementing and evaluating the Mindful Ethical Practice and Resilience Academy (MEPRA) to build moral resilience in nurses.

Albert Wu, MD, MPH, is Professor and general internist at the Johns Hopkins School of Public Health. He developed The RISE (Resilience In Stressful Events) program to support 'second victims' - healthcare workers who experience emotional distress following patient adverse events.

This year’s 19th Annual Meeting of the American Society for Bioethics and Humanities (ASBH), held in Kansas City, Missouri, featured an innovative presentation format: five-minute “Flash Sessions.” The Flash Sessions are one-hour sessions in which six to eight presenters give a five-minute overview of a current project, research question, teaching initiative or topic of scholarly interest. The presenters are allowed three slides to supplement their oral presentation, with the goal of combining the overview features of a poster presentation with the dynamic interactions of an oral paper. With time for one to two audience questions for each presenter, strictly moderated by a time keeper responsible for giving equal opportunity to both presentations and questions, the hybrid model offers much to both presenters and the audience. Similar to a poster presentation, the Flash Session allows scholars to highlight one area of their project and to elicit focused feedback. In addition, as with longer oral presentations, the Flash Session allows for dynamic engagement with multiple audience members at one time, expanding the opportunity for interdisciplinary-disciplinary and cross-institution conversation and learning.

The Flash Sessions at ASBH this year included a range of topics, disciplines and methodologies: the question of guidelines regarding social media and gifts (Nathanson and McKlindon); improving consent for genomic data sharing in a clinical setting (Currey, Ramos, et al.), changing the ethical climate in the pediatric intensive care unit (Trowbridge), the philosophical investigation of Jean Améry and the rational suicide (Howard), institutional conflict of interest policies (Gruenglas, et al.), establishing a high school bioethics club (Willard), a self-care/other-care model (Dean-Haidet), US military service members’ experiences as research participants (Cook and Doorenbos) and a poetic and creative performance challenging boundaries in the fields of bioethics and medical humanities and the inviting participants toward interdisciplinary collaboration (Case). Presenters ranged in experience from undergraduates and medical students, to graduate students and trainees, to experienced clinicians and senior scholars. Members of the Program Committee and the Board of Directors moderated the Flash Sessions.

The range of topics in each session also meant a range of disciplines, experiences and knowledge among both presenters and audience members – the diversity of which was apparent in the moderated questions and in the conversations of those lingering at the hour’s end to talk with the presenters and other attendees. In all three sessions, the post-session discussions extended through and past the break time before the plenaries. Such generative interactions illustrated the strength of the format: after the brief five-minute presentation, audience and presenter alike encountered unexpected discoveries of shared interests and new possibilities for collaboration, both of which are ongoing goals of ASBH, as well as for the Academy for Professionalism in Healthcare (APHC) and ProfessionalFormation.org (PFO). APHC is adding Flash Sessions to the 6th Annual Meeting in Baltimore April 26-28, 2018 – keep an eye out for the call for papers!

Flash Sessions are considered oral presentations for CV and conference attendance reimbursement purposes, making them especially attractive to students and junior faculty, as well as those seeking feedback and peer commentary on developing projects.

The doctor-patient relationship has peculiarities inherent to the affection that permeates the individuals involved. Physicians should balance professional boundaries and empathy in the doctor-patient relationship. Medical students can develop profiles for “behavior within professional boundaries,” while continuing to show trust, esteem and affection for their patients.

Our objective here is to report on an innovative, educational experience in a Brazilian institution. We made use of the Portuguese version of an online American medical education program which included videos, in-person classes and videos produced by students, to address the module “Professional Boundaries.”

We report on a teaching-learning experience in an elective course titled Communication in Healthcare. It is offered every six months during the fourth year of undergraduate study in Medicine at the Federal University of São Francisco Valley (UNIVASF, Petrolina, Pernambuco, Brazil). The starting point of this class was the “DocComBrasil,” an audiovisual educational teaching tool used to stimulate basic and advanced communication skills in health professionals. It was created by professors from Drexel University in Philadelphia and 10 modules were translated to Portuguese by professors from Santa Catarina University in Brazil. Twenty medical students enrolled in this class formed a group for debate and reflection on “Professional Boundaries.” The students from 2015.2 class produced four educational videos on the following dilemmas in the doctor-patient relationship: self-revelation, gifts, invitations and touch. This discussion resulted in different perspectives on professional behavior.

The video about “self-revelation” showed a consultation during which a patient asked the physician if he had ever practiced unprotected sex. Students reflected on the extent to which it would be beneficial for the doctor to disclose such personal information to the patient. Most of the participants observed that kindly declining to reveal personal information would be the best attitude, unless the information would benefit the patient.

In the video about “gifts,” the acts of receiving and giving gifts were analyzed. Students dramatized with monetary gifts. One part of the class did not agree to accept the gifts, whereas the other part thought that it would be acceptable, provided it resulted in something useful to benefit other professionals and patients, such as a coffee maker.

Regarding the video on “invitations,” students staged a scene in which a patient invites the doctor to go out. Most of the students thought that socializing with patients outside the office could be interpreted as a dubious relationship and that it would be wise to avoid or to pass the case on to another doctor.
Regarding “touches,” the students enacted a scene in which a patient hugs a doctor from another culture. It has been argued that people react differently to hugs and other forms of touch depending on their culture. Brazilian culture allows embracing respectfully while standing within professional boundaries and recognizes that hugs can be therapeutic.

Combining online classes, watching and producing videos and clinical situations on medical professionalism makes it possible for students to anticipate clinical experiences in the classroom environment and improves their abilities to place themselves in other people’s situations. It stimulates communication skills, decision-making, empathy and ethical principles to strengthen professional identity and is an excellent teaching-learning strategy in medical education.

Fernanda Patrícia Soares S. Novaes, Physician, PhD(c), Institute of Integral Medicine Professor Fernando Figueira (IMIP), and National Institute of Social Security (INSS) – Brazil

Publication of “Medical Professionalism in the New Millennium: A Physician Charter,” in 2002, expanded the concept of professionalism beyond a short set of values and behaviors to one that includes three core principles: patient welfare, patient autonomy and social justice, alongside 10 commitments.

The Physician Charter is a cornerstone of professionalism initiatives around the world. At the same time, health professions educators have expressed concerns that The Charter reflects Western values, often minimizing cultural differences, such as autonomy in settings where families are involved in medical decision-making since they often bear the financial impact of health care expenditures for their loved ones.

This essay looks at another core principle, social justice. I will argue that we need an expanded conceptual model of social justice as it relates to health, one that embraces health equity with inclusion of human rights, solidarity, cultural awareness and professional obligations.

The principle of social justice in The Physician Charter states,

The medical profession must promote justice in the health care system, including fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion or any other social category.

Social justice as it relates to health must embrace health as defined by the World Health Organization. At its founding in 1946, WHO declared health “is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.” Furthermore, “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without regard to distinction of race, religion, political belief, economic or social condition.”

This vision of health demands that we, as health professionals, provide excellent care to all persons, and that we also work beyond our immediate health care systems to address the social determinants of health of our patients and our communities. If we are committed to health and healing of individual persons, we must recognize the conditions in which they live, learn, love, work and play, contribute more significantly to health outcomes than delivery of more specialized medical services.

Health equity goes beyond fair distribution of health care resources. It demands we ensure marginalized persons and populations receive ALL of the resources necessary to ensure they live vibrant lives, the highest attainable standard of health. It necessitates that we not only eliminate health disparities and all forms of racism and discrimination in our societies, but that we achieve equity in education, housing and food security, payment for work, participation in community and civic activities. All of these are fundamental human rights recognized internationally for over 50 years and guaranteed by governments around the world. Those countries that have sought to fulfill these fundamental rights over the past several decades have achieved population health outcomes far superior to the United States.

We, as health professionals, live privileged lives while people around the world and in our own backyards suffer and suffer under our negligence to speak up. How can we tolerate a culture that allows for mass incarceration? How can we permit 20 percent of children in America live in poverty with hunger, violence and homelessness part of their reality?

Who we are as professionals and what we are as a profession is reflected in our determination to boldly confront social injustice all around us. We cannot confine our doctoring to our examining rooms if we are going to fulfill the professionalism principle of social justice.

Failure to educate for social justice is a form of professional injustice, a fundamental violation of what society expects of the health professions. Our social contract goes beyond the guarantee of honest, competent and ethical physicians. We must train students and residents with the values and skills necessary to transform a world where too many people die prematurely simply because we have failed to embrace solidary as a principle of global social justice.

Solidarity, a term from the global ethics and human rights literature, connotes deep caring and compassion, and reflects the reality that we live in an interdependent world. As members of a global world and as members of a profession, we have expanded obligations to persons beyond our immediate borders. It is time for us to use the power of our position and our professions to make a difference in the world, and in our immediate communities.

Global social justice IS doctoring, providing healing to a world. It is time to rewrite The Physician Charter to make it reflective of and relevant in the world we all live.

P. Preston Reynolds, MD, PhD, MACP, is Chair of the APHC Board of Directors and Professor of Medicine and Nursing at the University of Virginia.

For students of medicine, social media can serve as a professional tool for education, communication and networking. Establishing and clearly defining acceptable behavior as it pertains to social media use is an important aspect of students’ professional development.

Without proper instruction, students may unintentionally share information on social media that could be damaging to patients, an institution or themselves. Furthermore, posting certain information and/or images on social media sites may be viewed as unethical, unprofessional and, in some cases, illegal. Instituting policies pertaining to social media use can help a program define acceptable behavior and enforce protocol. For students, social media policies can help guide contemplative decision-making for professional behavior.

In 2011, the Drexel Physician’s Assistant (PA) Program developed its social media policy after a conscientious student approached the faculty during the clinical phase of his medical training to express concerns regarding how some of his classmates were communicating on social media. That clinical year student reported that some students, in their well-intentional enthusiasm for the medicine they were learning, were over-sharing information regarding clinical sites. Although the PA program routinely teaches professionalism throughout the curriculum as it pertains to the patient-provider relationship, personal comportment, communications skills, appropriate dress, participation on interprofessional teams, plagiarism and personal responsibility, it did not teach professionalism pertaining to social media use at that time. Clearly, teaching professionalism when using social media was a necessary addition to this already existing content. While there were no known incidents of intentional maleficence, the program recognized the need for enhanced digital professionalism education and began the process of developing the Drexel PA Program Social Media Policy (the Policy).

In 2011, there were no other departmental social media policies in the College of Nursing and Health Professions. When developing the Policy, the PA program consulted with university legal counsel, with other college programs and researched interprofessional peer-reviewed literature. Since that time, more robust research that supports specific content is now available and includes recommendations and most commonly addressed topics such as video, audio and photo sharing, best practices, copyright and fair use, respect, privacy, responsibility and other significant subjects (1, 2).

The Drexel PA Program Social Media Policy first reviews basic guidelines and best practices of social media use. These guidelines discuss maintenance of proper privacy settings, consideration that private content can still be shared by followers, underscoring concepts of “permanency” of information posted and emphasis on representing themselves in a mature and professional manner – including the use of civil, respectful language. Of note, a common misconception is that if a person keeps their profile settings “private” that their posts are also always private. In reality, on several occasions people who have been given access to private student profiles have screen-grabbed student-posted content that was felt to be unbecoming or unprofessional and have shared it and their concerns (sometimes anonymously) with the Drexel PA program. Disciplinary action has occurred after social media policy infractions have been shared in this manner. Students are reminded that potential employers, licensing boards and healthcare facilities where they may seek privileges and other individuals may screen online presence.

These basic guidelines differ from the Policy portion in that they are aspirational recommendations and generally unenforceable. After the guideline portion, the Policy then describes actions for which students may be disciplined including posting any patient information, including photos or cases. Further clarification that removal of a patient’s name does not de-identify that patient is included. Specified online behaviors for which program or university disciplinary action might be warranted are outlined and include:
• Posting program curriculum or examination material
• Misrepresenting themselves as an official representative or spokesperson for the university or the program
• Harassing or discriminatory postings that in any way violate the university’s Equality and Non-Discrimination Policies
• Non-compliance with the university’s Acceptable Use Policy pertaining to computer and network use
• Inappropriate relationships with patients or supervisors/teachers
• Violations of copyright/trademark
• Offering medical advice

Since the development of the PA Program policy, there is more literature available on the importance of crafting language (guidelines, policies) on social media use in higher education and also the advocation for discipline specific social media policies that explicitly define appropriate and inappropriate behavior on social media specific to that discipline (1). The Policy was drafted, vetted by university legal counsel, put up for vote of acceptance to the PA program full faculty and approved as an official program policy in 2012. The PA Program’s Policy was specific enough to provide clarity, but broad enough to allow for changing technology platforms and online behaviors. We believe the consideration given to the development of the policy is what has resulted in the fact that revisions to it have not been necessary since its inception.

The Social Media Policy is regularly reviewed with students when they enter the program and again when they start their clinical rotations. We consider this to be an educational and prophylactic activity. Since its development, the PA program has had very few issues with student infractions using social media. Recent research seems to indicate that instruction in social media use and/or familiarity with social media policies are associated with a more cautious approach to social media postings (3). The time for policy development is before a problem occurs. We have found that in developing our social media policy and using it to educate students about online professionalism, we have not only preceded problematic behavior, but have largely prevented it.

Diana D. Smith, MHS, PA-C, Assistant Clinical Professor, and Adrian S. Banning, MMS, PA-C, Assistant Clinical Professor in Drexel University Physician Assistant Department.

References
1. Campbell S, Chong S, Ewen V, Toombs E, Tzalazidis R, Maranzan KA. Social media policy for graduate students: Challenges and opportunities for professional psychology training programs. Canadian Psychology/Psychologie canadienne. 2016;57(3):202-210. doi:10.1037/cap0000053.
2. Pasquini, L. A., & Evangelopoulos, N. (2016). Sociotechnical stewardship in higher education: A field study of social media policy documents. Journal of Computing in Higher Education, 1-22. Advance online publication. doi: 10.1007/s12528-016-9130-0 Published Online November 21, 2016.
3. Lefebvre C, Mesner J, Stopyra J, et al. Social Media in Professional Medicine: New Resident Perceptions and Practices. Eysenbach G, ed. Journal of Medical Internet Research. 2016;18(6):e119. doi:10.2196/jmir.5612.

The term bioethics, thought for a while to have been coined in Wisconsin in the early 1970s, was discovered by 2007 to be older, perhaps from the late 1920s, from Germany. This rendered the term equivocal and, more often than not, the venue by which ideologies foreign to the inherent moral values of medicine distracted quite a few members of the medical moral community, misaligning their moral compasses from their true north.

A practical, easily understandable tool to assess adequacy (2) between the idea and the object (thing) in ethical discourse is needed. Such a tool, to achieve conceptual precision can be blended from a combination of two among many constructs: the respect for person construct (RFPC) and the criteria for ethical theory construction (3).

The RFPC (4) is comprised of four covariant attributes: respect for autonomy, veracity, fidelity and avoid killing innocent humans. It will show us how living a moral life ought to look like. Which attitudes (5) show respect for others and one self? Respecting those autonomous decisions of others which are morally good and technically right. Using language and other means of communication to share with others (truth) information they are entitled to. Honor those commitments/promises with others which are rightful and just. Avoid harming self and others.

The criteria for ethical theory construction will help determine the soundness or integrity of a particular theory, model, framework or construct. It requires clarity to be understood; simplicity, a few basic norms. Coherence calls for no conceptual inconsistencies nor contradictions. It should include all moral values for it to be comprehensive and complete. It explains the moral life, justifies beliefs and criticizes defective ones. It should be doable and produce judgments not in the original data base.

First, we grasp by intuition or common sense through the sieve of the RFPC, which among those principles presented to us, should be considered for recruitment into our moral discernment (6) device so as to discover the means that ought to be used to achieve a particular good. Then, we embark in a journey of strict scrutiny using the criteria for ethical theory construction to ascertain their validity and that the well they spring from is not poisoned nor are their practical applications malevolent.

This could be a useful tool to guarantee conceptual precision in the never ending conversation to discover what is good and what is right (7).

Raul Perez, MD, is Professor of Ophthalmology and Medical Ethics at the University of Puerto Rico School of Medicine.

References:
1. Some like Pellegrino in the early 1980s and others like Lolas Stepke in the 2000s called for conceptual precision.
2. Nicomachean Ethics, Aristotle [Definition of truth]
3. Principles of Biomedical Ethics, Beauchamp and Childress
4. The Basics of Bioethics. Veatch R.M.
5. How we think, feel, and tend to act towards an object.
6. FELAIBE Analogy used in Principles… by Beauchamp and Childress to describe the common morality.
7. KIE-IBC 1999-2016, Pojman, Gomez-Lobo, and others.

Managing with Power; Politics and Influence in Organizations by Jeffrey Pfeffer may seem like an unusual choice for a book review for a group focused on professionalism, but I think many of his suggestions will be of great value to physicians training and precepting new physicians. Pfeffer, Thomas D. Dee Professor of Organizational Behavior at the Stanford Graduate School of Business, opens his book discussing power in organizations by defining power as, “The potential ability to change behavior, to change the course of events, to overcome resistance and to get people to do things they would not otherwise do.” One could be quite fulfilled as a hermit in an organization, but don’t expect to make any career progress or to have any decision-making power. Interdependence is key to gaining power in your workplace.

You may be feeling wishy-washy about power at this point. It does not seem “professional” to say that you want more power and influence, but if you have no power you can’t get anything done and more than one person has stated that the medical profession needs a bit of attention in the area of professionalism and business acumen. If you are looking for sugar-coated advice then this is not the book for you, but if you are looking for research backed case-studies you might find it a great read.
So where should you start if looking to increase your level of power in an organization? First, check your personal attributes. Most of the traits on Pfeffer’s list are classically associated with physicians, except one, the ability to handle conflict. In order to gain power, you must be willing to do the jobs others do not want to do and be willing to take a stand, even if it is unpopular. Pfeffer cautions that this does not mean fight for hopeless causes. You should carefully assess the situation before you take your stand. Take care not to assign blame to a responsible person because the issue may be due to situational factors instead which we are likely to ignore. Gaining allies is another ingredient in the power recipe. In addition, you should watch for opportunities to control resources and aim to have the most physical space to work in as possible.

Pfeffer talked about the need to communicate throughout the book. Being in the center of the flow of information is key to successfully gaining and holding power. He contrasted being in the center of the advice network with the center of the social network and advocated that the social network was the more important of the two. Now you know why some people spend a good part of their work day socializing with others! This seems to contrast to the long-standing advice that working hard will lead to success. Research demonstrates that your job performance matters less on your evaluation than your supervisor’s opinion of you. To strengthen your power even more, ask for and provide favors. In contrast to what is commonly believed, Pfeffer said that asking for favors generally gives more power than providing them because the people who grant your request feel tied to your future success.

Let’s say you have overcome your tendency to think that power is bad and that all decisions have a right or wrong answer and you are ready to act. What should you do? First, assess the political landscape. Who currently has power? Where do they get their power from? Do you have access to these same people? After you have determined the true chain of command in your organization and identified the special interest groups, identify their motivations and points of view. Next, improve your communication skills and status in the social network. Develop strong connections with allies who share your interests. Make sure that you have a central spot in the information chain. Work hard and make sure that you have a sterling reputation. Finally, decide to do something, being fully aware that at the time you make the decision you will not know if it is right or wrong and act on it. Have the courage and desire to stand up to opposition. Innovation and change in almost any arena require the ability to develop power.

Pfeffer, J. (1994). Managing with power: Politics and influence in organizations. Boston, Mass: Harvard Business School Press. 391 pages.

Leann Poston, MD is a pediatrician in Dayton, Ohio.

My first impression when looking at the table of contents for Ethics in Everyday Places: Mapping Moral Stress, Distress and Injury was to question how the author could tie something so defined and prescriptive as map making to something as esoteric and illusive as ethics and morality. Tom Koch, PhD Adjunct Professor of Medical Geography at the University of British Columbia, a consultant in ethics and gerontology at Alton Medical Centre Toronto, and Director of Information Outreach, Ltd. does a masterful job of making the connections and demonstrating how even the most mundane of tasks can have significant ethical implications. He draws the reader in and makes the content relevant to all by asking each reader to consider the uncomfortable feeling they get when they are doing what they are told or what they feel is right but still have the feeling that something is just not right.

Dr. Koch makes his points with a series of case studies which are easy to follow and encourage the reader to ponder the implications of the misuse of statistics and misleading mapmaking. In one such case study, Koch asks his students and later participants in a seminar, what they would do if given a contract to develop a map based on data demonstrating the longevity of smokers. He then leads the reader through an analysis of statistics and how the data can lead to the conclusions desired by the researcher, the feeling of unease one gets with the statement that “it’s just business” and the assumption that the product of a technician does not have ethical implications. Most students end up deciding to honor the contract; generally, because they cannot afford not to. They ease their conscience with the statement that it is not the maps that hurt people, but the people who interpret the map. A correlate to the sentiment that guns do not kill, people do. Koch summarizes on page 114 with the Supreme Court argument that “intentions do not matter when the results are disastrous. When that happens, our communal moral declarations are violated, and we are all complicit.”

Koch’s other case studies look at the practice of “redlining” and mapping poverty to determine eligibility for bank loans, the inequity of school district financing, the inaccessibility of the transportation system in London, mapping the path of Hurricane Katrina, longevity in tobacco users and patient access to hospitals capable of organ transplantation. Dr. Koch researches and provides data on the relationship between race and the likelihood of donating and receiving an organ transplantation. His point is not so much about the data, but that we are not asking appropriate questions. Why have we not questioned the lack of correlation between numbers of donors and number of recipients when examined along racial lines? We go about our business, sometimes even lifesaving work, but not take the time to explore the ethics and moral choices we are making while completing these tasks.

So how does this happen? Why do we feel that we live ethically and have strong moral principles, but these case studies give evidence to the contrary? One theory is distance. The closer we are to the inequity the more we are compelled to help. Likewise, the greater the distance, the lesser the feeling. Another is that numbers without context can lose their meaning. The percent of people living in poverty is a number without a face. We lose the connection to the faces of the people suffering and the outcomes of this suffering. Koch states on page 179 that data does not speak through us, we speak through the data. Koch ends by stating that his book is not written to be a call to action, but a call to awareness and a realization that our choices matter and have consequences. The reader is left with the disquieting feeling that his points are all valid and have merit, but the issues seem so enormous. We can recognize the problems but feel helpless to provide a solution.

Koch, T. (2018). Ethics in Everyday Places: Mapping Moral Stress, Distress, and Injury. MIT Press.284 pages, ISBN 978-0-262-03721-1

Leann Poston, MD is a pediatrician in Dayton, Ohio.

Those who doubt the chasm that separates “professionalism” as an ideal and the realities of medicine practice[1] might consider this: Physicians are more likely to commit suicide than US military personnel and veterans (28-40 versus 20.6 per 1000,000).[2] Compared to the general population, physicians are nearly twice as likely to commute suicide: 1.87 times higher than the average American, according to findings from one study.[3] At least since 1996, with the introduction of "professionalism" as a key to "identify formation," practitioners have by every measure been seen more at risk than average members of society.[4]

Although early symptoms may be similar, the problem is not simple “burnout” resulting from the grind of practice but the moral injury that accrues in a health system of irremediably conflicted, simultaneously demanding allegiances – to patients, to employers and governing bureaucracies.[5] The resulting injury results stems from the gulf between an ethical perspective based on moral values and the directives of supervising powers.[6] Others have noted the moral distress of students struggling to hold to ethical ideals and moral perspectives in the face of classroom and clinical experiences.[7] That practitioners suffer similarly and over time more severely, should be no surprise.

“Professionalism” must shoulder the responsibility for student and practitioner distress. After all, when first advanced as a core teaching focus it promised to promote the long-term maturation and satisfaction of practitioners acting vocationally in service of patient needs and satisfaction.[8] It ignored from the start, however, the constraints imposed upon that moral mission by economic priorities, institutional policies and political realities.

None of this stems from some "hidden agenda"[9] but reflects one bioethicists promoted for years.[10] First, they insisted because medical knowledge was primarily technical, not ethical or experiential, practitioners were incompetent to deal with issues of ethics or organization. They then declared the cost of medical care more important than the care of the patient. Hastings Center co-founder and director Daniel Callahan led the charge arguing, as Rothman put it, that physicians must serve "the common good and collective health of society, not the particularized good of individuals."[11] That good was economic efficiency in a corporate environment, not medicine's Hippocratic vocational raison d'être: the care of persons. [12]

Relief will not result from courses in empathy, humanities or values[13] when those virtues are stymied by a system that places economic efficiency over patient need. It will come, if at all, from an insistence that any "social contract"[14] be negotiated to assure the importance of practitioner experience, perspectives and medicine's traditional Hippocratic mission.
Tom Koch is a Canadian-based ethicist and gerontologist consulting in chronic and palliative care. http://kochworks.com.

References

[1]. Lawrence C., Mhlaba T, Steart KA, Moetsane R. Gaede B. Moshabela M. The Hidden Curricula of Medical Education. A Scoping Review. Acad Med 93, 2018. doi: 10.1097/ACM.0000000000002004.
[2]. Anderson P. Physicians Experience Highest Suicide Rate of Any Profession. Medscape (May 07), 2018. https://www.medscape.com/viewarticle/896257 .
[3]. Hoffman M, Kunzmann K. Suffering in Silence: The Scourge of Physician Suicide. MD. Feb. 05, 2018. https://www.mdmag.com/medical-news/suffering-in-silence-the-scourge-of-physician-suicide.
[4]. Lindeman S, Laara E, Hakko H, Lonnqvist J. A systematic review on gender-specific suicide mortality in medical doctors. Br J Psychiatry. 1996; 168 (3):274-9. PMID: 8833679.
[5]. Talbot S, Dean W. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. Stat. July 26, 2018. Statnews.com. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/.
[6]. Koch T. Ethics in Everyday Places: Moral Stress, Distress, and Injury. Cambridge MA: MIT Press, 2017.
[7]. Carevalho-Filho MA. The Enemy Uncovered: Hidden Curriculum and Professional Identity. Professional Formation.org: Academy for Professionalism in Healthcare newsletter. July, 2018. https://webcampus.drexelmed.edu/professionalformation.org/Main.aspx.
[8]. Brody H,Doukas D. Professionalism: a framework to guide medical education. Medical Education 2014: 48: 980–987 doi: 10.1111/medu.12520.
[9]. Hafferty FW, MArtimianaks MA. A Rose by Other Names: Some general musings on Lawrence and colleagues' hidden curriculum scoping review. Acad Med 2017; 93 (4): 526-531. doi: 10.1097/ACM.0000000000002025.
[10]. Koch T. Thieves of Virtue: When Bioethics Stole Medicine. Cambridge Ma: MIT Press, 2011.
[11]. Rothman D. Rationing life. New York Review of Books (March 5, 1992: 33.
[12]. Callahan D. 1987. Setting Limits: Medical Goods in an Aging Society. New York: Simon and Schuster.
[13]. Schweiller M, Riberiro DL, Celeri EV, de Carvalho-Fiho Ma. Nurturing virtues in the medical profession: Does it enhance medical students' empathy? Int. J. Med Ed 2017, 8: 262-267. Doi: 10.5116/ijme.5951.6044.
[14]. Cruess RL, Cruess SR, Boudreau JD, Snell, L, Steinert Y. Reframing Medical Education to Support Professional Identity Formation. Academic Medicine 2014; 89 ( 11): 1446-1451.

Recently, Greiner and Kaldjian authored an article in Medical Education discussing the different contents of medical oaths in North American medical schools (1). The authors observed a variety of different concepts, ideas and, most importantly, values used by the various medical schools. In some of them, students had the freedom to decide about the nature of the statement they would profess at the end of the course. The authors concluded that there is a lower degree of concordance among the oaths regarding their guiding ethical principles. If we agree that medical oaths are symbols of our social contracts, what does this plurality mean to us and to medical students? Do we have different commitments to society? Is it up to local schools to choose or change the nature of our social contracts?

My first contact, as a medical student, with the Hippocratic oath stroked me with a question: Why did Hippocrates need to state the obvious? Is it not clear that we need to protect patients’ privacy or not use patients’ information to profit for ourselves? I was a naïve and optimistic young man at that time. With the years, the experience and after some disappointments – in a sort of reality check - I realized that practicing good and ethical medicine is also an act of resistance. Practicing under the guidance of the ethical principles is to fight constantly against the selfish nature of our genome. Pride, greed, envy and other deadly sins surround our daily activities. Virtue comes from a struggle, and medical oaths are a public way of showing how committed we are. If I profess my professional values loudly, the society in general and the patients, in particular, can follow my words and ask for coherence while witnessing my attitudes and behaviors. Social supervision is a necessary nest to breed social accountability.

Words matter. My grandfather, a wise illiterate farmer, my ethical mentor, used to say that if you cannot trust a man’s (or woman’s – please, forgive grandpa) words, this person has no value. Because I learned to pay attention to words, I was impressed by the variety of medical oaths in North America. Although it is true that some elements of the Hippocratic oath are outdated, particularly the lack of mention to equity and social accountability, we need to be conscious and careful during the process of modernizing our consecrated oath (2). Deliberating about the oath is also deciding about the nature of our social contract or at least about how society will perceive it. The idea of every school supporting a different oath can send the message that our social contract depends on the locale where we were trained.

Rituals also matter. Although I am a strong advocate for students’ engagement, the idea of inviting students to change our oath can send the wrong message about the meaning of professional autonomy. Medical doctors are free to behave in accordance with our ethical code. Surely, our social contract is not immutable; it is a product of a permanent negotiation that suffers the influence of different social agents. Students are one of those agents. Students bring fresh ideas, motivation, diversity; students renew outdated social practices and open our eyes to understating societal changes. However, students do not have the big picture of a doctor’s work. This lack of an overview, this lack of awareness and experience, prevents them from speaking for all the medical community. When students profess the oath, they are asking permission to enter our professional community; a community that is also a moral community committed to specific values; values that we want to preserve.

Maybe it is time to modernize our oath. Discussing a new version for our oath opens the door for debating our social contract (3). This discussion is an opportunity to contextualize our traditional values to address the current needs of patients and society. It is also an opportunity to bring new values to the table, like social justice and equity, both crucial elements in a time of profound economic inequality within and across national borders. Getting to a new social contract is not a local endeavor. Ideally, this discussion should break the academic barrier and involve not only students and medical educators, but also physicians, patients, health professionals, healthcare regulators and managers. I salute medical schools for starting the conversation, but let’s open the door and free places at the table. A contract is good when it works both for both sides.

Marco Antonio de Carvalho-Filho, MD, PhD, is Associate Professor of Emergency Medicine - School of Medical Sciences - State University of Campinas - Brazil and Research Fellow in Medical Education - Center for Education Development and Research in Health Professions (CEDAR) - University Medical Center Groningen - The Netherlands

1. Med Educ. 2018 Aug;52(8):826-837. doi: 10.1111/medu.13581. Epub 2018 Apr 27. Rethinking medical oaths using the Physician Charter and ethical virtues. Greiner AM1, Kaldjian LC2,3.
2. Med Educ. 2018 Aug;52(8):784-786. doi: 10.1111/medu.13623. Context, culture and beyond: medical oaths in a globalizing world. Helmich E1, de Carvalho-Filho MA2.
3. Med Educ. 2014 Jan;48(1):95-100. doi: 10.1111/medu.12277. Updating the Hippocratic Oath to include medicine's social contract. Cruess R1, Cruess S.

The Physician Charter, recognized by health professionals around the world as one of the defining documents on medical professionalism in the new millennium, lays out three key principles, one being social justice.

Principle of social justice: The medical profession must promote justice in health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion or any other social category.

This essay considers the right to health as a foundation to the principle of social justice, a right that health professionals accept throughout the world, but a right that is still contested in the United States.

The concept of universal rights emerged as a cornerstone of the Charter of the United Nation (UN), adopted by 51 nations in 1945, in the aftermath of World War II. Shortly thereafter, the UN General Assembly established a Commission on Human Rights (CHR) and charged it with creating a statement on global human rights.

Under the leadership of Eleanor Roosevelt, the 18-member Commission on Human Rights sought input from individuals and organizations from every corner of the world in an effort to capture ideas that reflected various religious traditions, political philosophies and human experiences. The Commission members themselves embodied breath-taking expertise and a depth of knowledge in their lives as scholars, lawyers, diplomats, theologians, writers and citizens of the world. Over the next three years, CHR members and UN delegates together drafted and refined their statement on global human rights. In December 1948, with unanimous support, representatives of 48 countries adopted the Universal Declaration of Human Rights. Article 25 states:

Everyone has the right to a standard of living adequate for the health and wellbeing of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

The Universal Declaration on Human Rights, along with the Covenant on Civil and Political Rights and the Covenant on Economic, Social and Culture Rights comprise the global Bill of Human Rights. Together, they led to the creation of additional international human rights treaties that further elaborate on this and other basic human rights.

The right to health, a cornerstone of universal human rights was captured also when the UN established the World Health Organization (WHO). Delegates to the first International Health Conference held in 1946, adopted the Charter of the WHO that from its inception defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This Charter further states, “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”

Over the past 40 years, the right to health has been upheld and expanded globally. International treaties now incorporate measures of accountability to ensure that nations who have signed onto these treaties are fulfilling their obligations to create living conditions and healthcare systems that enable their citizens to lead productive and healthy lives.

The core international human rights documents that support the right to health include:
· International Covenant on Economic, Social and Cultural Rights and the
Committee on Economic, Social and Cultural Rights’ General Comment #14 and General Comment #16
· International Convention on the Rights of Children
· Convention on the Elimination of All Forms of Discrimination against Women
· Convention on the Elimination of All Forms of Racial Discrimination
· Convention on the Rights of Indigenous People
· International Treaty to Ban Landmines
· Convention on the Rights of Disabled Persons
· Refugee Convention

Furthermore, the right to health has been incorporated into national constitutions. The impact of this constitutional language has been far reaching. For South Africa, its constitutional right to health provisions enabled health professionals, working with human rights experts in a global campaign, secure access to anti-retroviral medications that helped stem the AIDS epidemic and build out the infrastructure for delivery of education and treatment.

Achieving equity in health, a priority of the WHO, necessitates a social justice framework of action, one that rests on the right to health as a fundamental right simply because we are alive here and now. Social justice mandates that we direct resources to mitigate past discriminations to level the playing field, thus allowing everyone to reach their full potential. Achieving equity in health requires us to eliminate health disparities within our own country and between countries.

This seems like a daunting task, but one only needs to look at the work of WHO with its Millennium Development Goals to see the realization of the right to health in marginalized populations and developing nations around the world.

P. Preston Reynolds, MD, PhD, MACP, is Chair of the APHC Board of Directors and Professor of Medicine and Nursing at the University of Virginia.

Asking about sexuality in medical practice continues to be a very sensitive issue, which often includes various specialties. If medical professionals do not handle this topic appropriately during consultation, they may jeopardize a number of important aspects that define good investigation and/or the doctor-patient relationship, creating obstacles that hinder medical care. The goal of this text is to share a teaching-learning experience related to talking about sexuality with patients.

The methodology used was “Doctor Communication” (DocCom.org), an innovative online course that offers written and audiovisual content associated with drama in the classroom. It was prepared by professors from Drexel University and translated into Portuguese by a group from the Federal University of Santa Catarina (UFSC). The translated version received the name “DocCom.Brasil.” This platform works with professional practice situations in health, requiring basic and advanced communication skills.

DocCom.Brasil contributed to the origins of the course “Healthcare Communication,” which began in the first semester of 2015. “Healthcare Communication” is an elective course, which meets four hours a week, for 12 weeks. It is offered every semester; students may take the course only once. The course is open to medical students and students of other healthcare courses, such as nursing, pharmacy and psychology at the Federal University of São Francisco Valley (UNIVASF) in Petrolina, State of Pernambuco, Brazil. This specific educational experience occurred during the second semester of 2015. Participants were students in their eighth term of medicine, in the middle of medical school, about to begin clerkship. Medical school in this institution lasts 12 terms or semesters with clerkship occurring during the final four terms.

Initially, online access to DocCom.Brasil was made available for pre-reading material. The class was divided into eight small groups of two or three participants. Each group was responsible for a module in DocCom.Brasil. Acquisition of learning objectives of the Module 18, whose theme is “Talking about Sexuality,” took place in expository form, using a digital poster and video production. The group produced a subtitled video in which they enacted two scenes, the first addressing negative communication attitudes and the second presenting the same situation with positive communication attitudes. Each group socialized the knowledge they had absorbed in the form of posters and videos. The elective health professional students presented their final projects to a committee of professors of several areas of medicine for evaluation and feedback. The students received feedback from these educators and from their peers present with the committee of professors at the end of the presentation.

As a final product, the elective course participants created the video “Talking about Sexuality” (https://www.youtube.com/watch?v=bMlNqJa5uvI&t=11s), which resulted in audiovisual educational materials for teaching-learning communication on this topic. The video may be accessed online (see link below), on a video-sharing website, and it has been shown during subsequent semesters. It tells the story of a patient with multiple partners. In the first scene, she is received with moral judgments on the part of the doctor when asked about the number of partners. The consultation takes place with no possibility of dialogue. In the second scene, the doctor transmits information without judgment, allowing her to speak, and validating her emotions. The video shows an example of inadequate care and then an example of good practice in healthcare: avoiding judgments, reporting on confidentiality, asking about possible emotional repercussions and giving support.

The participants reported that the scenarios enabled them to put into practice the material covered in the module. The safe environment of the classroom, as opposed to that of the clinic, allowed them the possibility to experiment and learn through their mistakes before entering into contact with patients. They reported that they felt safer and less inhibited in talking about sexuality with patients after they received communication training for this particular situation.

DocCom.Brasil provides training to talk about sexuality with patients, reduces inhibition to speak on the subject, promotes safety and open dialogue with empathy and respect, and may improve early diagnoses of sexually transmitted diseases and other health issues related to sexuality. Using the intentional training in medical schools on communication and sexuality can contribute to an inclusive culture of professionalism and a consolidation of professional identity.

Fernanda Patrícia Soares Souto Novaes, Pediatrician, MD, PhD Candidate (IMIP), Professor Healthcare Communication, Federal University of Vale do São Francisco (UNIVASF), Brazil
Suely Grosseman, MD, PhD, is Professor, Pediatrics Department, Federal University of Santa Catarina, Brazil; Post-doctorate - Drexel University College of Medicine, Philadelphia, Pennsylvania, USA

References
1. Comunicação em Saúde Estudo. Talking about sexuality in healthcare [video on the Internet]. 2015. Available from:
2. https://youtu.be/m_5uBM5Fn1I?list=UUC0BGDE6nP3wdxJEK58HPpg
3. Frankel R, Edwardsen E, Williams S. Module 18: Asking about Sexuality. Doctor Communication (Doc.Com). Drexel University. Philadelphia, USA.
4. Liberali R, Grosseman S. Use of Psychodrama in medicine in Brazil: a review of the literature. Interface (Botucatu) [Internet]. 2015 Sep [cited 2018 mar 22];19(54):561-571.
5. Novaes FPSS, Souza GMC, Santos I, Grosseman S, Carvalho-Filho MA, Cruz RFC, Palitot BMDS. Contribution of Doc.Com in the improvement of communication in health care in a Brazilian University. Poster presented at: 4th Annual Academy for Professionalism in Healthcare Conference; 2016 apr 28-30; Pennsylvania, USA.
6. Schweller M, Costa FO, Antônio MA, Amaral EM, de Carvalho-Filho MA. The impact of simulated medical consultations on the empathy levels of students at one medical school. Acad Med. 2014 Apr; 89(4):632-637.

Less than one year after a fourth-year medical student leapt to her death at the Icahn School of Medicine at Mount Sinai, New York, the dean of the medical school described the environment in which the student had likely been functioning: “… a culture of performance and achievement that for most of our students begins in middle school and relentlessly intensifies for the remainder of their adult lives” (1). The research has not been sparse on this topic of late. In 2016, Rotenstein et al. (3) found increased prevalence in depression and suicidal ideation in medical students vs. in the general population. Outsiders might easily intuit that an anguished physician could struggle to meet professional demands. Yet many training institutions have not implemented comprehensive programs to address such concerns. In their study, Rotenstein et al. (3) identified a need for improved access to care for medical students, as well as preventive efforts which could ensure this population not only learns, but integrates, self-care into their daily lives.

For years, Stanford University School of Medicine has prioritized mechanisms of self-care for their students, identifying student champions and mentors, holding wilderness orientation trips for first year medical students, offering peer counseling and performing ongoing assessment of student needs and stressors (4). In July 2018, Western Michigan University Homer Stryker M.D. School of Medicine (WMed) welcomed Karen Horneffer-Ginter, PhD, to serve as assistant dean for wellness, and Horneffer-Ginter acknowledged Stanford as influencing her vision for the role. She noted that many professionals at WMed have been implementing wellness initiatives for some time and is positive about such internal resources.

Horneffer-Ginter graduated from the University of Michigan Honors College, and received a fellowship to the University of Illinois, where she completed an MA and PhD in Clinical and Community Psychology. She also completed a year-long internship focusing on mind-body medicine and biofeedback at the University of Massachusetts and has been working in the wellness field since undergraduate school when she was awarded a scholarship to attend one of the first Fetzer Institute conferences. Learning of the biopsychosocial approach to medicine set her on the course of her life, and it was the Fetzer Institute that partnered with the WMU Stryker School of Medicine to create the role she now holds. Her goal is not only to create programs, but also bring about structural and systemic shifts and improvements. “It’s not that students and residents and fellows don’t know how to manage stress,” said Horneffer-Ginter, “it’s more about looking at what causes stress, determining how those things can be improved, and balancing the importance of why some demands exist.”

Raj (2) asserted that maintaining social connectedness is critical to resident well-being, and this concept resonates for Horneffer-Ginter. A primary focus will be seeking opportunities to increase community relatedness, acts of kindness and appreciation, and creating “felt differences” in the physical environment. Not only will physicians-in-training benefit from such experiences, Horneffer-Ginter predicts more enriching experiences for patients, as well. The need to perform and produce, both as a medical student and physician, can elevate operational efficiency over wellness. Horneffer-Ginter is seeking the balance point.

Crafting an approach meant adapting the common definition of wellness, and she plans to cultivate wellness throughout the institution. At WMed, “wellness” will manifest as quality of life. “Whole-person care means different things, dependent upon context,” said Horneffer-Ginter. “I want to take into consideration and honor all dimensions of the whole being.” In these first months, information gathering to better understand the population – and sub-populations - will consume most of her time. “Mindfulness wasn’t being addressed 20 years ago,” Horneffer-Ginter pointed out. With the demands on medical students and physicians intensifying over the last two decades, according to Horneffer-Ginter, “There is a ripeness to taking this on now.”

Rebekah Apple, MA, DHSc, is the Director of Student Affairs and Programming, American Medical Student Association.

References
1. Muller, D. (2017). Kathryn. New England Journal of Medicine, 376, 1101 – 1103. http://dx.doi:10.1056/NEJMp1615141
2. Raj KS. (2016). Well-being in residency: a systematic review. Journal of Graduate Medical Education, 8(5), 674– 684. https://doi.org/10.4300/jgme-d-15-00764.1
3. Rotenstein, L. S., Ramos, M.A., Torre, M., Segal, J. B., Peluso, M. J., Guille, C., … Mata, D.A. (2016). Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: A systematic review and meta-analysis. JAMA, 316(21), 2214-2236. http://dx.doi:10.1001/jama.2016.17324.
4. Stanford Medicine MD Program Student Wellness. (n.d.) Retrieved from https://med.stanford.edu/md/student-affairs/student-wellness.html

The reader’s first impression of Ethics and Health Care: An Introduction by John C. Moskop may be similar to mine when viewing the cover of the text. Two medical professionals are featured – one leaning over the patient and providing what appears to be emotional support and the other clearly intellectually pondering the medical record. This scene set the stage for a discussion that would attempt to marry two roles of healthcare professionals, ethical compassionate care with technical excellence. The name tag on the female was a bit difficult to read but clearly said nurse. The male did not have a nametag. After my high expectations, I was a little dismayed to see the gender specific and role specific, female nurse taking care of the emotional needs of the patient and male doctor caring for the “technical needs.”

Luckily, the book fell much more in line with my first impression. John Moskop, MD is a Professor of Internal Medicine at Wake Forest School of Medicine, Winston-Salem, North Carolina. He starts each chapter with an ethical dilemma featuring a single or group of patients, many of whom are easily recognizable from news stories. The reassuring familiarity of the case stories will make an immediate connection with students. The chapter continues with a clear, concise presentation of foundational information needed to understand the ethical issues in the case. Dr. Moskop’s explanations are clear and well thought out. The cost of this clarity is the sacrifice of presenting some of the nuances of the issues sometimes making them seem more straightforward than they are. He provides references for the case studies, so the reader can consult the original source for more detail and background information.

The book claims to be an introduction to the major concepts, principles and ethics in healthcare and I feel that the author clearly met that goal. The topics chosen are appropriate to teach medical ethics in an undergraduate course or a basic foundational course in ethics at a health care professional school. The discussion in each chapter seems to be comprehensive on an introductory level and the tone is educational rather than argumentative. By presenting various options the author allows the reader to gain perspective and then apply their new-found knowledge to the introductory case for each chapter. I could see an instructor developing questions to assess learners critical thinking, as well as encouraging further research into areas of interest or allowing students to debate their perspectives in the classroom.

Dr. Moskop, a prolific writer on bioethics, provides references for further information throughout the text. However, there are few citations in the body of the text itself. I found myself wondering frequently throughout the text if the writing of the ethical options presented and the subsequent reasoning were solely the author’s interpretation of the standard of ethics. A fairly robust reference section can be found at the end of the text as well as an index. Since the purpose of the text is for teaching an introductory class the amount of references and citations are more than appropriate. Most instructors teaching ethics have a series of books that they consult to present various perspectives on ethical issues. I could easily see this book being a foundational book for a college bioethics course with supplemental books providing a more in-depth exploration of areas of interest or differing points of view.

Moskop, J. C. (2016). Ethics and health care: An introduction. Cambridge: Cambridge University Press. ISBN-13: 978-1107015470 388 pages


Leann Poston, MD, is Assistant Dean of Admissions and Career Advancement at WSU-Boonshoft School of Medicine in Dayton, Ohio.

All human beings are vulnerable, inescapably and universally, and this inherent vulnerability requires greater recognition within the healthcare professions (1). We prefer not to recognize our vulnerability. We tend to believe that we can control what occurs around us. However, we are all vulnerable. Vulnerability is an unavoidable human condition and is part of us. We experience vulnerability daily; examples of when we feel it most powerfully is when we lose our job, when we kiss someone for the first time or when we ask someone for a date, while taking exams, when we apply for a new job and we face an interview, when we feel we are getting older, when someone fails us, when we have fears…we are vulnerable. We all are embodied beings, embedded in social relationships and institutions, and inevitably vulnerable (2).

Each of us as individuals are positioned differently. And in the context of our job in healthcare, we are also vulnerable because of our profession. We witness suffering, pain, death, anxiety, fear, tears daily at work. Caring for patients and their families, healthcare professionals share and reflect on the gladness and sadness that accompany these interactions. And in many ways, we are suffering too. These circumstances put the professionals in a unique position. Professionalism must recognize vulnerability at the core of healthcare professions (1). There is nothing wrong with us because we are vulnerable in our workplace; it is part of our profession. There is "a vulnerability that arises out of the experience of others’ vulnerability, and this vulnerability may require more recognition by the profession” (1).

The problem is that we are rarely taught how to address this huge issue, which is there at the bedside. Nursing schools and medicals schools have long socialized us to avoid, to hide and not express this vulnerability. That is, healthcare professionals go out, go to bathrooms to cry, go alone and pretend that their team and colleagues don´t realize that they are suffering. It has been understood for long time as a weakness, as a lack, as something that we don´t want. Thus, we try to hide it, to say it doesn´t exist…but it is there. We question whether we are in error to feel vulnerability. But it is not wrong! We need to recognize it and not deny it.

It is important to recognize that vulnerability is not necessarily negative, but that it also contains the possibility of openness, creativity and generativity (1,3,4). There is a positive element associated with its inherent openness to the world, an opening that is necessary to grow and flourish. In that sense, "allowing ourselves to be vulnerable," recognizing and accepting our vulnerability, is a precondition for creativity (1). Our vulnerability presents opportunities for innovation and growth, creativity and fulfillment, since it is what encourages us to reach out to others and form relationships.

Some qualitative researchers (5,6) have explored extensively how vulnerability can be a strength for healthcare professionals. Qualitative research can usefully explore and analyze clinical events in which vulnerability had been experienced and addressed by clinicians in ways that may benefit their patient. In a focus group study with family physicians, some described that the vulnerability of identifying with the patients’ circumstances or situation, may promote more creative or thoughtful responses to their patients. Another area of vulnerability was feeling uncertain or having made clinical errors and deciding how best to address it with patients or learning from errors. These are only a few of the examples gleaned from qualitative research; and among different health care professionals, in different specialties or even practice locations, no doubt many more can be explored.

Further, while vulnerability gives strength, it also must be used prudently. On the one hand, it can help professionals to build patient’s trust, and the patient may feel more understood. On the other hand, if the clinician’s emotions are exposed primarily for the professional’s needs, the patient may feel unsupported (7). Overall, recognition of the fact that experiencing vulnerability in the context of healthcare may be a strength, which can lead healthcare professionals to a deeper understanding of the impact of relationships in healthcare. A focus on relationships can help professionalism to overcome the fracture between theory and everyday practice. That is why I propose the turn to a patient relationship centered professionalism.

For more information: http://web.gs.emory.edu/vulnerability/

Janet Delgado Rodríguez, RN, MA, Ph, is a Visiting Scholar at the Vulnerability and Human Condition Initiative, Emory University, Atlanta, US. Researcher at the Institute of Women´s Studies at the University of La Laguna, Spain.

References
1.Carel, H (2009), “A reply to ‘Towards an understanding of nursing as a response to human vulnerability’ by Derek Sellman: vulnerability and illness”, Nursing Philosophy (10), 214-219.
2. Fineman, M. A. (2008). The vulnerable subject: Anchoring equality in the human condition. Yale
Journal of Law & Feminism, 20 (1).
3. Fineman, M A (2012), “‘Elderly’ as vulnerable: Rethinking the nature of individual and societal responsibility”, The Elder Law Journal (20:1), 71-112.
4. Fineman, M A. (2014), “Vulnerability, Resilience, and LGBT Youth”, Temple Political & Civil Rights Law Review (23), 307-329.
5. Malterud, K & Hollnagel, H (2005), “The doctor who cried: a qualitative study about the doctor's vulnerability”, Annals of Family Medicine (3:4), 348-352.
6. Malterud, K, Fredriksen, L & Gjerde, M H (2009), “When doctors experience their vulnerability as beneficial for the patients. A focus-group study from general practice”, Scandinavian Journal of Primary Health Care (27), 85-90.
7.Gjengedal, E, Ekra E M, Hol, H, Kjelsvik, M, Lykkeslet, E, Michaelsen, R et al. (2013), “Vulnerability in health care – reflections on encounters in every day practice”, Nursing Philosophy (14), 127–138.

“No one wants to be forgotten like an old shoe.”

From Philadelphia to New Orleans to Palo Alto, this sentiment was shared among all of the individuals I spoke with for my Homeless but Human project.

The Medical Humanities Program at Drexel University College of Medicine provides students with a unique opportunity to explore disciplines that are often sidelined in medical education. The program, one of the first of its kind, uses Grand Rounds and electives taught by a wide range of medical professionals to better prepare future physicians to understand the lived experience and psychosocial impact of illness, identify social determinants of health and discover a deeper value in medicine – particularly important with today’s focus on physician burnout and resilience.

In order to attain the Medical Humanities Scholar certificate, we also need to complete an independent project in the field. My idea for Homeless but Human was born the summer after my first year of medical school when I encountered a homeless man I had walked past many times while in college but had never truly seen. Without knowing why, this time I decided to chat with him over a meal and our conversation launched me on a path that re-shaped my vision for my future in medicine.

Inspired by this conversation, I conceptualized a project where I would speak with homeless individuals in various parts of the country – taking advantage of having to travel for several conferences. The goal of the endeavor was to better appreciate the factors contributing to homelessness, to identify differences in health services and access between states, and to humanize an oft-overlooked population.

While I believe I accomplished this, what was more impactful for me was seeing the clear effect a simple conversation had on each of these people, who were so used to being alone and ignored. I couldn’t help the veteran in New Orleans get surgery on his shoulder nor could I prescribe medications to help my Philadelphia friend with her depression, but I found that a conversation brought some relief, at least for a few minutes.

Since then, my passion for helping the underserved has led me to help write policy on ending homelessness for the American Medical Association, to pursue a Master of Public Health degree, to do a rotation with the Boston Health Care for the Homeless Program (BHCHP) and Drexel’s Health Outreach Program clinics (HOP), and, ultimately, to pursue a career in preventive medicine and advocacy.

As a result of this project, I am spending more time getting to know the patient as a person and recognizing and addressing the social determinants that serve as barriers to positive health outcomes. At BHCHP, for example, free bus tickets and Uber Health are used to ensure that lack of transportation does not prohibit a patient from picking up medications or making appointments on time. In addition, the physicians I’ve worked with through BHCHP and HOP are some of the most empathetic and clever physicians I know. They figure out how to use minimal resources to diagnose and treat patients without compromising care.

At BHCHP, nearly every clinic site has both a physician or nurse practitioner and a case manager present to assist with every aspect of a patient’s needs. This inter-professional effort is critical to ensuring that patients receive the care they require. It also serves to uphold several of the professional responsibilities identified in the 2002 American Board of Internal Medicine’s Medical Professionalism Physician Charter, including commitments to improving the quality of and access to care.

To ensure that the next generation of physicians maintains the highest level of professionalism, such training needs to be included in medical education. One of the fundamental principles recognized in the professionalism charter is that of social justice. Physicians are bound by professionalism to “promote justice in the health care system” and “to eliminate discrimination in health care.”

As witnessed by my project, integrating the humanities into medical education will aid in the development of professionalism in our medical students and also encourage them to advocate for more equitable health care. The process of developing a project promotes thinking about medicine differently, beyond the lab values and the diagnoses.

At the very least, experiences like mine would remind physicians of the beauty of medicine, the power of empathy and the importance of professionalism.

For more information: Homelessbuthuman.wordpress.com


Aleesha Shaik is completing her final year of medical school at Drexel University College of Medicine and is applying for a residency in Internal Medicine. She received her MPH from the Harvard T.H. Chan School of Public Health and her Bachelor of Science degree from Johns Hopkins University.

The Patient Will See You Now: The Future of Medicine is in Your Hands by Eric Topol, MD would have seemed like a science fiction novel before the smartphone. Dr. Topol, a cardiologist and professor of genomics and director of the Scripps Translational Science Institute in La Jolla, California, compares the effect of Guttenberg’s printing press on democratizing access to written literature to the ability of the smartphone to make health care accessible to all and lower costs. Smart phone enabled applications will allow both healthcare practitioners and patients access to an almost unimaginable number of data points on their health and fitness due to sensors such as breath monitors, sleep monitors and microscopic blood born sensors capable of monitoring changes in blood chemistry.

With the advent of direct to consumer genetic testing by companies such as 23 and Me and Ancestry.com, Dr. Topol feels the focus in healthcare will move to genetic testing for prevention of disease as opposed to diagnostic testing. He cites the impact Angelina Jolie made when she went public with her BRCA 2 results and subsequent decision to have a double mastectomy. Genetic testing allowed her to make an informed decision about how aggressively she wanted to minimize the risk of future disease. According to Dr. Topol, the internet makes it possible for consumers to research their genetic mutations, read medical and research journals online and join patient groups for people with similar diagnoses to discuss symptom control and treatment options. He seems to discount the role of medical professionals in aiding patient synthesis of information, as well as providing context and verification for accuracy.

Dr. Topol feels that the most significant roadblock to the rapid progression of technology in healthcare is the paternalistic attitude of many of its practitioners because of their insecurity with technology and with losing control of medical information. Barriers between the patient and their medical data make it difficult for them to participate in a meaningful discussion about their health and to be an equal partner in decision making. However, the ability to accumulate vast amounts of medical data can lead to problems with security and storage as well as an understanding of who is going to track and evaluate this data. Market forces also contribute to the delay in integrating technology into healthcare and empowering patients. Medical practitioners have formulas and requirements for reimbursement and treatment, and many of these new technology models for healthcare do not easily fit into these models.

With the advent of genomic and precision medicine, large aggregates of genomic data will be needed to determine the significance, if any, of individual mutations, as well as the interaction between the genome and modifier genes and proteins. The significance of a mutation is commonly found by reverse genetics in which case an individual with an unusual disease has their genome sequenced to identify a suspect gene. Familial genomes are needed for comparison and verification of the mutation, but it cannot stop there. The complexity of the genome makes it necessary for genomes from unrelated people with and without the mutation in question to be evaluated. The same argument can be made for pharmaceutical testing. Individual drugs are suspected to work on approximately 20 percent of the population with efficacy determined by individual molecular makeup of channels and proteins. Genetic studies are needed to determine which 20 percent of the treatable population a drug will work for and what modifications can be made to a drug to allow it to work in others. According to Dr. Topol, pooling genetic data is likely to markedly increase progress in both diagnosis and treatment of disease.

There are significant risks. Cybersecurity and privacy laws have not progressed at the same rate as technology use in healthcare. Dr. Topol argues that the White House Consumer Privacy Bill of Rights and the Do Not Track legislation desperately need to be made law. He advocates for individuals having complete and unhindered access to their genetic data. He feels it should be illegal for any party to use genetic data or information obtained from genetic data without the owner’s consent and consent does not mean pushing a button to access an application after trying to decipher a disclaimer. Dr. Topol concedes that large amounts of data are needed to look for trends and to advance research, but ultimately the ability to use artificial intelligence and biomedical and molecular sensors to predict disease is the goal. He ends his well-researched and thoughtful book by urging large companies to lead the charge towards more autonomous healthcare, which could negate the need to move their businesses offshore to cut costs.

Topol, E. (2016) The patient will see you now: the future of medicine is in your hands. New York: Basic Book. 393 pages ISBN 978-0465054749

The Patient Will See You Now: The Future of Medicine is in Your Hands by Eric Topol, MD would have seemed like a science fiction novel before the smartphone. Dr. Topol, a cardiologist and professor of genomics and director of the Scripps Translational Science Institute in La Jolla, California, compares the effect of Guttenberg’s printing press on democratizing access to written literature to the ability of the smartphone to make health care accessible to all and lower costs. Smart phone enabled applications will allow both healthcare practitioners and patients access to an almost unimaginable number of data points on their health and fitness due to sensors such as breath monitors, sleep monitors and microscopic blood born sensors capable of monitoring changes in blood chemistry.

With the advent of direct to consumer genetic testing by companies such as 23 and Me and Ancestry.com, Dr. Topol feels the focus in healthcare will move to genetic testing for prevention of disease as opposed to diagnostic testing. He cites the impact Angelina Jolie made when she went public with her BRCA 2 results and subsequent decision to have a double mastectomy. Genetic testing allowed her to make an informed decision about how aggressively she wanted to minimize the risk of future disease. According to Dr. Topol, the internet makes it possible for consumers to research their genetic mutations, read medical and research journals online and join patient groups for people with similar diagnoses to discuss symptom control and treatment options. He seems to discount the role of medical professionals in aiding patient synthesis of information, as well as providing context and verification for accuracy.

Dr. Topol feels that the most significant roadblock to the rapid progression of technology in healthcare is the paternalistic attitude of many of its practitioners because of their insecurity with technology and with losing control of medical information. Barriers between the patient and their medical data make it difficult for them to participate in a meaningful discussion about their health and to be an equal partner in decision making. However, the ability to accumulate vast amounts of medical data can lead to problems with security and storage as well as an understanding of who is going to track and evaluate this data. Market forces also contribute to the delay in integrating technology into healthcare and empowering patients. Medical practitioners have formulas and requirements for reimbursement and treatment, and many of these new technology models for healthcare do not easily fit into these models.

With the advent of genomic and precision medicine, large aggregates of genomic data will be needed to determine the significance, if any, of individual mutations, as well as the interaction between the genome and modifier genes and proteins. The significance of a mutation is commonly found by reverse genetics in which case an individual with an unusual disease has their genome sequenced to identify a suspect gene. Familial genomes are needed for comparison and verification of the mutation, but it cannot stop there. The complexity of the genome makes it necessary for genomes from unrelated people with and without the mutation in question to be evaluated. The same argument can be made for pharmaceutical testing. Individual drugs are suspected to work on approximately 20 percent of the population with efficacy determined by individual molecular makeup of channels and proteins. Genetic studies are needed to determine which 20 percent of the treatable population a drug will work for and what modifications can be made to a drug to allow it to work in others. According to Dr. Topol, pooling genetic data is likely to markedly increase progress in both diagnosis and treatment of disease.

There are significant risks. Cybersecurity and privacy laws have not progressed at the same rate as technology use in healthcare. Dr. Topol argues that the White House Consumer Privacy Bill of Rights and the Do Not Track legislation desperately need to be made law. He advocates for individuals having complete and unhindered access to their genetic data. He feels it should be illegal for any party to use genetic data or information obtained from genetic data without the owner’s consent and consent does not mean pushing a button to access an application after trying to decipher a disclaimer. Dr. Topol concedes that large amounts of data are needed to look for trends and to advance research, but ultimately the ability to use artificial intelligence and biomedical and molecular sensors to predict disease is the goal. He ends his well-researched and thoughtful book by urging large companies to lead the charge towards more autonomous healthcare, which could negate the need to move their businesses offshore to cut costs.

Topol, E. (2016) The patient will see you now: the future of medicine is in your hands. New York: Basic Book. 393 pages ISBN 978-0465054749

The nursing faculty in the College of Nursing and Health Professions took a keen interest in improving how to assist students in understanding expectations of good conduct and professionalism. In 2007, a task force convened to develop a Code of Conduct, among other objectives. The purpose of the student conduct code document was to provide guidelines for nursing students concerning their professional conduct and character in the classroom, clinical settings and online classes and in communications. The document explicated the civil, ethical and respectful behavior expected of all nursing professionals. This code gave more specificity to a nursing student’s professional conduct, compared to the general university’s student code of conduct, since licensed health professionals in general and nursing students in particular, are held to a higher standard of conduct.

The eventual Code was organized around eight sections: 1. Purpose, 2. Rationale, 3. Student Civility, 4. Classroom Conduct, 5. Clinical Conduct, 6. Academic Integrity, 7. Communication and 8. Appendices. The document became an appendix in each nursing program’s student handbook. It influenced other non-nursing program leaders to devise ways of communicating “good conduct” and professionalism. One area germane to the work we are doing in education for professionalism is defining more specifically for students what we mean be “being civil.”

Civility and Uncivility Defined
Civility has to do with courtesy, politeness and good manners. Civility is the awareness and recognition of others in all interactions and demonstration of a high level of respect and consideration. In civility we recognize that no action of ours is without consequence to others or ourselves. We need to anticipate what these consequences will be and choose to act in a responsible and caring way. Some may also call this “The Social Compact or Contract,” derived from the philosophies of Locke, Hobbes, Rousseau, among others. The Social Compact is a tacit agreement among individuals when they enter society that the latter is a space that is organized in consideration of order and mutual protection and welfare – it also implies respect for one another at its core.

Uncivil behaviors are acts of rudeness, disrespect and other breeches of common rules of courtesy. These acts of incivility range from disrespectful verbal and non-verbal behaviors to physical threats to another’s well-being. Uncivility is a lack of awareness and recognition (intended or unintended) of others in our interactions when we fail to give them a high level of respect and consideration. Uncivility usually results when one does not anticipate how actions will affect others.

Core Concepts of Being Civil
· Shows common courtesy and respect
· Aware of others (corporeal, emotions and intellect)
· Actions have consequences (intended or unintended)
· Shows self-control
· Responsible for your personal actions
· Emotional intelligence
How Do You Know When You’re Being Uncivil?
· Being rude, disrespect or lacking common courtesy
· Being insensitive to others’ feelings
· Fail to see any consequences to one’s actions
· Self-centered; lack of self-control
· Dismissive of personal responsibility in the school and work environment

Shift from Private to Public Sphere
One’s behavior needs to change when moving from the private sphere to the public sphere. Sitting with feet tucked under you on your couch at home while watching TV is not uncivil. However, when sitting in the public sphere (classroom, dining hall, shuttle, public transportation, etc.) the context changes; therefore, behavior expectations change. Sitting this way in the public sphere can be considered uncivil, if not bad form. One needs to shift from his/her self-awareness used in the private sphere to awareness of others in the public sphere.

Anticipating Consequences of Actions
In the public sphere, you need to anticipate how others are affected by your actions (words and deeds) regardless of how insignificant they may seem. A routine, functional act in the private sphere may not be appropriate in the public sphere. One needs to be disciplined to shift from private to public sphere awareness and anticipate actions on others. This can also be interpreted as emotional intelligence, appreciation of the impact our words and actions have on others.

What you “Mean to (or not to) Do”
We stressed with students that being civil is part and parcel to professionalism for a student in the College of Nursing and Health Professions at Drexel. We explained that students are held to a higher standard of behavior. Their actions will be judged not only on what they know to do and not do but what they should have known to do. An example of this is explicated by several of the American Nurses’ Association publications (see below) as well as the various jurisdictional Boards of nursing, medicine, law and other professions where licensure is required that regulate the licensee’s professional conduct. Students are taught that what the licensee should have known to do is the standard that all licensed health professionals are held to and the individual is held accountable for conduct being one of the standards.

Contemporary Examples of Uncivil Behavior
Unfortunately, we are not at a loss of examples of uncivil behavior by high-profile people to show our students. Politicians, entertainers, sports stars, public servants, corporate leaders are all too frequently reported in the news for uncivil behavior and often with impunity. Almost daily we can read about an individual announcing their resignation from a prominent position for violating the social compact, rules of professional conduct and/or other torts that are legally actionable. The action could be an ethnic slur, poor choice of words, joke or comment about another, including language and conduct that reaches sexual harassment and/or assault. Think about how the person makes amends. The person usually apologizes by saying “I did not mean to….” or “I did not know it would have that effect on….” In most cases the jury of public opinion, aside from the petty politics, says that he or she “should have known better.” In other words, the person is not excused for being less mindful of the act because he or she is held to a higher standard. This is the standard students in the College of Nursing and Health Professions – future health professionals – are held to and this Code of Conduct goes a long way to explicate these high bar expectations.

Stephen F. Gambescia, PhD is professor of health services administration and Katherine Anselmi is associate professor of nursing in the College of Nursing and Health Professions at Drexel University in Philadelphia.

In a recent article published in Academic Medicine, Lawrence et al. challenged the validity of “Hidden Curriculum” as a concept (1). Their main argument refers to a possible lack of precision in the term accompanied by a lack of practical implications. Hafferty and Matiamakis rebutted: the plurality of definitions and nuances related to the term have opened the eyes of the medical education community to the complexity of the socialization process of medical students by revealing the unplanned forces that push medical students towards unprofessional behaviors (2). This essay aims to contribute to the debate sharing a story and two ideas.

The story: My first contact with the term “Hidden Curriculum” was six years ago when I was organizing the emergency medicine rotation at the University of Campinas in Brazil. At that time, we realized that last year medical students were fighting to keep their moral values against an undefined force nourished by the hierarchical environment of medical schools and hospitals. To my surprise, other schools were also facing the same problem. The hope arrived when in an insightful movement, social scientists named that force and gave birth to the concept of the Hidden Curriculum. Finally, our enemy was uncovered. When you name something, you get a sense of control that is vital to fighting back.

The resultant awareness guided the clinical teachers involved in the emergency training through the process of understanding the local nuances of the hidden curriculum. We got closer to students, listened to their demands, opened spaces for guided reflection, developed simulations and debriefing sessions to foster empathy and to discuss their professional identities (3-6). Clinical teachers often forget that medical students are critical human beings, even when they opt for silencing. They see, desire, think of, criticize, approve, disapprove, and incorporate or not, the behaviors they testify during the clinical activities; and, eventually, they suffer when the medicine they voted for and idealized succumbs to the constraints imposed by the health system or unprofessional doctors. Suffering in silence opens the door for emotional dissonance (7). Students feel powerless and abandoned.

As a counteroffensive, to give voice to medical students, we bridged the clinical training with the humanities developing a curricular course to address professional identity formation based on the “Theater of the Oppressed” by Augusto Boal (8). During his professional life, Boal developed a methodology to empower oppressed populations through theater. We called our initiative MEET: Medical Education Empowered by Theater. The consequence was the consolidation of a real community of practice shared by undergraduate students, residents, and teachers. The students are feeling safer and respected. We are proud. The change has begun.

The ideas: first, we believe that the hidden curriculum has two dimensions: one, universal and another, particular. The hidden curriculum is universal because all medical schools have to deal with unplanned elements of the socialization process of medical students. We have plenty of evidence showing that these unintended experiences can be extremely harmful. The hidden curriculum is also particular because different medical schools have different organizational cultures, with local nuances and singular rituals and norms. Why is it important to acknowledge both dimensions of the hidden curriculum? When we recognize its universality, we understand that we, clinical teachers, should question why the medical culture is nesting unprofessional silos strong enough to poison the moral commitment of idealistic medical students. The answer to this question can help us to figure out an organizational strategy to change this reality.

On the other hand, mapping the particularities within one medical school allows curriculum designers and course coordinators to target specific issues, such as identifying negative role models, problematic rotations, covert prejudice, practices of moral and sexual harassment, etc.

Second, the hidden curriculum represents a real source of emotional distress that contributes to burnout and cynicism, hampering the professional development of medical students. Moreover, cynicism is eroding the social contract of the medical profession. The ultimate consequence is that young doctors do not feel empowered enough to become the agents of change we require, which is terrible for a health system that needs to adapt to an ever-evolving complex society. In a less hierarchical environment, each new group of young physicians could bring us, senior physicians, a singular opportunity to reflect on old professional habits; habits that we are not proud of perpetuating. In the actual context, however, medical students are faded to reproduce our mistakes in a vicious cycle.

To foster a professional identity committed with the moral values of the good medical practice, we need to dissect the hidden curriculum exposing and analyzing all its components. The hidden curriculum is more than a concept; it is a reality that we urge to change. A change that may rescue our social contract.
Highlight: Medical students are newcomers, fresh air in a closed room; they have a comprehensive and critical view of the institutional culture. If we dare to listen, we will promote potent agents of change.
Practical tip: Curricular designers need to create safe spaces for medical students reflect on negative experiences. Ideally, the reflections should be guided by supervisors acknowledged by students as positive and accessible role models.

Marco Antonio de Carvalho-Filho, c is Associate Professor of Emergency Medicine - School of Medical Sciences - State University of Campinas - Brazil and Research Fellow in Medical Education - Center for Education Development and Research in Health Professions (CEDAR) - University Medical Center Groningen - The Netherlands

References
1. Lawrence C, Mhlaba T, Stewart KA, Moletsane R, Gaede B, Moshabela M. The Hidden Curricula of Medical Education: A Scoping Review. Acad Med 2017.
2. Hafferty FW, Martimianakis MA. A Rose By Other Names: Some General Musings on Lawrence and Colleagues' Hidden Curriculum Scoping Review. Acad Med 2017.
3. Schweller M, Costa FO, Antônio M, Amaral EM, de Carvalho-Filho MA. The impact of simulated medical consultations on the empathy levels of students at one medical school. Acad Med 2014;89(4):632-7.
4. Schweller M, Passeri S, Carvalho-Filho M. Simulated medical consultations with standardized patients: In-depth debriefing based on dealing with emotions. Revista Brasileira de Educação Médica 2018;42(1):84-93.
5. Carvalho-Filho MA, Schaafsma ES, Tio RA. Debriefing as an opportunity to develop emotional competence in health profession students: faculty, be prepared! Scientia Medica 2018;28(1):1-9.
6. Schweller M, Ribeiro DL, Celeri EV, de Carvalho-Filho MA. Nurturing virtues of the medical profession: does it enhance medical students' empathy? Int J Med Educ 2017;8:262-267.
7. Monrouxe LV. Identity, identification and medical education: why should we care? Med Educ 2010;44(1):40-9.
8. Boal A. The Aesthetics of the Oppressed. USA and Canada: Routledge (Taylor & Francis Group); 2006.

The use of gallows humors – also called black humor or cynical humor – is widespread in healthcare and is often described by those who use it as a coping mechanism for dealing with the daily stresses of work in the medical field (1). It is also, according to American Medical Association, American Nurses Association and National Association of Social Workers codes of behavior, of dubious professionalism due to the lack of respect for patients that gallows humor can communicate (2-4). Although those who use gallows humor typically report that they use it to cope with the stresses and tragedies of a profession in healthcare, evidence demonstrating that gallows humor is better than other measures of emotion processing or coping is mixed (5).

Katie Watson, in a broad ethical analysis of dark humor, argues that gallows humor and derogatory humor should not be grouped together based on the distinction between making light of a serious subject (i.e. laughing at a particularly ironic patient death) and making light of a patient (6). This distinction is important. All of the professionalism codes above indicate that a medical professional must communicate respect, which requires an intersubjective space between patient and provider. If a family does not appreciate the distinction between the ironic nature of the death and actively mocking their deceased loved one, professionalism is still breached. Similarly, a professional should not make cruel jokes at the expense of patients even to a friendly audience.

Therefore, what’s required to maintain professional ethics in joking is both a sympathetic room and an awareness of the relative power between the jokester and the occasion of humor (6). ‘Punching up’ at the expense of fate and mortality is laudable and perhaps beneficial, ‘punching down’ against patients is unprofessional. Gallows humor is a ‘backstage’ behavior in Goffman’s sense – whether it is tolerated as ‘professional’ among in-group peers varies based on its context (7). Among a group of doctors, nurses and medical professionals, gallows humor is expected and accepted. It should not, however, be engaged in when patients, family members or members of the public are around to hear it. This, indeed, is the position supported by Watson’s analysis.

Students, however, are neither peer nor public, and the behavior that they are exposed to in their early clinical rotations serves as formative material for their acculturation into the medical profession – that is, apart from official codes of conduct, their first experiences “backstage” tell them how members of the profession “really” behave. Their discomfort navigating the social rules surrounding both gallows and derogatory humor – and whether students differentiate between the two – can give us an insight into how students are inducted into the medical profession. Wear, Aultman, Varley, and Zarconi’s study of medical student response to derogatory humor found students initially struggling to navigate backstage medical spaces, often being included in instances of questionable humor which they were expected to participate in or at least tolerate (8). Students were not, however, expected to make jokes on their own. One comment in particular stands out in light of Mak-Van der Vossen, Teherani, Van Mook, Croiset, and Kusurkar’s Expectancy-Value-Cost framework of evaluation: medical students in Wear, et. al’s study reported being acutely aware of the rules of the “humor game,” with one student claiming, “There’s nothing a medical student can gain by [making derogatory jokes]” (8, 9). There’s no perceived value in making jokes, but neither is there an expectancy of successful resolution should a student report.

Medical students also reported identifying certain classes of patient as acceptable targets for disrespectful humor – those who were perceived to have caused their own complaints were chief among these acceptable targets, but other identified groups included psychiatric patients, clinic patients, and even sexually attractive patients (8). The existence of “acceptable targets” raises an interesting possibility for medical student reporting of professionalism lapses: they may not report disrespectful communications, because they do not perceive these incidents as lapses. Instead, the hidden curriculum of hospital medical education may be communicating that disrespect toward patients is not itself a lapse, but merely a possible occasion for professionalism lapses – that the lapse exists not in the disrespect but in the location, the tone or the target, exactly the same conditions to be considered with more innocuous jokes. While Watson’s distinction between gallows and derogatory humor is important, students engaged in active discourse are being led toward not acknowledging the difference except in examples of egregious comments that “crossed the line.”

It’s never stated that a repertoire of dark jokes is expected of a well-rounded and competent professional, but nearly all healthcare workers are exposed to and included in instances of both gallows and derogatory humor. The failure to distinguish between gallows and derogatory humor in hospital discourse results an activity which is explicitly discouraged in public codes of professionalism but is being communicated to students as a core part of the coping strategies required to succeed in the profession. Students begin acculturation into the ‘backstage’ space by occupying a position where there is nothing to be gained by any action but complicity in both relatively-innocuous incongruity-based humor and more pernicious derogatory humor.

In a follow-up study published in 2008, Wear, Aultman, Varley, and Zarconi reached out to panels of residents and attending physicians (10). The panels confirmed many of the findings of their 2006 study, but one physician provided what might be seen as a direction by which the ideals and group cohesion of the medical profession might both be respected: using instances of gallows humor or derogatory humor to evoke reflection. This need not take the form of confrontation or reporting. The physician reported using reframing devices to refocus care team attention on the human dimension, asking questions such as, “How many of you have an addicted person in your family?” (10)

This approach resists the conflation of gallows and derogatory humor during students’ acculturation to the clinical setting. However, it requires attentive preceptors at both the attending and resident level: students first learning how to “be” in their role as a medical professional can best learn to distinguish between appropriate and inappropriate “backstage” humor with a model of an established professional willing to self-interrogate at moments of potential transgression.

John Minser, MFA, is an Instructor in the Department of Medical Education Program in Medical Ethics, Humanities, and Law at Western Michigan University Homer Stryker M.D. School of Medicine.

References
1.Rowe, A., and Regehr, C. (2010). Whatever gets you through today: An examination of cynical humor among emergency service professionals. Journal of Loss and Trauma. 15. 448-464.
2. American Medical Association. (2007). Code of medical ethics, opinion 2.3.3: Informing families of a patient’s death. Retrieved from https://www.ama-assn.org/delivering-care/informing-families-patient-s-death.
3. American Nurses Association. (2015). Provision 1, Code of ethics for nurses. Retrieved from https://www.nursingworld.org/coe-view-only.
4. Workers, N. A. (2008). NASW Code of Ethics (Guide to the Everyday Professional Conduct of Social Workers). Washington, DC: NASW.
5. Craun, S. and Bourke, M. (2014). The use of humor to cope with secondary traumatic stress. Journal of Child Sexual Abuse, 23:7, 840-852.
6. Watson, K. (2011). Gallows humor in Medicine. The Hastings Center Report. 41:5. 37-45.
7. Goffman, E. (1959). The Presentation of Self in Everyday Life. New York: Doubleday Anchor Books.
8. Wear, D., Aultman, J., Varley, J., and Zarconi, J. (2006). Making fun of patients: Medical students’ perceptions and use of derogatory and cynical humor in clinical settings. Academic Medicine. 81:5. 454-462.
9. Mak-van der Vossen, M., Teherani A., van Mook, W., Croiset, G., and Kusurkar, R. (2018). Investigating US medical students’ motivation to respond to lapses in professionalism. Medical Education. 52:7.
10. Wear, D., Aultman, J., Varley, J., and Zarconi, J. (2008). Derogatory and cynical humour directed toward patients: views of residents and attending doctors. Medical Education.

How We Do Harm: A Doctor Breaks Rank About Being Sick in America by Otis Webb Brawley, M.D. with Paul Goldberg opens with a raw story set in Grady Memorial Hospital Emergency Room in Atlanta, Georgia. Edna, who waits for hours to be seen with a paper bag in her hand, requests that her breast be reattached. Her diagnosis - breast autoamputation due to stage 4 metastatic breast cancer. Why she waited nine years to be seen and why black women have a higher mortality rate from breast cancer are questions Dr. Brawley, chief medical and scientific officer for The American Cancer Society, attempts to answer. Poverty is the number one driver for a poor health outcome and race is second. Dr. Brawley believes there are poor health outcomes on both ends of the socioeconomic spectrum. The poor get little or no quality care with little preventative care due to a lack of health insurance and the wealthy get too much care with interventions that, at best, have not been scientifically proven to be beneficial and, at worst, may be harmful or fatal.

Dr. Brawley tells the story of Helen next, another black woman with breast cancer, but at the other end of the socioeconomic spectrum from Edna. Helen had a good paying job, was married and had insurance. She had a 3cm breast cancer which was also receptor negative. She felt relieved that she had great insurance, support and a steady income. Treatment with high dose chemotherapy was followed by an autologous bone marrow transplant. After suffering significant complications, she was not able to return to work for a year. The reoccurrence of her metastatic breast cancer was untreatable because she had reached her maximum lifetime dose of chemotherapy and radiation and ironically maximum benefit limit on insurance coverage as well. She ended up in Grady oncology clinic to see Dr. Brawley due to her lack of insurance and subsequently became his colleague in the fight against breast cancer in women of color.

The themes of the book seem to be that being on either end of the financial and treatment spectrum can be detrimental to health and that treatment choices should be based on science not market forces or providing false hope to cancer patients. A comparison between the use of medications and scans to diagnose illness shows that the United States treats more and images more patients than Canada, but their lifespan is approximately three years longer than ours. Interestingly, Dr. Brawley pointed out that if you did need an MRI you were more likely to get it done on a timely basis in Canada than in the United States. To make his point about excess and the U.S. patient’s conception of good medical care, Dr. Brawley tells the story of an upper middle class, insured, educated woman with Stage 1A colon cancer, who was diagnosed early and had an excellent surgery with more than 15 nodes biopsied and who sought chemotherapy because she wanted zero chance of a re-occurrence of the cancer. Her first oncologist told her that chemotherapy was not warranted, and the risks outweighed the benefits. A second oncologist concurred. She sought the care of a third oncologist who provided the requested chemotherapy. She informally consulted with Dr. Brawley who told her that the chemotherapy was a poor choice and she should stop it immediately. She chose to disregard this advice. Dr. Brawley concluded that she has increased her risk for leukemia for the next 10 to 15 years and the doctor who provided treatment earned an additional $5,000 for his office.
The tone of the book is impassioned with a purpose of providing a wake-up call to patients seeking treatment. No longer can we claim ignorance about the failings of our current healthcare system. The conflicting goals of humanistic medicine and financial interests are obvious, but solutions are not in sight. Lobbyists and large conglomerates of pharmaceutical companies will ensure that drug prices remain high, direct to consumer advertising will educate patients with skewed data to encourage them to seek unnecessary and perhaps harmful treatment, and productivity requirements will make it difficult for physicians to fully educate their patients on the risks of medical excess. While these points seem valid, Dr. Brawley did not provide a map to changing healthcare for the better and his strong bias towards academic medicine was apparent. Hopefully, educated consumers may take the first step by not pushing doctors to prescribe unwarranted medications and treatments.


Leann Poston, MD, is Assistant Dean of Admissions and Career Advancement at WSU-Boonshoft School of Medicine in Dayton, Ohio.

Brawley, O. W., & Goldberg, P. (2012). How we do harm: A doctor breaks ranks about being sick in America. New York: St. Martins Press. 317 pages

Timothy Brigham, MDiv, PhD, Chief of Staff and Senior Vice President, Education of the Accreditation Council Graduate Medical Education (ACGME) delivered an inspiring keynote address at the recent APHC annual meeting. Dr. Brigham’s talk focused on the concept that professionalism is at the heart of mastering medical knowledge. Well-being of physicians and trainees is a critical component of professionalism. The ACGME’s hypothesis is that physicians who are cognizant of self-care are likely to better model professional behaviors that will lead to the delivery of high quality and safe patient care.

Dr. Brigham discussed the disturbing proliferation of suicide among medical students and trainees. However, the ongoing collective efforts of the ACGME and collaborators focus on provider well-being and require a deepened awareness of how we may incrementally improve the transformative experience of medical education. Dr. Brigham suggests that the focus to improve well-being must be on sincere healthy guidance and mentoring of individuals to genuinely internalize the development of their professional identity as they interact within their complex professional environments.

This effort will require a collective effort to change environments within our medical training institutions. Dr. Brigham motivates us to be the thought leaders of change in our institutions. Mindfulness, healthy eating and self-care are forms of encouraging well-being, but they are not the only efforts that should be made. We must focus on each unique individual learner and their needs. We must discover what it is that makes a human being do what they do. Perhaps the motivating factors are a desire for autonomy, a sense of developing mastery and a connection to purpose that is deeper than the individual. To achieve our goals of high quality and safe patient care, deepening our positive connections to one another and finding our meaningful seriousness of purpose are the incremental steps on which we should focus to improve the resilience of our medical trainers and trainees.

Dr. Brigham concluded his talk in a profound manner. He suggested that we each focus on “becoming an intentional grace note” in our learners’ lives, to be that one extra note in another person’s existence that is meant to simply delight the soul and bring a deeper connection. He accents that we each may be the only one (or grace note) in another person’s midst who are singing such a song of encouragement and motivation. These small, but critically important, gestures are those that may be the impetus to change another person’s life and contribute to their important work of caring well for their patients.

Albert Wu, Director of the Center for Health Services and Outcomes Research and Professor of Health Policy and Management at the Johns Hopkins School of Public Health, coined the term “second victim,” in a 2000 British Medical Journal article. The second victim is described as a “healthcare provider involved in an unanticipated adverse patient event and/or medical error who is traumatized by the event.” Dr. Wu discussed two children who died, one through medical error. One provider stopped practicing and the second one committed suicide. He disclosed a story about his own patient where he missed a cancer diagnosis, and his patient died after another doctor eventually discovered the condition.

In a survey of three to four hundred Johns Hopkins providers, 75 percent wanted a prompt debriefing after an adverse event for the individual or group/team. As a result, Johns Hopkins founded R.I.S.E. (Resilience In Stressful Events), whose mission is to “provide timely support to employees who encounter stressful, patient-related events.” The program is built on a safe and confidential conversation with no report back, notification or investigation; 24/7 on call support; call back within 30 minutes; one-to-one group support by peers and psychological first aid. The 40-peer responders are all volunteers with the exception of the team leader.

By addressing the second victim’s needs early, the story can be changed and is not seared into one’s memory.

Johns Hopkins found the RISE services economically valuable, as well. At over 100 calls per year the savings is over $22,000 per call for the R.I.S.E. program.

The Joint Commission advises hospitals to help staff after traumatic events. In addition to the triple aim to enhance the patient experience, improve the health of population and reduce the per capita cost of healthcare, a fourth aim was added: the well-being of the healthcare team. And one of the best ways to ensure the team’s well-being is to provide support for the second victim.

To listen to the ACH/DocCom podcast where Dr. Wu
discusses second victims and the R.I.S.E program (6/2/18 release) click on: http://bit.ly/ACHDocComPodcast

The presentation was remarkable. The presenters invited the audience to watch and reflect on videos that displayed unprofessional behavior in relation to medical students. But the videos were far beyond: the viewers could capture how complex it is to be a health professional and how nuanced the relationships are among patients, supervisors and medical students. While inviting the audience to reflect on unprofessional behavior, the presenters explored how to support professional identity development of young professionals, which is, in my opinion, the only way to improve the social contract of the health professions.

Cynda Hylton Rushton, the Anne and George L. Bunting Professor of Clinical Ethics at the Johns Hopkins Berman Institute of Bioethics and the School of Nursing, gave an informative talk on the prevalence of moral adversity and the role of moral resilience in clinical practice. Dr. Rushton described moral resilience the capacity of a person to sustain, restore or deepen their integrity in response to moral complexity, confusion, distress or setbacks. It is founded on self-knowledge and commitment to our values. It also offers clinicians the skills and practices that support them in the midst of clinical complexity.

Moral distress was discussed as arising when one recognizes one’s moral responsibility in a situation; evaluates the various courses of action and identifies, in accordance with one’s beliefs, the morally correct decision – but is/feels prevented from following through.” Dr. Rushton also spoke about moral suffering as a response to moral harms, wrongs or failures. Various types of distress may arise from awareness of a moral problem, felt moral responsibility, moral judgment and the need for corrective action. Both internal and external constraints can thwart corrective action leading to loss of integrity, moral distress and ultimately to moral harms.

Resilience seems to have particularly distinct and easily recognizable almost tactile presence, so as to be considered an additional component of courage. Dr. Rushton’s tool to neutralize moral distress with moral resilience surges from the literature from which moral distress was first described. This is a great contribution to help preserve the humanistic trend in healthcare.

Although an increasing number of institutions are incorporating professionalism in their curricula; teaching professionalism in an interprofessional education (IPE) environment remains limited. Interprofessional Professionalism is defined as “Consistent demonstration of core values evidenced by professionals working together, aspiring to and wisely applying principles of, altruism and caring, excellence, ethics, respect, communication, accountability to achieve optimal health and wellness in individuals and communities.”

The National Academy of Medicine (formerly IOM) recommends that health professions should be educated together. Drexel University is a leader in teaching across disciplines, although initially there were barriers, such as schedules, supervisory issues, etc. Drexel developed a curriculum for an IPE on professionalism, which includes TeamSTTEPPS, leadership simulation, interprofessional leadership and clinical experience, professional formation identity integration and interprofessional professionalism collaborative. The disciplines include medical, nursing, law, physician assistant, pharmacy, social work and physical therapy students. Drexel is the lead institution on a grant from the Macy Foundation to incorporate professionalism training across disciplines. Thirteen institutions are piloting the program.

For more information visit - www.ProfessionalFormation.org

1. Building an Infrastructure for Personnel and Organizational Resilience Among Hospital Staff presented by Dan Huppert, MA from Assuta Medical Centers Network in Israel.
2. Care for the Caregiver: The Impact of Creating a Successful Peer Support Program at Christian Care Health System presented by Jen Schulak, BSN and Lauren Speakman, MBA, BSN.
3. Health Literacy: A Critical Component of Professionalism and Resilience presented by Julie Agris, PhD, JD from Stony Brook University.
4. Incorporating Balint Groups into a Pediatric Residency Program presented by Sinduja Lakkunarajah, MD from Albert Einstein College of Medicine.
5. Peer-led Self-Reflection at a Student-Run Free Clinic presented by Sam Gold, MD candidate at SUNY Downstate.
6. The ZIKV Epidemic: Professional Ethics Issues presented by Raul Perez, MD from the University of Puerto Rico School of Medicine.
7. Why “To Tell or Not to Tell – That’s the Question”: A Study on Confidentiality in an Academic Setting presented by Laura Granero from Pontifical Catholic University of Parana in Brazil.
8. Creating a Wellness Curriculum Using Internal Medicine Resident Feedback presented by Rob Colon, MD from Wright State University Boonshoft School of Medicine.

Steve Rosenzweig, Clinical Associate Professor of Emergency Medicine at Drexel University College of Medicine and the Director of the Program in Professionalism, Bioethics and Humanities in the Office of Educational Affairs, gave an inspirational talk on resilience. Resilience was described as an “in-touchness.”

Methods to address stress may contribute to significant personal shifts, some of which may be documented by psychometric scales, such as the Maslach Burnout Scale Jefferson Empathy Scale and Physician Belief Scale.

Stress reduction activities include mindfulness meditation, which attendees engaged in briefly to enhance being in the present, with Dr. Rosenzweig’s leadership. It has the potential to improve resilience in five areas: psycho-behavioral domains (increase in interconnectedness, social support, empathy and compassion), brain activity (increase in attention, metacognitive awareness, emotional regulation and cognitive reappraisal) stress response (increase in parasympathetic response and vagal tone and decrease in inflammation and stress hormones), gene expression (decrease in chromosomal deterioration and inflammatory gene expression) and post-traumatic growth (increase in positive reappraisal, goal-directed problem-solving and spiritual growth).

Dr. Rosenzweig further spoke of empathy and described accurate empathic understanding as the therapist being completely at home in the universe of the patient. It is a moment-to-moment sensitivity that is in the “here and now.” The client’s inner world of private personal meanings “as if” is sensed as if it were the therapist’s own, but without ever losing the “as if” quality. To sense the client's anger, fear or confusion as if it were your own, yet without your own anger, fear or confusion getting bound up in it.

The significance of being in touch with a moment-to-moment experience, also called interoceptive awareness, is acknowledging what is actually happening, making room or metabolizing/integrating the experience, opening wider and asking what else is here, accessing “wholesome states” e.g. equanimity and compassion, and maintaining greater closeness and intimacy with oneself. Dr. Rosenzwieg further referenced a book, Hardwiring Happiness, by Rich Hanson, PhD in relation to taking in the good i.e. taking a positive experience and extending it. That is, bringing attention, presence and being attuned to in the moment sensations and emotions, and extending the experience by staying with it for a few moments or a few breaths, and riding it out further; savoring the experience and allowing it to sink in and soak in.

Geisinger Commonwealth School of Medicine realized that although professionalism competency was infused throughout the curriculum, there were several areas where they could develop: the competency standards could be more clearly and regularly articulated to all faculty, staff and students; professionalism expectations for each year should be reviewed at all annual orientations; the process and system for accessing, monitoring and remediating student professionalism concerns should be reviewed; and serious professionalism concerns should be directed to the Promotions Committee as early as possible during a student’s career.

They decided to centralize the monitoring of professionalism competency in Student Affairs, to establish and deliver Professional Identity Formation curriculum to students at orientation and through courses in each year, to develop Pre-clinical and Clinical Professionalism Standards, to establish a referral system through Student Affairs for professionalism concerns and to establish a collaborative process for professionalism remediation housed in Student Affairs and infused throughout the medical school. It was anticipated that with these changes, students would integrate their professional development into their progression through the other core competencies and professionalism concerns could be identified earlier in a student’s career leading to interventions that would support timely and more holistic development.

Over 25 students have been identified as remediation candidates and asked to develop a one-year Professional Development Plan. Learners meet monthly with self-identified, approved mentors; read and reflect on both general and tailored material, including a capstone reflection; and complete assessments, such as Groningen Reflection Ability Scale and stress inventory, such as the Social Readjustment Rating Scale.

Student retention and graduation rate for the initial students in the program is 100 percent. The first students to complete the program are now in residency and will soon be receiving follow up surveys to analyze the program for further improvement and design. Students still in the program have given very positive feedback individually as they complete their year-long plan. Some students have requested to formally continue the program into their next academic year.

Dr. Hafferty began the workshop with the provocative premise that often medical students are the ‘perfect sheep’ vs. the cat. That is, in medical schools, medical students are expected to follow all the rules, remain within boundaries defined for them; they comply and learn this formula well. This behaviour contributed to their success to this point, and they were rewarded for not straying, aka not challenging educators to engage in ‘herding cats.’ During the course of the workshop, it was demonstrated that compliance may not be reflective of success in professionals and it may not even produce the types of healthcare professionals that patients want. Based on participants’ response to four questions around the topic, results showed participants preferred a range of compliance by their healthcare providers depending on the questions asked.

This workshop was entertaining, memorable and informative, opening the door to explore possibilities; somewhere between major disruption and strict compliance as a potential way forward for professionalism in medical education. As an educator, I resonated with the broader challenge facing education overall: traditional educational systems (more of an industrial complex) vs. the call by disruptors for a new educational system that fosters innovation and creativity. Dr. Hafferty’s closing quote from the movie Truman, perfectly encapsulated the workshop, “We accept the reality of the world that we are presented.”

Tyler Cymet, Chief of Clinical Education at the American Association of Colleges of Osteopathic Medicine (AACOM), kicked off the meeting with a keynote about “My Profession, My Community, My Capacity: Sources of our Strength.” He discussed the dilemma that associations are facing regarding a loss of members. The question he posed is how do associations attract members? His answer was to find ways to make their members more successful. AACOM is providing student services, such as helping with career development, providing behavioral health resources, encouraging interprofessionalism, instilling resilience through various activities and using learning communities. With the continuing deaths of associations, Dr. Cymet recommended credentialing as way to provide more value for an association.

Dr. Elisabeth Rosenthal’s book An American Sickness: How Healthcare Became Big Business and How You Can Take It Back is an eye-opening book diagnosing and prescribing for our most pressing chief complaint - the failing US health care system. Dr. Rosenthal is currently editor-in-chief for Kaiser Health News. She earned her medical degree from Harvard Medical School and trained as an Emergency Room physician. Dr. Rosenthal sets the stage for her book by explaining the history of healthcare and insurance in the United States. What started as an altruistic effort to provide insurance from financial ruin due to catastrophic medical conditions grew into a business monster. She explains the business model of pharmaceutical companies and medical device manufacturers. She explains why physicians have moved their practices to hospitals and became employees and why hospital bills are uninterpretable even for the most medically educated. Dr. Rosenthal’s 10 economic rules seem unbelievable. Read on, she provides a very strong case for them. Rule number 9, “There’s money to be made in billing for anything and everything.”

What makes sense from a business perspective models to improve the bottom line and increase the value of a company can be devastating to a sick patient with no other options. Business models are kept in check in the regular economy by competition. The American healthcare system is functionally a monopoly. Patients are left with no real options. Rule number 5, “There is no free choice. Patients are stuck. And they’re stuck buying American. Dr. Rosenthal’s daughter was at Princeton during the Meningitis B epidemic. In other countries where meningitis B is more widespread, children are vaccinated at birth. One colleague suggested she fly her daughter to England to get vaccinated.

The medical profession, pharmaceutical profession and medical device companies have no real competition. In another example, she explains how medical devices that apply for class 2 status merely need to say that they are substantially the same as another device, and they can be approved without patient testing. A pharmaceutical company knows that when its drug’s patent is about to expire, competition will drive the price down. How does the company respond? It makes an adjustment in the delivery method of the drug, re-patents the drug in the new delivery method and takes the old drug off the market. If the new delivery method worsens the palatability or bioavailability of the drug, it is not relevant. An example - a chewable birth control pill. As Dr. Rosenthal says, “What adult woman wants to chew her birth control pill?” Dr. Rosenthal explains how each sector knows how to ‘game the system’ to make continuous and increasing profits. A system that inhibits competition and leaves the patients with no choice but to pay exorbitantly high prices. Rule number 10, “Prices will rise to whatever the market will bear.”

Dr. Rosenthal’s presentation style is clear and informative. She provides background information and statistics, explains why certain medical decisions make sense from the business perspective, compares the same product or innovation to cost and testing in other countries, presents compelling patient examples, carefully building her case that the current health care system is dysfunctional. Dr. Rosenthal takes the time to thoroughly understand the perspectives of the insurance company, hospital, physician, patient, medical device and pharmaceutical company. Her information is well researched. Her tone clearly shows her outrage at the system and her compassion for the patients involved but stays factual instead of opinionated.

After explaining the “history of present illness,” Rosenthal takes each facet of the healthcare system and offers practical tips that consumers can use to try to cut their costs and force the system to be more transparent. Some suggestions she makes: only sign consent for paying your hospital bill after writing “if in network only,” be cautious about telehealth since it may not be the great deal it seems to be and don’t let pharmaceutical companies pay for medical meetings or pay a fee to be on your board. Overall, a very informative book that all healthcare consumers in the United States should read. As Dr. Rosenthal says, we may not be able to get the government to change and pass laws to improve the system, but each of us can do our part to be a savvier, more educated consumer. Her goal was to start a conversation. With her in depth knowledge and understanding of the issues, we can hope she goes a step further than that and spearheads a healthcare revolution.

Rosenthal, E. (2018). An American sickness: How healthcare became big business and how you can take it back. New York: Penguin Books. ISBN 978-1-59420-675-7. 406 pages.

Leann Poston, MD, is Assistant Dean of Admissions and Career Advancement at WSU-Boonshoft School of Medicine in Dayton, Ohio.

The grounding of medicine as a moral enterprise (1) and not commerce or a mere exchange of services or goods rests on three claims: the unique moral dimension of medical practice arises from the universal phenomena of human illness which render humans vulnerable and dependent on the good will and competence of others for health to be restored, the way society’s social contract allows health professionals to acquire medical knowledge coerced from patients by illness and the oath that symbolizes the physician-in-training joining of the medical moral community. Both (2) medical schools and members-in-training of the medical moral community are required to be virtuous moral agents. Integrity is asked from the medical schools: “In the conduct of all internal and external activities the medical school demonstrates integrity (3, 4) through it consistent and documented adherence to fair, impartial and effective processes, policies and practices” (5).

Members-in-training (6) of the medical moral community are asked to be compassionate: “Residents must be able to provide medical care that is compassionate, (7) appropriate and effective for the treatment of health problems and the promotion of health” (8). In most medical schools, some faculty members, including physicians, seem to be oblivious to the moral dimension of the medical profession, its humanistic strains and those medical ethics principles (9) around which learners have structured their professional identities. Curricular structures seem not to be grounded on constant objects but swayed by funding opportunities, accreditation requirements and, in some cases, by ideologies foreign to the moral medical community’s values and commitments. Professional integrity is threatened.

Raul Perez, MD, is Professor of Ophthalmology and Medical Ethics at the University of Puerto Rico School of Medicine

References:
[1] Guarding the Art: Edmund D. Pellegrino, MD. Virtual Mentor. November 2001, Volume 3, Number 11.
[2] Both integrity and compassion are virtues. Principles pp. 38-40.
[3] “In its more general sense, moral integrity means soundness, reliability, wholeness and integration of moral character, in its more restricted sense moral integrity means, fidelity in adherence to moral norms. The first coherence integration of aspects of the self… the second character trait of being faithful to moral values… and standing up in their defense…” If a person has structured his or her life around personal goals that are ripped away by the needs and agendas of others, a loss of personal integrity occurs.”
[4] Flexner called for intellectual honesty. Flexner Report 1910.
[5] Liaison Committee for Graduate Medical Education {LCME}: Functions and Structures of a Medical School Standard 1.
[6] Physician Candidate seems not to emphasize the salience of the moral commitment symbolized by the “White Coat “ceremony.
[7] “The Virtue of compassion combines an attitude of active regard for another’s’ welfare with an imaginative awareness and emotional response of sympathy, tenderness, and discomfort for another’s’ misfortune or suffering.” “Compassion… is expressed in acts of beneficence… focused on others.” “..Humanizing medicine and health care.”
[8] Accreditation Council for Graduate medical Education[ACGME] Core Competencies 1: patient care. [The learners’ initial encounter with patients is after the white Coat ceremony.]
[9] The Respect for Human Construct: respect autonomy, veracity, fidelity, and avoid killing innocent humans. (Respectfully modified from Robert Veatch)

Automation processes from the industrial revolution still influence work relations today. Consequently, professional development is grounded in an educational worldview based on the accumulation of information and the mastering of specialized knowledge. Healthcare professional practice, on the other hand, is characterized by situations which this worldview alone cannot handle. Healthcare professionals are constantly dealing with people in fragile states and with situations that demand agile decision making in uncertain territory. This brings about the need for reflective competency, emotional balance and empathy in professional practice. The principal doubt regarding this current teaching-learning model and automated healthcare services is that they lack creativity and do not stimulate reflective attitudes regarding clinical situations, neglecting behavioral-affective competencies and sensitivity in human relations. In this context, it is necessary to reflect on possible interventions from the educational point of view and on strategies for transitioning from an automated healthcare professional profile to a humanistic one.

In healthcare, many professionals treat patients systematically, as though they were facing a line of production, placing limits on dialogue and consultation time, thus making it impossible to develop a deeper relationship. This is detrimental to patient health, because the quality of the doctor-patient relationship influences adhesion to treatment and cure. According to the Hippocratic maxim, it is possible to cure using plants, knives or words. In the light of our current reality, regardless of the area in which they practice, all healthcare professionals use words as part of the cure. According to Balint, the healthcare professional’s personality is the first medication the patient receives. In this manner, the pyramid elaborated by Miller, which consisted of “knowing,” “knowing how,” “showing how” and “doing,” was enhanced by Cruess so that “being” or “professional identity” are at the top of the pyramid.

The use of routines and protocols is important as a general indication for attitude and procedure, principally for professionals at the beginning of their careers, because they provide a basic sense of direction and facilitate agility in healthcare. The protocols, however, can automate professionals when they are not associated with the professionals’ active, living presence in what they are actually doing. An example of a way to keep routines without losing sensitivity and reflection is the six-step protocol for communicating bad news developed by Buckman, which orients professionals not merely to state the news but to value the affective components of the person giving and the person receiving the news, making it possible to use different attitudes in different circumstances without completely discarding a guiding mental plan. This is like a poet who repeats a similar message, infusing it with the living presence of his or her words. Bonamigo recommends the use of dramatization and art as educational practices to promote empathy.

The worldview of technical, scientific and procedural formation, when hegemonically prioritized in professional development, seems to contribute to the automation of practices. It is recommended that education include training in reflective and affective competencies, sensitivity to the quality of relationships and knowledge related to ethical principles. The challenge with which healthcare education is faced is, thus, to affirm the importance of routines without allowing them to desensitize or automate healthcare practice. Possible solutions include: active teaching-learning methods; reflection on actions, thoughts and consequences; dynamic pedagogical activities with artistic production that make it possible to construct, to appreciate, to feel and to mobilize sensitivity, experience, emotion, inspiration and creativity in a manner that awakens vocation and virtue as the basis of healthcare professionalism. The dilemma involves the fact that productivity and routine in healthcare cause a reduction in the time and quality of the doctor-patient relationship. In this context, continuing education in communication skills is recommended to ensure excellent verbal and non-verbal communication in the doctor-patient relationship. Health professionals give something of themselves to the patient, so it is important to be with the mind and feeling present in what they do.

Fernanda Patrícia Soares S. Novaes, Physician, PhD(c), Institute of Integral Medicine Professor Fernando Figueira (IMIP), and National Institute of Social Security (INSS) - Brazil

Marcelo Silva de Souza Ribeiro, PhD, Federal University of San Francisco Valley - Brazil

References:
1. Baile W, Buckman R, et al. SPIKES—A Six-Step Protocol for Delivering Bad news: application to the patient with cancer. Oncologist. 2000; 5(4): 302-11.
2. Balint M. O Médico, seu Paciente e a Doença. Rio de Janeiro: Livraria Atheneu, 1984.
3. Blin JF. Représentations, pratiques et identités professionnelles. Paris: L’harmattan,1997.
4. Bonamigo EL, Destefani AS. A dramatização como estratégia de ensino da comunicação de más notícias ao paciente durante a graduação médica. Rev Bioet 2010;18(3):725-42.
5. Cruess RL, Cruess SR, Steinert Y. Amending Miller’s Pyramid to Include Professional
Identity Formation. Acad Med. 2016;20(10).

Automation processes from the industrial revolution still influence work relations today. Consequently, professional development is grounded in an educational worldview based on the accumulation of information and the mastering of specialized knowledge. Healthcare professional practice, on the other hand, is characterized by situations which this worldview alone cannot handle. Healthcare professionals are constantly dealing with people in fragile states and with situations that demand agile decision making in uncertain territory. This brings about the need for reflective competency, emotional balance and empathy in professional practice. The principal doubt regarding this current teaching-learning model and automated healthcare services is that they lack creativity and do not stimulate reflective attitudes regarding clinical situations, neglecting behavioral-affective competencies and sensitivity in human relations. In this context, it is necessary to reflect on possible interventions from the educational point of view and on strategies for transitioning from an automated healthcare professional profile to a humanistic one.

In healthcare, many professionals treat patients systematically, as though they were facing a line of production, placing limits on dialogue and consultation time, thus making it impossible to develop a deeper relationship. This is detrimental to patient health, because the quality of the doctor-patient relationship influences adhesion to treatment and cure. According to the Hippocratic maxim, it is possible to cure using plants, knives or words. In the light of our current reality, regardless of the area in which they practice, all healthcare professionals use words as part of the cure. According to Balint, the healthcare professional’s personality is the first medication the patient receives. In this manner, the pyramid elaborated by Miller, which consisted of “knowing,” “knowing how,” “showing how” and “doing,” was enhanced by Cruess so that “being” or “professional identity” are at the top of the pyramid.

The use of routines and protocols is important as a general indication for attitude and procedure, principally for professionals at the beginning of their careers, because they provide a basic sense of direction and facilitate agility in healthcare. The protocols, however, can automate professionals when they are not associated with the professionals’ active, living presence in what they are actually doing. An example of a way to keep routines without losing sensitivity and reflection is the six-step protocol for communicating bad news developed by Buckman, which orients professionals not merely to state the news but to value the affective components of the person giving and the person receiving the news, making it possible to use different attitudes in different circumstances without completely discarding a guiding mental plan. This is like a poet who repeats a similar message, infusing it with the living presence of his or her words. Bonamigo recommends the use of dramatization and art as educational practices to promote empathy.

The worldview of technical, scientific and procedural formation, when hegemonically prioritized in professional development, seems to contribute to the automation of practices. It is recommended that education include training in reflective and affective competencies, sensitivity to the quality of relationships and knowledge related to ethical principles. The challenge with which healthcare education is faced is, thus, to affirm the importance of routines without allowing them to desensitize or automate healthcare practice. Possible solutions include: active teaching-learning methods; reflection on actions, thoughts and consequences; dynamic pedagogical activities with artistic production that make it possible to construct, to appreciate, to feel and to mobilize sensitivity, experience, emotion, inspiration and creativity in a manner that awakens vocation and virtue as the basis of healthcare professionalism. The dilemma involves the fact that productivity and routine in healthcare cause a reduction in the time and quality of the doctor-patient relationship. In this context, continuing education in communication skills is recommended to ensure excellent verbal and non-verbal communication in the doctor-patient relationship. Health professionals give something of themselves to the patient, so it is important to be with the mind and feeling present in what they do.

Fernanda Patrícia Soares S. Novaes, Physician, PhD(c), Institute of Integral Medicine Professor Fernando Figueira (IMIP), and National Institute of Social Security (INSS) - Brazil

Marcelo Silva de Souza Ribeiro, PhD, Federal University of San Francisco Valley - Brazil

References:
1. Baile W, Buckman R, et al. SPIKES—A Six-Step Protocol for Delivering Bad news: application to the patient with cancer. Oncologist. 2000; 5(4): 302-11.
2. Balint M. O Médico, seu Paciente e a Doença. Rio de Janeiro: Livraria Atheneu, 1984.
3. Blin JF. Représentations, pratiques et identités professionnelles. Paris: L’harmattan,1997.
4. Bonamigo EL, Destefani AS. A dramatização como estratégia de ensino da comunicação de más notícias ao paciente durante a graduação médica. Rev Bioet 2010;18(3):725-42.
5. Cruess RL, Cruess SR, Steinert Y. Amending Miller’s Pyramid to Include Professional
Identity Formation. Acad Med. 2016;20(10).

Dan Ariely, a behavioral economist and New York Times bestselling writer, writes about why people make the choices they do. The book has 15 chapters discussing patterns of behavior and the controlled experiments the author and his collaborators conducted on mostly MIT college students to evaluate decision making and to test their theories. In his first chapter, Ariely discusses relativity and how we need anchors to make decisions. For example, if we have two equally good options we have difficulty deciding between them, but if we add an inferior variation of one of them we will likely choose the better version of that option. If we are given the option of attending one lunch lecture discussing drug A and another lunch lecture discussing drug B, we will have difficulty deciding which to attend. If there is a third lecture after work on drug A at which no food is offered, invariably, people will choose the Drug A lecture with lunch. They compare the Drug A lecture with lunch to the Drug A lecture without food and determine the one with food is a better deal even with no basis of comparison for the lunch on Drug B.

In Chapter 3, Ariely explains why we often pay too much when we pay nothing. Ariely et al. ran several experiments using candy and pricing to determine if our decision making is rational. Generally, people consider the upside and downside when we make decisions, but when something is free we tend to forget about the downside. Human’s have a disproportionate fear of losing something. If something is free we don’t have that fear. We will purchase accessory items or stand in line for long periods of time to get something for free. When France charged the equivalent of 20 cents for shipping Amazon products, sales did not go up like they did in the rest of the world, but as soon as they went to free shipping the increase in sales was equivalent to other countries. Making something free is demonstrated to be a powerful trigger for a desired behavior. When a drug company offers a coupon for a free copay, a free trial or even free information, it gets our attention and we are prone to make irrational decisions as a result.

In Chapter 4, Ariely begins his discussion of the social norm and the market norm. If someone offers us money or tells us how much a gift costs, then we expect to be fairly paid for our labor. If they ask us to do work as a favor we do it without expectation for payment because we anchor it in our social world of normal behavior instead of using market norms. If you want your patients to think of you as a member of the family in the hopes that they will be understanding if you make them wait, then you are operating in a social relationship, but then if you charge them an extra copay or fine them for a missed appointment they will move to thinking of your practice in terms of a market relationship and it will be very difficult to move them back to thinking in terms of social norms.

In an experiment by Gneezy and Rustichini (2000), parents who were late picking up their children in an Israeli daycare were charged a fine. This moved behavior from a social norm of feeling guilty for picking their children up late to a transactional nature- minutes for dollars. Instead of picking their children up on time, more parents were late after the fine was instituted. Why? Because the guilt was removed. Even after they were no longer fined they continued to pick their children up late. The relationship had moved from one based on social norms to one based on market norms. Ariely suggests choosing one or the other and sticking with it. He cautions that social norms tend to motivate people much more than market norms and are more economical.

Preventative health care is much more cost effective than reactive health care, but people have a hard time making time for preventative care. Ariely conducted several experiments in which students were given firm deadlines, where they gave themselves firm deadlines and where the deadline was the last day of the semester. After evaluating their work, those with the firm deadlines performed best, those with no deadlines performed worst and those with self-imposed deadlines were in the middle. He suggested that if a cost was imposed on patients who do not follow through on preventative care, follow through may be more consistent. Patients have good intentions when walking out of the physician’s office, but then life gets in the way.
Expectations have a huge effect on how we evaluate the success of something. Ariely asks would a $2.50 pain pill be perceived as working better than a $.10 pill, the results, yes. The placebo effect is powerful, and we have higher expectations for results from more expensive items. He then tested stereotypes and demonstrated the same results. What we expect will happen, invariably will be what we think did happen.

Honesty in test taking is certainly in the realm of professionalism as are free lunches from drug representatives and “borrowing” office supplies. What would make a student more honest when taking a test? Ariely showed that nearly all groups of students cheated when they thought they could. Most cheated a little though, not a lot, even when the experiment was designed so they could not be caught. Eventually their superego stopped them. What decreases cheating? Having the test takers sign an honor code or personal honesty statement before taking the test markedly decreased the amount of cheating on the test. Ariely’s experiments also demonstrated that people were more willing to steal when money was not involved. In one experiment, students were paid for the number of correct answers they achieved on a test, the control group. The second group self-reported correct answers and were paid.

The average number correct went up but not a lot. In the final group, the students were paid with tokens for the number of correct answers. They then took the tokens across the room to exchange them for money. They number correct went up significantly higher, some even reporting 100 percent. People are reluctant to cheat or steal when money is directly involved, which begs the question, what will happen when our financial system no longer utilizes paper currency? Cheating or stealing is not limited by risk because we rarely do a risk benefits analysis on our actions. It is limited by our ability to rationalize our actions for ourselves.

In the last chapter of the book, Ariely explores how people change their behaviors when they want to have a certain image or be perceived in a certain way. He evaluated people ordering dinner privately verses in a group setting and showed that people are willing to sacrifice their own pleasure to be perceived in a certain way.

A critique of the book would be that it was a no more than a description of a series of experiments providing evidence for theories on human behavior. The sample population were from MIT and other Ivy League universities which would certainly not be representative for an entire population. The theories came before the experiments which could have led to a demonstration of the very irrational decision making that Ariely says we make, basing the conclusions on what we expect will occur.

Ariely, D. (2014). Predictably irrational, revised and expanded edition. HarperCollins e-Books.
Gneezy, U., & Rustichini, A. (2000) A fine Is a price. The Journal of Legal Studies. (29:1), 1-17.

Leann Poston, MD, is Assistant Dean of Admissions and Career Advancement at WSU-Boonshoft School of Medicine in Dayton, Ohio.

Resilience as the process of humans adapting well in the face of adversity seems to be a character trait. This process could also be an attribute of or proxy for the Fortitude Construct, one of the four hinges or Cardinal Virtues that open the door to a virtuous/just life. Thus, resilience either as a character trait, a capacity to be developed or an attribute of the Fortitude Construct will require a particular pedagogy to promote its development in individuals just as professionalism does.
Virtue acquisition needs to be anchored in a particular philosophy that provides ample explanatory power.

Modern theologians propose a philosophy that probably satisfies that criteria. It is grounded in the following claims:

1. That there is a truth, which truth is amenable to discovery by rational inquiry and can be articulated and shared with language.
2. Human beings and the world around them are real objects and not an illusion.
3. Humans being are a psycho-physiological unit.
4. Humans do not come into being by a conscious act of their wills but are rather creatures (of the stars?).

If resilience is seen as a capacity or a virtue to be developed, then, just like in Chomsky’s language construct and Principles’ Common Morality, it is an innate capacity, it precedes the individual, develops in community, is perfected by practice and evolves within constraints. In state education environments in which most people are children of moral relativism, disengaged from the so called Judeo-Christian values and shun the notions of a common morality, a pedagogy for moral resilience beginning in elementary school is essential for adequate moral development. The state education programs must be designed so as to arm children with the moral discernment tools needed to live a moral life.

Raul Perez, MD, is Professor of Ophthalmology and Medical Ethics at the University of Puerto Rico School of Medicine

Over the past two decades, healthcare professionals have come to embrace and successfully integrate social media into their personal and professional lives. Social media’s popularity and utility has mirrored our evolving reliance on digital technology throughout healthcare. The generational divide between digital immigrants (those born prior to advent of digital technologies) and digital natives (those born since) has decreased as familiarity has led to acceptance of the necessity of such advancements. Health professionals continue to examine and grapple with the implications of digital technologies and more specifically with the use of social media on their professional relationships with patients and colleagues. The impact of social media extends far beyond relationships though. It has influenced the societal role of healthcare professionals too.

Among the challenges presented are balancing traditional core values of professionalism with political expression, engagement and activism. Physicians, nurses and all health professionals have a well-established history of civic engagement and advocacy on behalf of patients and communities. Healthcare workers have helped to educate and empower fellow citizens on the need for protecting and promoting public health needs regarding water sewage systems, food safety, dietary and nutritional needs, reproductive health, drug and alcohol use and treatment, seatbelt laws, gun safety and many other examples. Health professionals do not always share the same ideological perspectives about these and many other health issues. These differences are important to explore as there should be continued dialogue and respectful engagement amongst health professionals.

Political expression in the age of social media has greatly expanded the ability of all individuals to access information, but also share and create new content to support and promote viewpoints along an ever-widening political spectrum. Social media’s ease of use has accelerated the growth and influence of grassroots movements to motivate those who might have otherwise been passive observers into active participants and leaders. There is general agreement that healthcare providers do not want their respective and collective profession to become politicized. Unfortunately, the power to prevent or limit this is not within the realm of professional self-regulation and thus healthcare has become a powerful and at times divisive political wedge throughout the world.

Healthcare professionals should proactively approach these challenges by creating opportunities that honor core values, promote the well-being of patients and communities, and foster interprofessional and intergenerational dialogue through social media. Politicization of healthcare requires more effective and engaged healthcare advocates, not fewer. In a letter to the editor (1), Schickedanz and fellow medical resident colleagues proposed training young physicians to represent the higher purposes and values of their profession in public discourse and to exercise their civic and professional duty to educate political decision makers with the best evidence. The responsibility should not lie with physicians and medical students, but all health professionals and not only those viewed as Digital Natives. It would be shortsighted to not call upon the expertise and wisdom of more experienced health professionals in this effort to honor the ideals of professionalism and its significance to political engagement.

There remains a need to help provide guidance to social media novices regardless of prior professional expertise or political activity. The following should be considered by health professionals. When engaging with others online in a professional capacity, be forthcoming in identifying your expertise and credentials. If you are not authorized to represent your institution, include a disclaimer acknowledging this distinction. Create and/or share only credible information. If presented with false or misleading claims, refute with facts and evidence-based research. Do not discuss information about patients or colleagues without their permission. Avoid providing medical advice to others online. In all your interactions, online as when offline, be respectful of differing opinions, values and the willingness of others to engage professionally and civically. In doing so, you are not only role modeling the values of the healthcare professions, but principles that are necessary for preservation of democratic values.

Patrick D. Herron, DBe, is Director of Bioethics Education at Albert Einstein College of Medicine

(1) Schickedanz A, Neuhausen K, Bennett H, Huang D. Do medical professionalism and medical education involve commitments to political advocacy? Acad Med. 2011;86:1062.

A common response to the enduring question of just what is professionalism is, “We may not be able to agree on an exact definition, but we know unprofessional behavior when we see it.” Enter exhibits A through Z when watching the popular TV Series House, M.D. Dr. Gregory House is the preeminent diagnostician; he solves medical mysteries that no other doctor or team of doctors can solve. He and his triad of young cracker jack doctors take on only the most complex cases - those that most doctors would give up on. He saves lives routinely with heroic efforts of differential diagnoses and sometimes saves a life even more impressive than a miracle. There is only one problem. Dr. Gregory House is the antithesis of every virtue we aspire to for health professionals, and he is the antithesis of every virtue we have witnessed in humanity. But there are two characteristics to counter these major shortcomings. He saves lives and he possesses an intellectual virtue (1) that is mesmerizing—enough to keep viewers interested through eight successful seasons (117 episodes).

Showing video clips is nothing new in preprofessional and continuing education teaching in the health professions; there are libraries full of them and the quality ranges from amateurish to well-done and expensive. The benefit of using this TV series is, well, the actors are professional. But more so, the content of House, M.D. is so good that the best simulation or case study writer could not top the material we can use in House to show unprofessional behavior. Dr. Gregory House is an abrasive, arrogant, callous, lewd, crude, rude, unsympathetic, misanthrope. He practices cowboy style medicine with impunity and without peer. He rewrites the rules on informed consent and is dismissive of patient autonomy. He breaks almost all administrative rules and goes to the edge and often over best practices and ethical guidelines. He lives by the code that “All patients lie.” But he saves lives and gains the envy, even at the cost of great personal and professional pain, of those close to him at Princeton-Plainsboro Teaching Hospital.

So why show clips or even full episodes to students and practitioners of what is patently unprofessional? One set of reasons is House has a brush with every person in a hospital setting from the volunteer candy striper to the chairman of the board of trustees. He unsettles every area of the hospital from the parking lot to the ER to the rooftop. He gets under the feet of those in every department in a hospital from maternity to the morgue. And he is an equal opportunity insulter. Thus, the series is a treasure trove of tense, critical and volatile patient care cases that can bring out the worst in every health professional. He can get on your last nerve. However, as with any video, TV series or motion picture teaching tool, one should exercise best practice on planning the components of this student learner activity, such as a) context for why the video or clip was selected and used; b) disclaimer, which includes movie or TV rating and permission for students to opt out of the viewing; c) overall purpose of the learner activity; d) hints on what to look for in the showing; e) video setting; and f) questions for class discussion and assessment after viewing the video (2). The antics of Gregory House are so entertaining that instructors could slip into showing clips that are gratuitous, thus risk minimizing their pedagogical purpose.

A second set of reasons, and ones that faculty can benefit from in teaching students about professionalism if they have the time and inclination, is the much deeper lessons House, M.D. presents to health professionals. The series prompted a group of philosophers to write chapters in a book House and Philosophy (part of the Blackwell philosophy and pop culture series) (3). The authors examine deep philosophical questions of the multiplicity of everyday events in health professionals’ challenge to be good people while doing everything possible, and even unthinkable, to save a life.

The characters explore who they are and who they want to be. They become aware of what type of doctor they are becoming and what drives them to solve a case. They explore the borders of friendship versus colleagueship and the thick or porous boundaries between mentor and mentee. The show has episodes of the classic administrator versus clinician tension. Patient care ranges from simple sniffles in the free clinic to those one in a million cases that burn hundreds of thousands of dollars for care, even if it means breaking expensive equipment and inconveniencing others. There are cases of therapeutic privilege, decisions by proxy and decisions by House that trump a patient’s death bed preferences. The series is certainly a useful exhibit to show what not to do, but with a little bit of research and review (and some guidance from the House and Philosophy project) you have a priceless Grand Rounds material on teaching about professionalism.

Stephen F. Gambescia, PhD, is professor of health services administration at Drexel University in Philadelphia.

References
(1) Battalay, H. & Coplan, A. “Diagnosign Charactere: A House Divided.” In H. Jacoby, (Ed.). (2009). House and philosophy. Hoboken, NJ: John Wiley & Sons, pp. 222-238.
(2) Gambescia, S. F. (2015). Teacher prep in using cinema in the classroom. Journal of Health Education Teaching Techniques. 1(4), 36-46.
(3) H. Jacoby, (Ed.). (2009). House and philosophy. Hoboken, NJ: John Wiley & Sons.

Blogs and Tweets, Texting and Friending Social Media and Online Professionalism in Health Care by Sandra DeJong is a timely resource covering a whole curriculum in professionalism education on the use of technology. Dr. DeJong begins by defining professionalism in several different ways. She moves from classic literature, through a look at physician attributes to patient centered care and the resulting contract physicians have with society. She defines boundary crossings and violations and explains how they are facilitated by a power differential between physician and patient. This power differential is narrowing due to ready access to health care information on the internet and the desire of the anti-hierarchal millennial generation for collaborative care. Dr. DeLong explains that the internet pervades our lives both professionally and personally and blurs the lines between them making boundary crossing more probable. She describes a need for an effective curriculum in health care on technology use and implores that it not be a hidden curriculum.

Dr. DeJong begins with comparing and contrasting online and digital media. Her use of vignettes and everyday life circumstances uses a conversational style. She then devotes the next eight chapters to the following topics: liability, malpractice and standard of care; confidentiality; patient and practitioner privacy; libel; conflict of interest; academic honesty; mandated reporting and safety issues; and netiquette. In each chapter background information is provided first with a wealth of resources for the reader to consult and then vignettes are presented that are pertinent to the health care provider. Each of these vignettes involve health care professionals in situations that nearly anyone could identify with. Dr. DeJong gives the reader many perspectives and consequences for actions that could be taken based on the scenario. She then devotes a section of each chapter to general recommendations. Each chapter could easily be converted to classroom curriculum. Learners could be asked to read the introduction and research several of the resources to prepare for classes. The vignettes could be utilized as cases for problem based learning and perhaps medical professionals or patients could be asked to provide their insight on the topics.

Boundary crossings are much easier in the electronic world where social media makes it possible to easily confuse and intermix your private and professional life. To make matters worse from a legal perspective all interactions online are documented and legally admissible in court. Online medical advice also blurs the line between a blog providing general medical advice and a true physician- patient relationship. Patients have the freedom to express their opinions on your medical care and practice style in a public forum, while practitioners need to exercise the utmost care not to respond or reciprocate. Dr. DeJong does an excellent job of providing enough information that the reader is given plenty to think about while recognizing the time restrictions of busy professionals.

In the final chapters Dr. DeJong offers practical advice to all health care providers and discusses the future of health care technology. Use of email is widespread throughout health care. She distinguishes between the use of email with patients in which there is an established patient-physician relationship and when there is not. She stresses setting communication boundaries and standards early in the relationship, limiting liability, using security measures such as encryption, paying attention to how to handle unsolicited email as well as practicing medicine online across state lines. For websites and blogs, Dr. DeJong refers the reader to http://www.medbloggercode.com/thecode/ to review their five standards for health care blogs and websites. Texting is ideal for appointment reminders, receiving up-to-date information and emergency alerts, but there are confidentiality and security concerns. An important reminder is that having your patients phone number or email address is not consenting to communicate by text or email. She concludes with imploring readers to check their motives for posting information, to consult professionals to help manage technology for the practice and to carefully guard against blurring the line between your personal and professional life.

DeJong, S. M. (2014). Blogs and tweets, texting and friending: social media and online professionalism in health care. San Diego, CA: Academic Press, is an imprint of Elsevier.

Leann Poston, MD is Assistant Dean of Admissions and Career Advancement at WSU-Boonshoft School of Medicine in Dayton, Ohio.

Many news organizations have documented the horrific details of the crimes Larry Nassar, the disgraced former MSU and USGA gymnastic physician, committed against women and children over the course of his career (see, e.g., Indianapolis Star, Detroit Free Press, the New York Times, ESPN, and many more). [1] I will not recount his crimes here, but instead will focus on how he was permitted regular, unsupervised, intimate contact with so many victims, some children as young as six-years-old, even after victims complained about his actions.

Because he was a physician [2]

Nassar’s medical license was revoked after his crimes came to light within the past few months, but there were complaints of inappropriate behavior many years earlier. Both USA Gymnastics [3] and Michigan State University were formally notified of concerns about Nassar’s behavior, but failed to decisively intervene —allowing Nassar the opportunity to victimize more children. [4] Investigations about the nature of these failures are on-going, but we can all expect the institutional repercussions to be significant. I cannot help but draw a comparison between the Nassar-MSU situation and that of Jerry Sandusky at Penn State that captivated the country a few years ago. [5] In both circumstances, institutions that had moral and legal duties to protect minors failed to protect children from harm. If Sandusky’s crimes were repulsive because he leveraged his position as a coach, so much more repulsive are Nassar’s because of his role a physician.

Nassar hid his criminal conduct under the guise of medical treatment. One of the most troubling statements to come out of the Nassar reporting is of another MSU coach who, in response to allegations of abuse, defended Nassar’s actions as “a legitimate medical treatment.” [6] How could any adult believe this to be the case? Physicians, we are taught from a young age, are worthy of our trust. We assume, as a matter of course, that physicians have our best interest at heart. There are certainly counter-intuitive aspects to modern medicine, but how could a reasonable adult interpret vaginal penetration to be a legitimate treatment for back pain? The answer is still confusing to many. The efficacy of osteopathy is evident, and, in some cases, can complement or replace more invasive treatments. However, it seems clear that Nassar's misuse of legitimate treatments [7] —including Sacrotuberous Ligament Release—and the public's unfamiliarity with osteopathy, in general, created enough uncertainty to allow for the abuse to continue. [8]

In retrospect, it is easy to assume that Nassar’s behavior would have been unmistakably inappropriate to any parent, adult or other physicians in the room. But his carefully groomed reputation as a gifted healer of Olympic gold medalists, his powerful position as a physician and the attendant privilege to tell his victims and others, that he was performing 'legitimate treatment,’ [9] with which they were unfamiliar, compounded the violence he inflicted. In our society, physicians are permitted to touch the bodies of their patients in ways that would be criminal in any other context. This privileged social status is justifiable only because of the benefit that physicians are able to provide to their ill or injured patients.

Nassar was not only violating the bodies of his patients, but was doing so under the mantle of medical care. The public trust of medicine — the body of caring, competent, professional healers — which the medical guild has a duty to protect, has also been considerably marred by Nassar’s crimes. Physicians, regardless of their training background, must be vigilant of their colleagues and better informed of different types of legitimate therapy. Just as the physician’s guild did in the late 19 th century when they ran off snake oil salesmen and charlatans, physicians, both MDs and DOs must again decide what is legitimate medicine and who may enjoy the privilege of calling themselves a doctor. Internally regulating what is good medicine is not only the privilege of physicians, but is their moral duty. The failure to do so will further corrode the public’s trust in the noble profession and continue to put us all at risk.

Tyler S. Gibb, JD/PhD, is Assistant Professor and Clinical Ethicist at Western Michigan University Homer Stryker M.D. School of Medicine

References

[1] Editorial Board. MSU’s secrecy in Larry Nassar sex abuse scandal threatens its mission. Detroit Free Press [Online]. 2017 Dec 12 [cited 2018 Jan 18]. Available from: https://www.freep.com/story/opinion/editorials/2017/12/12/msu-nassar-sex-abuse-scandal/942597001/; Hoffman B. Gymnastics Doctor Larry Nassar Pleads Guilty to Molestation Charges. New York Times [Online]. 2017 Nov 22 [cited 2018 Jan 18]. Available from: https://www.nytimes.com/2017/11/22/sports/larry-nassar-gymnastics-molestation.html?_r=0 ; Townes C. Think there’s little justice in Larry Nassar’s guilty plea? Not so fast. ESPN W [Online]. 2017 Jul 12 [cited 2018 Jan 18]. Available from: http://www.espn.com/espnw/voices/article/19972466/think-there-little- justice-larry-nassar-guilty-plea-not-fast ; Campbell M. Dr. Larry Nassar: A history of preying on people. Lansing State Journal [Online]. undated [cited 2018 Jan 18]. Available from: http://interactives.indystar.com/news/standing/OutofBalance/NassarTimeline/LSJ.html
[2] Mack, J. Larry Nassar’s ‘perfect excuse’: He was a doctor. MLive [Online]. 2018 Jan 29 [cited 2018 Feb 05] Available from: http://www.mlive.com/news/index.ssf/2018/01/why_nassar_got_away_with_it_fo.html
[3] Busbee J. McKayla Maroney’s lawyer says USA Gymnatics paid for her silence. Yahoo! Sports [Online]. 2017 Dec 20 [cited 2018 Jan 18]. Available from: https://sports.yahoo.com/mckayla-maroneys-lawyer-says-usa-gymnastics-paid-silence-190040363.html
[4] Mencarini M. MSU let Larry Nassar see patients for 16 months during criminal sex assault investigation. Lansing State Journal [Online]. 2017 Dec 19 [cited 2018 Jan 18]. Available from: http://www.lansingstatejournal.com/story/news/local/2017/12/19/michigan-state-larry-nassar/964034001/
[5] Wolcott RJ. Expert sees parallels in MSU, Penn State sex assault cases. Detroit Free Press [Online]. 2017 Dec 19 [cited 2018 Jan 18]. Available from: https://www.freep.com/story/news/local/michigan/2017/01/26/msu-penn-state-sex-assault-cases/97079408/
[6] Gosk, S. MSU Abuse Scandal: Coach Had Gymnasts Sign Card for Dr. Larry Nassar. NBC News [Online]. 2017 Mar 21 [cited 2018 Feb 05] Available from: https://www.nbcnews.com/news/us-news/msu-abuse-scandal-coach-had-gymnasts-sign-card-dr-larry-n731781
[7] Lawler, E. What was portrayed as medical treatment, alleged victims claim is sexual assault. MLine [Online] 2017 Mar 01 [cited 2018 Feb 05] Available from: http://www.mlive.com/news/index.ssf/2017/02/what_was_portrayed_as_medical.html
[8] Hobson, W. Police Investigated Larry Nassar for abuse 13 years ago. Here’s how he got away. The Washington Post [Online] 2018 Jan 31 [cited 2018 Feb 05] Available from: https://www.washingtonpost.com/sports/police-investigated-larry-nassar-for-abuse-13-years-ago-heres-how-he-got-away/2018/01/31/9ea865bc-06c4-11e8-8777-2a059f168dd2_story.html?utm_term=.1ba2dcffd937
[9] Rabin Caryn, R. Pelvic Massage Can Be Legitimate, but Not in Larry Nassar’s Hands. The New York Times [Online] 2018 Jan 31 [cited 2018 Feb 05] Available from: https://www.nytimes.com/2018/01/31/well/live/pelvic-massage-can-be-legitimate-but-not-in-larry-nassars-hands.html

Anthony Orsini, DO, serves as vice-chairman of neonatology and medical director of the Level II neonatal intensive care unit at Winner Palmer Hospital for Children and Babies in Orlando, Florida. Orsini is also the founder of Breaking Bad News, an organization dedicated to providing clinicians requisite skills to deliver devastating information with compassion. The impetus to create Breaking Bad News was not only observations made throughout the course of his career, but fears Orsini personally experienced during clinical training. “The thought of telling someone their child was dying or would likely suffer from severe neurological impairment frightened me,” Orsini admits. Years later, he grew further aware of this issue’s gravity. “Today’s patient demands and, quite frankly, deserves a relationship with their doctor.”

The Breaking Bad News program includes improvisational role-playing sessions, with trained actors serving in standardized patient and family member roles. Certified instructors observe the interactions remotely, review the recorded session with participants and provide feedback and coaching. This approach was formalized after Orsini performed over a decade of research on the topic of delivering bad news and discovered a paucity of literature on the topic. Says Orsini, “Traditionally, healthcare professionals receive very limited training on communicating bad news. In fact, only 10 percent of even senior physicians report any training in delivering tragic news.” Lectures or observations of other clinicians – each at their own varying level of communicative skill – limit meaningful training for medical students, resulting in residents assuming a responsibility for which they have not been adequately prepared. Orsini proceeded to interview patients and families, gleaning details about their experiences receiving tragic news and determined there is an appropriate way to discuss poor prognoses and devastating diagnoses.

The development of a healing relationship is a defining factor in patient-centered care and communication (1). Orsini says it is possible to establish a strong relationship in minutes and has reached a balance between teaching communication skills and eliciting compassion from clinicians. His program emerges at a time when technology encourages distraction, rather than connection, clinician attention is often steeped in the electronic medical record, and younger providers are increasingly comfortable communicating digitally rather than personal exchange. Yet, the majority of professionals Orsini has worked with stated that their main goal during patient interactions is to share information. Patients, states Orsini, can find information anywhere, including Google. Knowledge is important, but not at the expense of human relationships.

After spending a day of training with Orsini, clinicians are better able to demonstrate both their ability to address the issues and commit to helping patients through the next steps. This is important because, according to Orsini, the manner in which a patient receives tragic news leaves an emotional shadow that can persist for decades. Having trained almost 1,000 physicians, nurses and practitioners, he has isolated the importance of ensuring patients and families believe in the reliability of their clinician; patients must know they will not be abandoned during duress. The onus is on providers to build this confidence, rather than report information and extract themselves from the situation. The Breaking Bad News Program represents the evolutionary manner of providing healthcare. No longer, says Orsini, is it “ acceptable to be a good doctor with a bad bedside manner."

Rebekah Apple, MA, DHSc is the Director of Student Affairs and Programming, American Medical Student Association.

Reference:
1. Levinson, Wendy, et al. Understanding Medical Professionalism. McGraw Hill, 2014

Who Owns Your Health? Medical Professionalism and the Market State by Thomas Faunce, B. Med, PhD utilizes the author’s knowledge of history, ethics, law, philosophy and literature to explore the conflicts between privatizing healthcare and the medical professional’s contract with society. He starts with the Hippocratic Oath and narrates a brief history about all the “legends in the history of medicine.” The reader will note the irony that we have not learned from history. An example that struck me as a faculty member in a school undergoing an accreditation review is that concerns about medical education that were identified by Flexner in 1908 are still the same today. The healthcare provider consistently grapples with the dual conflicting goals of private income and social standing verses an ethical and moral responsibility to patient care. Examples of this can be seen throughout history in all cultures, countries and religions.

The author is Australian and provides an interesting perspective on the shortcomings of the United States healthcare system especially its basis in a free market system and the role of a free market economy in driving pharmaceutical drug prices. He discusses the conflict of caring for the patient with drug patents and managed care. He feels that instruction in medical professionalism should include policy makers and legal students along with clinical mentors, and the focus should always be on human suffering. Medical education should explore the legal system, healthcare management and policy making, in addition to medical ethics and clinical decision making. He sees medical professionalism sitting on a pyramidal base of loyalty to relieve suffering then moving through various ethical perspectives and culminating in law and managerial principles. The market state, both locally and globally, must be acknowledged along with the pressures that it puts on healthcare management. According to the author, it is a system that increases wealth for the wealthy and encourages greed. Dr. Faunce argues that our current system of medical malpractice and reimbursement for healthcare does not work and provides arguments for moving beyond privatized healthcare toward a more universal healthcare system. The market state puts undo pressure on companies to produce innovative research and new drug formulations, and then the companies require monopoly protection to recoup their costs. Government involvement in a market state has tended to worsen the problem instead of ameliorate it.

Dr. Faunce feels that reimbursement to patients who are injured should be a no-fault system and should include both medical professionals, healthcare administrators and legal experts. Medical professionals upholding a patient’s right to be autonomous and to maintain the confidential nature of their medical information are key tenets of medical professionalism. Dr. Faunce feels that the market state encourages breach of confidentiality by providing a number of loopholes and a lack of judicial protection of the patient-physician relationship. In the next several chapters, he uses examples from criminal law, public health and nations at war to illustrate the contradiction between the requirements of a market state and the requirements to provide medical care in a caring and professional manner. Dr. Faunce feels that a market state drives corporate greed and moves medical professionals’ focus away from professional, altruistic medical care and toward an employee, career mindset.

The solution put forth by the author sounds like a universal healthcare system paid for by taxes in which everyone has an equal right to treatment for no-fault injuries and illnesses. He proposes that the ill and disabled get “credits” to pay for transportation and copays. Corporations should consult healthcare professionals to guide them in decreasing human suffering both medically and in terms of global sustainability. Healthcare professionals should be everyday “heroes,” according to Dr. Faunce, by providing the best medical care, investigating poor outcomes, apologizing for errors and alleviating human suffering. He concludes with saying that the age of the market state will be “looked back on with a mixture of curiosity and disgust.”

Leann Poston, MD is Assistant Dean of Admissions and Career Advancement at WSU-Boonshoft School of Medicine in Dayton, Ohio.

Faunce, T. A. (2008). Who owns your health? Medical professionalism and the market state. Baltimore: Johns Hopkins University Press.
ISBN-13 978-0-8084-0821-7 298 pages

Doctor Edmund Pellegrino[1], physician, philosopher and educator introduced the subjects of humanism, professionalism and a philosophy of medicine to the American conscience. Sustaining his claims on reason, logic and evidence[2], he also was the crown jewel of the Kennedy Institute of Ethics Intensive Bioethics Course with his Virtue Ethics Conferences.

Dr. Pellegrino insisted that the place were medical ethics should be learned is in the clinic or at the bedside[3] of the patient where the learner confronts a concrete case and is herself part of its resolution. This structured ward round has a sequence: fact gathering, diagnosis, prognosis and treatment alternatives. Three practical ethical questions need to be answered: Who decides? By what criteria? How are conflicts resolved?

Each criterion – prognosis, brain status, balance of benefits and harms, financial resources, quality of life, and age -- helps in deciding how vigorously to treat, that is to calibrate, the intensity of the medical intervention. Physicians-in-training, patients and facilitators enjoy this clinical activity but feel that most of the available evaluation tools are not adequate. The ideal evaluation device must describe some elements of the clinical encounter phenomena in easily understandable stages that work well for self-evaluation and evaluation of others.

RIME[4], a system to evaluate clinical competence in physicians-in-training, describes four roles that the learner must progressively master as four criteria for assessment and self-assessment: reporter, interpreter, manager and educator. Somewhat simplified and applied to undergraduates (after the White Coat Ceremony), the learner must be able to grasp, understand and articulate (report) the facts of the case. The person must also correlate, associate (interpret) facts to discover relevant information that is not explicit and prioritize or order clinical problems to allow an orderly and effective resolution.

Commensurate with training and level of knowledge, the learner also must be able to propose reasonable options for resolution that respect patient’s wishes (manage). Choosing adequate self-learning strategies, as well as sharing new learnings with others, transform the learner as an educator. These four attributes constitute easily understandable and measurable attributes of the competent clinician construct, and seem to fit well within Dr. Pellegrino’s phenomenological system.

Raul Perez, MD is Professor of Ophthalmology and Medical Ethics. UPR-SOM

References:
[1] Humanism and Ethics in Roman Medicine: Translation and Commentary on a Text by Scribonius Largus Literature and Medicine Volume 7, 1988, pp. 22-38 (Article) Edmund D Pellegrino & Alice A. Pellegrino
[2] Guarding the Art: Edmund D. Pellegrino, MD Virtual Mentor November 2001, Volume 3, Number 11
[3] An approach to bedside ethics. Pellegrino E. The Mayo Alumnus – 15 1989
[4] A New Vocabulary and Other Innovations for Improving Descriptive In-training Evaluations Academic Medicine, Vol 74, NO 11 November 1999

One adage I recall from a graduate program in Curriculum & Instruction from a college of education is “Curriculum is like a full six-pack; if you want to put something in, you have to take something out.” In sharing ideas for the teaching of professionalism in this newsletter, one approach to consider in your health professions colleges is partnering with the recent Interprofessional Education (IPE) movement leaders. As new knowledge and competencies emerge in preprofessional training and the push to move something new in the curriculum, academic leaders can look to “plug-in approaches” that may expedite and satisfy the need to expose students to new material and experiences.

In fact, as with our own debates and discussions in teaching professionalism as either a discrete course or set of lectures and experiences or teaching professionalism “across the curriculum,” the IPE initiative confronts this same challenge. Both initiatives share the notion by many that these are traits and skills we have been “teaching all along” but need to do it with more intentionality and have more concrete outcomes measures.

Across the country recently, teams and committees of Interprofessional Education and Research are thinking about and creating ways to expose health professions students to Interprofessional experiences as “this is how health care is really practiced.” In 2009, six national education associations of schools of the health professions in the US formed a collaborative (IPEC) to promote and encourage constituent efforts that would advance substantive interprofessional learning experiences to help prepare future health professionals for enhanced team-based care of patients and improved population health outcomes (Interprofessional Education Collaborative, 2011). These organizations that represent higher education in allopathic and osteopathic medicine, dentistry, nursing, pharmacy and public health created core competencies for interprofessional collaborative practice to guide curricula development across health professions schools. Since this collaborative, almost all health professions preparation programs are planning (formally via curriculum changes or informally via co-curricular activities) how to expose students and those in continuing professional education programs to interprofessional practice (Interprofessional Education Collaborative, 2016).

In approaching these teams and committees within our colleges, you can make the strong rationale that the subject of professionalism is a natural and easy fit with interprofessional education initiatives, in which we can create meaningful learning experiences for students. Doing so should satisfy both curricular and co-curricular needs of interprofessionalism and professionalism’s learning objectives. The approach is efficient and should create some synergy among curriculum and instruction efforts. For example, when unprofessional behavior takes place in the clinical setting, it often involves a dynamic between or among several types of health professionals. And the “issues at hand” often involve one or more of the IPEC competencies or sub-competencies, such as responsive communication, mutual respect or fidelity to one’s scope of practice.

Curriculum and instruction for professionalism leaders should be welcomed by the interprofessional education leaders at health professions colleges. While these initiatives are always challenging to institutionalize, working with the IPE advocates should be a win-win for those looking to stimulate more activity in the formation of professionalism among learners.

Stephen F. Gambescia, PhD is professor of health services administration at Drexel University in Philadelphia.

References:
Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: Interprofessional Education Collaborative.
Interprofessional Education Collaborative Expert Panel. (2011). Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, DC: IPEC.

Author James A. Marcum, PhD discusses professionalism and quality of care, which in his view are the two main crises in medicine, in his book The Virtuous Physician. He puts forth some of the social and governmental initiatives that have been developed to deal with these crises. He explains the evidence-based and patient-centered models of care and then introduces the concept of a virtuous physician and how this concept may alleviate both crises.

Marcum has written three other books: Tampering with Nature: Empirical Methodology and Experimentation Onto-Epistemology, Thomas Kuhn’s Revolution, and An Introductory Philosophy of Medicine: Humanizing Modern Medicine. Marcum is a professor of philosophy at Baylor University and has earned doctorate degrees in both philosophy and physiology.

The Virtuous Physician is written in an expository style, but there is clearly an underlying layer of persuasion. After presenting the crises in medicine, according to Marcum, and explaining why neither evidence-based medicine nor patient-centered medicine have been able to resolve them, Marcum introduces his solution: a virtuous physician.

To set the stage, he reviews virtue theory. He starts with a historical perspective leading up to modern virtue ethics and epistemology. He contrasts virtues and vices and then explains each of the major virtues and vices and how they are defined and related to each other. The review is well written and even readers without a background in philosophy would be able to follow his premises. In the third chapter, Marcum provides a more in-depth analysis of the three main categories of virtues and vices: the intellectual or epistemic, the ethical or moral, and the theological or transcendental. At the end of each section Marcum pulls in the views of Pellegrino and Thomasma (1996) who are felt to be among the most influential writers on the moral nature of being a physician when explaining how these virtues are required of a good physician. The chapter concludes with Marcum stating that he feels that the chief virtue for a virtuous physician is the compound virtue of prudent love.

In the fourth chapter, Marcum discusses caring verses uncaring. First, he presents evidence for an against the premise that caring is a virtue. He then expounds on how caring is made up of two ontic virtues – care and competence – and how one or the other alone will not lead to caring. He concludes the chapter by examining Howard Curzer’s assertion that care is not an appropriate virtue for healthcare providers, because it can lead to burnout, paternalistic care and further increase an imbalance of power.

Curzer proposes that benevolence and not caring is the appropriate virtue for healthcare providers. Marcum responds that physicians are not required to like their patients, but instead to care about them as a care for humanity and to have the competence to provide that care. He also argues that caring or emotional attachment to a patient with appropriate boundaries leads to less burnout.

In the fifth chapter, Marcum extends his concepts of care and competence to personal radical love and prudent wisdom. His continuum extends from the virtuous, caring, competent physician who practices with love and is prudent to the unvirtuous physician who is careless, incompetent and demonstrates lovelessness and imprudence. This physician is an example of the most unprofessional physician who provides the poorest healthcare.

Marcum illustrates his points by synopsizing and then commenting on two case studies that have been in the literature. The first is taken from an editorial written by gastroenterologist, Dr. Richard Weinberg, as he recounts caring for a patient who suffered sexual abuse leading to abdominal pain. The second is the story of Shelley Diamond a sufferer of chronic atopic eczema and her experience as a hospitalized child recovering from tumor removal from her clavicle and how the nursing and medical staff treated her and failed to recognize how restraining both her arms affected her physically and psychologically.

The book ends with Marcum’s description of a virtuous physician having the compound virtue of prudent love which is made possible by caring and competence. The virtuous physician will practice a virtuous holistic style of medicine incorporating both evidence based medicine and patient centered care. A physician practicing in this way will deliver quality healthcare utilizing the available technology while taking care of their patient’s existential needs. He feels that a background in the humanities should be required for medical school to prevent the unintentional teaching of vices.

ISBN 9789400727069 (electronic bk.)

Marcum, J. A. (2012). The virtuous physician. [electronic resource]: the role of virtue in medicine. Dordrecht; New York: Springer, c2012.
Pellegrino, E.D., and D.C. Thomasma. 1996. The Christian virtues in medical practice. Washington, DC: Georgetown University Press.

How do we define professionalism?
Individual Professionalism - One of the most widely recognized descriptions of professionalism is The Physician Charter (2002), endorsed by over 130 organizations. It indicates professionalism is the basis for our implicit social contract with society through the principles of patient welfare, patient autonomy and social justice. Additionally, it defines numerous professional responsibilities for individual physicians. In Canada, the CanMEDs framework describes seven essential roles of individual physicians and defines milestones for different levels of training. The CanMEDS Professional Role (2015) emphasizes our ‘commitment to’: the health of patients and society; ethical practice; high personal standards of behavior, accountability to the profession and society; physician led regulation and maintenance of personal health. Including commitment to one’s wellness as part of the professional role is novel and supports the importance of cultivating resilience, the latter a focus for our 2018 APHC conference in Baltimore.

Institutional or Organizational Professionalism - There is increasing emphasis on how context may either support or detract from individual professional behaviors. Lesser, Lucey, Egener et al. (2010) have developed a framework for both individual and organizational professionalism based on the values of compassion, respect and collaboration; integrity and accountability; excellence and fair and ethical stewardship of healthcare resources. During my recently completed nine-year term as an Associate Dean, Equity and Professionalism at the Cumming School of Medicine (CSM), University of Calgary, our professionalism network of students, staff and faculty members took on the challenge of how we would define professionalism. We reached a consensus that we could achieve more by fostering an organizational culture that supports individual professional behaviors. Our purpose statement became ‘an appreciative, inclusive culture of respect and professionalism’ in support of the vision of our medical school. Professionalism education, awareness, scholarship and consultation allowed us to support this purpose. Jo Shapiro, Anthony Whittemore and Lawrence C. Tsen (2014) have written about the role of an institution in supporting individual behaviors. The Centre for Professionalism and Peer Support Programs led by Dr. Jo Shapiro determined that trust is central to “mutual respect for individuals, teams, the institution and patients and families.” They defined professionalism as any intent, action or words that foster trustworthy relationships. Leaders are considered central to supporting environments of trust.