Jennifer Simons

Professor Evans

3 April 2016

Medical Professionals: When EQ Is as Necessary as IQ

There are approximately 18,000 medical school graduates annually across the United States.[1] These recent grads have toiled through a minimum of eight years of rigorous education, many going beyond the required eight to complete Masters programs or combined curriculums, obtaining two degrees in MD-PhD and MD-MBA programs. These doctors now have to enter into the workforce and in the words of J.D. from the popular TV show Scrubs, “four years of pre-med, four years of med school, and tons of unpaid loans have made me realize one thing…I don’t know jack.”[2] Why do J.D. and internally, many doctors, feel this way on their first day as a practicing physician? For all of the studying that these doctors do, the day-to-day skills necessary to be a medical practitioner can seem somewhat separated from their first six years of education, which often solely consist of learning the hard sciences - biology, chemistry, organic chemistry, physics, and math. While understanding basic science is necessary to be a physician, it is unhelpful when needing to decide one’s views on physician-assisted suicide or how to best tell a family that one of their loved ones has passed away.[3] With the advance of technology and better drugs being released on the market, the implementation of ethics education in medical schools has become increasingly important. Furthermore, preventable medical errors are the cause of death for 100,000 patients a year and these deaths can often be prevented with correct decision making from medical professionals. First, I will explore three possible causes of the low ethicality of some physicians. Then, I will explain what discrepancies still remain and what can be done to close the gap between what is taught in a classroom and the ethicality of doctors.

The Problem

It is no surprise that the goal of doctors is to bring their patients to a healthy state. The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”[4] One individual who understood this well was Dr. Edmund D. Pellegrino, one of the founders of bioethics, a professor, a recipient of 54 honorary doctorates and an author or coauthor of 23 books in philosophy, ethics, and medical science. [5] In one paper, “The Internal Morality of Clinical Medicine,” Pellegrino lists, in order from least to most important, four components of the Good of the Patient - the medical good, the patient’s perception of the good, the good for humans, and the spiritual good.[6] “The medical good” pertains to what we normally think of physicians doing, returning their patient to a healthy body. “The patient’s perception of the good” refers to what the patient believes to be in their best interest. “The good for humans” calls attention to the importance that humanity as a whole must be considered when trying to heal individual patients. Finally, the spiritual good, points out that a patient’s spirituality is the ultimate goal that we are trying to attain. Unfortunately, not all of these goods can always be achieved. The important task of doctors is to prioritize the higher good, which can prove to be difficult in some cases and require a firm foundation in morality.

In order to judge the moral reasoning of doctors, one study gave eighty orthopedic students a standardized test. The results showed a range from the moral reasoning of junior high students to moral philosophers.[7] This discrepancy is concerning and I will explore three possible causes of those with low moral reasoning.

Reason One: The Students

There are three reasons for the inconsistency of the ethicality of doctors. The first is that medical schools can seek the wrong type of medical student. Medical students are admitted mostly based on their undergraduate science GPA and MCAT score. Many medical schools boast their holistic admissions process but the unwritten 3.5 GPA rule still looms over pre-med students. Next in importance is research and having one’s name anywhere in a published study, even if the only skill acquired was pipetting liquids for twelve hours, is highly valued.

As an executive board member of the Pre-Medical Society on campus, I have been to nearly every lecture that a medical school admission officer has held. These meetings usually last approximately an hour and admission officers from around the country speak about what they are looking for at his or her respective medical school. Though schools do have different focuses, the advice is always the same. One’s GPA is most important and if it is around a 3.2 when you graduate, Masters degrees or post-bac courses will probably be necessary. Some of these pre-med students are science or math majors on top of being premed. Unlike Georgetown, which has a core curriculum, being a science major and pre-med at another institution could mean that this student may only take science and math courses in college. Though this type of student will have a firm grasp on the sciences, it is concerning if that same student has not developed his or her ethical and moral views. Moreover, these classes are not easy and though I do not think that medical schools should have to sacrifice on intelligence, the difference between a student with a B+ or an A average may not prove to be all that significant in the long run.

I may be bias in this subject matter. I am an ex-math major who turned to the humanities in search for a more integrated pre-med experience. As a result of becoming a theology major with a concentration in ethics, I do have more free time but the recognition that I will be studying the same science courses as everyone else in medical school lessens the worry that I am doing the right thing. My goal is to be the best physician that I can be and by the end of medical school, my science background and those around me will be of the same level. I can afford to solidify my morals now and as one who will care for people for the rest of my life, it is important that I have the time to do so.

Ideally medical students would all have 4.0 GPAs and have the moral character of philosophers but if we are willing to accept the 4.0 student who has the moral judgment of a junior high student, we should consider the alternative.

Reason Two: Hospital Hierarchy

The second problem is the way in which hospitals or private practices run. The hospital hierarchy is necessary to make final decisions but with experienced doctors on top and nurses on bottom, tensions can quickly arise when respect is not a part of the equation. Theresa Brown, an oncology nurse, wrote an article in the New York Times about the hierarchy in hospitals and how daunting it is to question a physician’s order. Brown recounts a time that a doctor blamed her in front of a patient for a late test result, though it was not her fault. His excuse? “It’s a time-honored tradition - blame the nurse whenever anything goes wrong.”[8] This offense does not go unpunished; Theresa goes on to say that unfortunately a cycle of displacement is easily created with “nurses in turn [bullying] other nurses, attending physicians [bullying] doctors-in-training, and experienced nurses sometimes [bullying] the newest doctors.”[9] She says that fixing this cycle of displacement should not be difficult but will not happen until the “overall tone of the workplace” changes and that requires everyone to pitch in.[10]

In another article, she writes about how hospital paperwork can take priority over the actual patient. The documentation is necessary but it is “notoriously inefficient” and instead of accounting for the work that is being done, it is replacing it instead.[11] Instead of focusing on relieving pain in very ill patients in hospice, where Theresa works, the focus in on filling out the records so that the hospital receives reimbursements. She implores the system and the methodology of recording to change to “serve just one master: the patient.”[12]

Reason Three: Ethics Education

The third problem is that ethics is either not being taught at all in medical school or it is not being taught well.

“In 1985, the Liaison Committee on Medical Education (LCME)…created a standard requiring medical colleges to teach those ethical, behavioral, and socioeconomic topics pertinent to the practice of medicine.”[13] Without any standardized curriculum, each medical school has the option of teaching ethics on its own standard. “This standard (ED-23) has evolved over the years and currently states, “A medical education program must include instruction in medical ethics and human values and require its medical students to exhibit scrupulous ethical principles in caring for patients…”[14] Less than half of the 141 medical colleges belonging to the American Association of Medical Colleges (AAMC) currently teach ethics within their curriculum.[15] Instead, teaching ethics is replaced by education in “professionalism,” and assumed to have the same effect, though the two are quite different. Professionalism is defined as “the competence or skill expected of a professional,” whereas ethics is defined as “moral principles that govern a person’s or group’s behavior.” D Wear and MG Kuczewski, American philosophers and bioethicists, write that “[t]he professionalism of the student is not often measured by emotional investment in a patient or participation in their care, but by dress, attendance, and meeting set learning goals.”[16] Along with doctors, they are concerned by the increasing desire for “professionalism,” because many “attitudes, values, and behaviors [have been] subsumed under the label.”[17]

Georgetown Medical School teaches both professionalism and ethics as a part of its curriculum. Dr. David G. Miller, the Associate Director for Academic Programs in the Center for Clinical Bioethics at Georgetown Medical School, directs the bioethics classes for first and second year medical students. Before Dr. Pellegrino passed away, they co-taught Philosophy of Medicine. Currently, first year medical students have eight two-hour sessions in “professionalism,” which covers everything from how medicine is different from a business to physician-assisted suicide. These two-hour sessions consist of 20-minute lectures and then small group breakout sessions for one hour and 40 minutes. One example of a discussion topic is whether it is professional if a doctor chooses not to accept patients over a certain weight. Second year medical students undergo a similar program, but have fewer lectures and instead use case studies in their small group discussions. In their third and fourth years, medical students go on rounds and discuss the ethics of actual cases in the hospital.

Miller attributes some of the school’s higher focus on ethics to Georgetown’s Jesuit identity. With the label comes with a set of values that were inspired by St. Ignatius of Loyola, who discovered the Society of Jesus. Nine main values are grounded in a 450-year old academic history and two of the nine - “Educating the Whole Person” and “Cura Personalis” - aid in identifying why ethics in particular is emphasized at Georgetown.[18] “Educating the Whole Person” showcases Georgetown’s belief that the development “of the spiritual, intellectual, artistic, social, and physical aspects of a person” is critical to grow. [19] “Cura Personalis,” when translated from Latin, means “care for the entire person.” This principle highlights the importance of “individualized attention to the needs of the other [and] distinct respect for his or her unique circumstances and concerns.”[20]

Georgetown Medical School is undergoing a shift from two years in pre-clinical studies to a year and a half. Dr. Miller goes to meetings once every two weeks to discuss the projected changes in ethics education. Like modern medicine, the best way to teach ethics is changing with new studies. The current trend is to move away from lectures, where one person speaks at students, and instead to utilize short movie clips, newspaper articles, case studies and patient contact. When asked about how the shortening of the program would affect the quality of ethics education, Dr. Miller says that this “flipped classroom” experience, in which the students come to small group discussion already having a background in each topic, takes shorter and sinks in more than a longer lecture series. The sessions are more productive because before class, a student has already asked himself or herself, “What is it that I believe and why?” In discussion, when interacting with students of different beliefs, the same student can ask himself or herself, “What is the biggest challenge to my belief and why?”

Solutions

These three problems are interrelated and feed into each other. The wrong type of medical student can miss an education in ethics and quickly become the doctor without empathy who is not respectful of other members in the hospital. There is no clear solution other than for each unit to individually do the best that they can. Medical schools can value those students who exhibit empathy as much as adeptness in the sciences. Those medical schools can implement ethics education in their curriculums, and if they exist, they can better them. Like the hard sciences, ethics education can become standardized across the country. Every medical school can undoubtedly create small group discussions with a required list of topics and case studies that go beyond professionalism. Included on that list should be teaching doctors how to respect and view nurses as part of a team as opposed to inferior members.

Institutional changes are rarely quick to change and though the problem is recognized, it may take a while before significant modifications are noticed in the workplace. Fortunately, institutions are taking steps to fixing these issues. Dorrie Fontaine, the dean of the School of Nursing at the University of Virginia, pushed the requirement for “interprofessional education for its nursing and medical school curriculums.”[21] These classes teach mutual respect for each other’s professions and highlight the shared goal between the two.[22] Hopefully, other medical and nursing schools will soon implement similar programs and create a new generational trend of medical professionals who use mutual respect instead of intimidation to cure patients.