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NEWSLETTER
Welcome
Welcome from Janet de Groot
Janet de Groot, MD Newsletter Editor | Wednesday, January 31, 2018

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

We, the Academy for Professionalism in Health Care (APHC) – Professionalism Formation Organization (PFO) newsletter team, are pleased to launch our first newsletter. Professionalism education in health care is central to both organizations. Thus, it is fitting to invite each of you to join the conversation as to what is professionalism?

Newsletter Vision
APHC – PFO Vision: A global community of practice that advances conversations and perspectives on the practice, education, and research of clinical professionalism as it evolves. Your input and feedback to this brief introductory commentary on individual and organizational definitions is welcome. Shall we through our on-line 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, conferences towards the aim of fostering professionalism to ultimately support excellent patient and family care and health research.


Conference
APHC 2020 Annual Meeting April 29 to May 1, 2020 Sofitel Chicago Magnifcent Mile
Brian Carter | Tuesday, January 08, 2019

Registration, sponsorships and hotel reservations

https://www.academy-professionalism.org/


Professionalism
Professionalism Helps Company Compliance Programs
Stephen F. Gambescia | Saturday, January 11, 2020

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.


Professionalism
Practitioners as Resource Stewards
Tom Koch | Saturday, January 11, 2020

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.


Professionalism
Professionalism (1) and its Moral Component (2): Culling the List (3)
Raul Perez | Saturday, January 11, 2020

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


Book Review
APHC Members' Scholarship
Books authored by APCH Members | Saturday, January 11, 2020

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


Biography
An interview with Dr. David J. Doukas on His Role in Founding and Implementing the Academy for Professionalism in Health Care
Janet de Groot | Saturday, January 11, 2020

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.


Education
Empathy – A Missing Link in Healthcare
Anne Converse Willkomm | Saturday, January 11, 2020

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


Education
A Professional Obligation to Advocate for Enhanced Medical Education and Training Through Suicidal Risk Assessments
Steven M. Henick | Saturday, January 11, 2020

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.


Education
Are You Ready for the Multitude of Questions from Patients Regarding the Use of CBD
Cynthia Sheppard Solomon | Saturday, January 11, 2020

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.


Ethics
Hume and Neuro Ethics:  The Passions (1) and Blame
Raul Perez | Saturday, January 11, 2020

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”


Professionalism
Professionalism as a “Soft Skill” - Ouch!
Stephen F. Gambescia | Saturday, January 11, 2020

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.


Education
Empathy as a Praxis
Marco A. Carvalho-Filho | Saturday, January 11, 2020

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


Professionalism
The Professionalism in Suing Patients
Rebekah Apple | Saturday, January 11, 2020

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


Education
Maximizing Your Impact: Energize Relationships with Healthcare Colleagues
Cynthia Sheppard Solomon | Saturday, January 11, 2020

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.


Ethics
Neuro-ethics,[1] Death[2] and the Passions[3]
Raul Perez | Saturday, January 11, 2020

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


Professionalism
Heeding the Call: Addressing the Impact of Opioid Abuse and Healthcare Crisis
Samantha George | Thursday, August 22, 2019

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.


Professionalism
There Is No Place for Good Citizenship in Professionalism
Tom Koch | Thursday, August 22, 2019

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.


Education
The Importance of Active Methodologies in the Training of Socially Committed Health Professionals
Fernanda Patrícia Soares Souto Novaes | Thursday, August 22, 2019

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.


Education
Physician Health as a Science
Janet de Groot, MD, FRCPC, MMedSc | Saturday, July 27, 2019

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.


Book Review
New Book Aims to Ease  Clinicians' Moral Distress
Jamie Smith | Saturday, July 27, 2019

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


Education
A Transformative Experience
Renato Soleiman Franco, MD | Saturday, July 27, 2019

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


Conference
APHC 2019 Conference Presentation Reviews
Various | Saturday, July 27, 2019

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.


Education
Partnerships, Social Justice, Ethics and Transforming Health
Janet de Groot, MD, FRCPC, MMedSc | Saturday, July 27, 2019

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.


Book Review
Minority Populations and Health: An Introduction to Health Disparities in the United States
Leann Poston, MD | Saturday, July 27, 2019

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.


Book Review
The Legacy of the Crossing, Life, Death and Triumph Among Descendants of the World's Greatest Forced Migration
Leann Poston | Tuesday, March 19, 2019

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.


Education
From Abstract to Tangible: A Professionalism Curriculum for Postgraduate Psychiatry Training
Rachel Grimminck, Janet de Groot and Elizabeth Wallace | Tuesday, March 19, 2019

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.


Education
APHC Pre-Conference Workshop From Teaching Professionalism to Supporting Professional Identity Formation: Transforming a Curriculum
P. Preston Reynolds | Tuesday, February 19, 2019

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.


Professionalism
Professional Formation and Communication Skills in Health Care
Fernanda Patrícia Soares Souto Novaes and Suelleen Thaisa Henrique de Souza | Tuesday, February 19, 2019

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.


Book Review
The Knowing-Doing Gap: How Smart Companies Turn Knowledge into Action
Leann Poston | Tuesday, February 19, 2019

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.


Book Review
Finding Inspiration to Walk the Walk
P. Preston Reynolds, MD, PhD, MACP | Saturday, January 26, 2019

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.


Professionalism
The Medical Act: Non-Cognitive Endeavor?
Raul Perez, MD | Saturday, January 26, 2019

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


Ethics
Will the Real Professional  ?Please Stand Up
Patrick D. Herron, DBe | Saturday, January 26, 2019

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.


Book Review
Giving Voice to Values as a Professional Physician: An Introduction to Medical Ethics
Rebekah Apple | Tuesday, January 08, 2019

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


Education
Educational Alliance and the Challenges of Role Modeling
Marco Antonio de Carvalho Filho | Tuesday, January 08, 2019

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.


Conference
APHC 6th Annual Meeting  April 26 - 28, 2018 in Baltimore  Resilience - The Intersection with Professionalism
APHC | Wednesday, January 31, 2018

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.


Conference
ASBH “Flash Sessions”: Innovative Format Provides Opportunities for Engagement
Virginia L. Bartlett, PhD | Wednesday, January 31, 2018

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.


Professionalism
Contribution of Videos to the Development of Professional Boundaries in the Doctor-Patient Relationship. Experience Report
Fernanda Patrícia Soares Souto Novaes | Tuesday, January 08, 2019

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


Professionalism
The Call for an Expanded Principle of “Social Justice”
P. Preston Reynolds, MD, PhD, MACP | Wednesday, November 28, 2018

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.


Ethics
Development of a Health Profession’s Education Social Media Policy
Diana D. Smith, MHS, PA-C, Assistant Clinical Professor, and Adrian S. Banning, MMS, PA-C | Wednesday, November 28, 2018

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.


Ethics
A Call for Conceptual Precision
Raul Perez, MD | Wednesday, November 28, 2018

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.


Book Review
Managing with Power: Politics and Influence in Organizations
Leann Poston, MD | Wednesday, November 28, 2018

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.


Book Review
Ethics in Everyday Places: Mapping Moral Stress, Distress and Injury
Leann Poston, MD | Wednesday, November 28, 2018

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.


Professionalism
Professionalism's Moral Injury
Tom Koch | Wednesday, November 28, 2018

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.


Education
Medical Oaths and the Social Contract – Do We Say the Same Words?
Marco Antonio de Carvalho-Filho, MD, PhD | Wednesday, November 28, 2018

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.


Professionalism
Professionalism, Social Justice and the Global Right to Health
P. Preston Reynolds, MD, PhD, MACP | Wednesday, November 28, 2018

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.


Education
Asking About Sexuality: Contributions of Pedagogical Teaching Tool DocCom.Brasil to Improve Doctor-Patient Communication
Fernanda Patrícia Soares Souto Novaes, Pediatrician, MD, PhD Candidate (IMIP) | Friday, September 28, 2018

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.


Professional Profile
Professional Profile: Karen Horneffer-Ginter, PhD
Rebekah Apple, MA, DHSc | Friday, September 28, 2018

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


Book Review
Ethics and Health Care: An Introduction
Leann Poston, MD | Friday, September 28, 2018

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.


Professionalism
Vulnerability and Professionalism in Healthcare
Janet Delgado Rodríguez, RN, MA, Ph | Friday, September 28, 2018

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.


Professionalism
Lessons in Professionalism from the Streets
Aleesha Shaik | Friday, September 28, 2018

“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.


Book Review
The Patient Will See You Now: The Future of Medicine Is in Your Hands
Leann Poston, MD | Friday, September 28, 2018

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


Book Review
The Patient Will See You Now: The Future of Medicine Is in Your Hands
Leann Poston, MD | Friday, September 28, 2018

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


Ethics
Defining Civility
Stephen Gambescia, PhD and Katherine Anselmi | Friday, July 27, 2018

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.


Professionalism
The Enemy Uncovered:  Hidden Curriculum and Professional Identity
Marco Antonio de Carvalho-Filho, MD, PhD | Friday, July 27, 2018

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.


Professionalism
Humor, Students and Professionalism
John Minser, MFA | Friday, July 27, 2018

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.


Book Review
How We Do Harm: A Doctor Breaks Rank About Being Sick in America
Leann Poston, MD | Friday, July 27, 2018

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


Professionalism
APHC Keynote: ACGME Focus on Physician Well-Being: Deepening Our Commitment to Faculty, Residents and Patients  - Presented by Timothy P. Brigham, MDiv, PhD
Reviewed by Julie Agris, PhD, JD, LLM, FACHE | Monday, June 04, 2018

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.


Professionalism
 APHC Keynote: Institutional Resilience and Supporting the Second Victim - Presented by Albert Wu, MD, MPH
Reviewed by Barbara Lewis, MBA, Managing Editor APHC-PFO newsletter | Monday, June 04, 2018

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


Conference
APHC Workshop: Learner Mistreatment: Enhancing Awareness to Promote a Resilient Clinical Learning Environment -  Presented by Kelcie Lahey, MD candidate; Janet de Groot, MD; Alya Heirali, PhD candidate; Nazia Viceer, EdD candidate, Cumming School of Medicine, University of Calgary
Reviewed by Marco Filho, MD, PhD | Monday, June 04, 2018

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.


Professionalism
APHC Keynote: Moral Resilience: Preserving Integrity in the Midst of Complexity - Presented by Cynda Hylton Rushton, PhD, RN
Reviewed by Raul Perez, MD | Monday, June 04, 2018

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.


Conference
APHC Workshop: Breaking Down the Silos: Building an Interprofessional Professionalism Curriculum - Presented by Kym Montgomery, DNP; Dennis Novack, MD; Owen Montgomery, MD, FACOG; and Sandy Friedman, CNM, MSN
Reviewed by Barbara Lewis, MBA, Managing Editor APHC-PFO newsletter | Monday, June 04, 2018