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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 2021 Annual Meeting April 15 to April 17, 2021 Sofitel Chicago Magnificent Mile
Brian Carter | Tuesday, January 08, 2019

Registration, sponsorships and hotel reservations

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


Professionalism
Expanding the Social Contract for the Health Professions
P. Preston Reynolds, Saleem Razack and William Agbor Baiyee | Wednesday, June 24, 2020

Recent events from COVID-19 to international protests calling for equity and the end of racially charged police brutality mandate expansion of medicine’s social contract.
For too long we have considered the social contract in transactional terms limited to what the health professions owe society and what, in exchange, society owes the health professional [1]. This consideration of the contract tends to limit the capacity of medicine to expand its responsibility to include promoting justice in health care systems, and society at large.

The conventional contract has been couched in an air of “benign neutrality,” stripped of its ideological underpinnings. The institutions of medicine, such as professional organizations, health professional schools, hospitals and clinics are presented as ahistorical and somehow apart from the injustices of the societies they serve. Yet, the three big tools in the perpetuation of institutional racism wherever it expresses itself have been health care, systems of education and law enforcement. It is in these contexts that oppressed and marginalized citizens are likely to interact with the power of the state and expert practitioners, and the likelihood for interactions to go badly with serious negative outcomes and real-life consequences.

The current pandemic due to COVID-19 has exposed stark disparities and the failure of society to ensure safe working environments illustrated by the lack of personal protective equipment for everyone, fair compensation for employees in situations of extreme risk and financial support for essential and frontline workers who become ill with COVID-19. The disproportionate higher rates of infection and deaths of African Americans from COVID-19 are not just a difference in health outcomes by race or ethnicity, but attributable to factors other than access to care, particularly social determinants of health [2-4].

The right to safe employment and the right to health are foundational human rights, established long ago with adoption of the Universal Declaration of Human Rights [5] in 1948 and in 1946, the establishment of the World Health Organization [6,7]. They go far beyond recently published statements on the principles of professionalism [8].

Medicine, for its part of the social contract, must ensure its practitioners are competent, ethical, compassionate and committed to ongoing quality improvement and just use of finite resources. COVID-19 has revealed health professionals’ incredible sacrifice of time and family, willingness to work beyond human limits while honoring their patients and team members, and to do so often at personal risk without security of employment if they became ill.

At the same time, COVID-19 has revealed the failure of medicine to solve the problem of health disparities [9]. While medicine is rendering heroic therapeutic interventions, as an institution in society, we see clinicians and health professions educators push aside the persistent racial injustice against African Americans and other persons of color. These realities force us to ask questions including the following: What should our schools teach future health professionals?

We train health professional students to believe their role is to treat individuals with a focus on disease without anchoring illness in a social context. Instead the illness narrative remains separated from anatomy, physiology, biochemistry, immunology, genetics, microbiology, pharmacology and disease systems, such as neurology and the brain, cardiovascular, renal, pulmonary, gastroenterology, endocrinology and so forth. This disconnect creates confusion and anger since our students see that the world our patients live in serves as the driver of the mental, emotional and physical diseases they present with. Sadly, discussion of our world and our patients’ lives is left to sessions that are optional or electives that come at the end of medical school.

For over 10 years, one of us (PPR) has taught courses for undergraduate and medical students that focus on the history of structural racism in American medicine, health disparities and the contributions of African American health professionals in the struggle to create a health care system with attention to justice and equity. Truthfully, as committed as we are to social justice, these courses offer a White gaze on health inequities, where the downstream effects of discrimination are experienced by persons that are the “other,” and not by the students in the classroom. The role of medicine and its institutions in the maintenance of systemic racism is rarely, if ever, “owned” as central to the perpetuation of the systemic injustices we teach as historical and current realities.

Year after year, students lament the fact that the content of these courses has for the first time enabled them to understand the discrimination they experience and the problems their patients confront in their struggle to get the medical care they need and their journey to live healthy and vibrant lives.

We must find ways to develop students’ seeing into the invisible: the structures that permeate each clinical encounter. Whether that be appreciating that a child transported 1500 kilometers from his home in a remote Indigenous community without his mother on the flight because the air ambulance staff fears that she will “act-out” is an act of medical colonialism or that police violence against Black men should be understood as a public health emergency, we must provide the opportunities to develop this “seeing,” as a relevant competence to bring to every clinical encounter.

These examples and others that provide possibilities for transformative learning for greater social justice are present every day in our real world of health professions education. In short, we must develop students’ critical consciousness into appreciating the structures that determine the injustices of health inequities.

The broader movement for equity and justice is calling us to reimagine what we can do given that we function in polite, arcane and stodgy health care and educational systems. We believe the content of health professions education MUST be radically transformed to include the history of structural racism in medicine and the medical professions’ unethical role in that history. For too long, we have turned our back on racial injustice, including police brutality. Our students are now challenging us to own this history and, at the same time, to join the movement with protests and training to facilitate deep conversations in the community and among themselves, as well as skills and strategies to eliminate health disparities.

It is time to remove the white gaze of elitism that has been cast on constructs of professionalism. Instead of pledging to students that they will join a profession where they will gain expert knowledge in exchange for privileges, how about this formulation?

“You might be vomited on by a patient, in real life or metaphorically. Your consciousness will be transformed by your experience. A door may be opened to the hidden structures promoting injustice and discrimination at play within each clinical encounter. When this happens, you will do your best to find the cause of the discrimination or injustice and to put a poultice of caring over health disparities and inequities using remedies that come from your best scientific understanding at the time. You will seek to understand your patient’s life in a context of relationships in broader society, some of which may not be helpful to her health. Maybe, she is vomiting because her landlord is not held accountable for the mold that is in her apartment?”

As health professionals, we must expand our concept of the social contract to embrace restorative justice and engage the larger community of health educators and practitioners in understanding the impact that the health professions such as medicine and nursing has had on creating the inequities that are fueling this movement for justice in society. We must stand together in solidarity with our students and those in the community calling for transformation of our society and also our educational and health care systems.

P. Preston Reynolds, MD, PhD, MACP, is Immediate Past Chair of the APHC Board of Directors and Professor of Medicine and Nursing at the University of Virginia. Saleem Razack MD is a Pediatric Intensivist, Professor of Pediatrics and Health Sciences Education, and Director of the Office of Social Accountability and Community Engagement at McGill University, Montreal, Canada. William Agbor-Baiyee, PhD, is Associate Professor and Assistant Dean for Educational Research and Student Learning at Chicago Medical School, Rosalind Franklin University.

References
1. Cruess RL, Cruess SR. Expectations and obligations: professionalism and medicine’s social contract with society. Perspect Bio and Med. 2008;51:579-98.
2. Gomes C, McGuire TG. Identifying the source of racial and ethnic disparities. In Smedley B, Stith AY, Nelson AR, eds. Unequal Treatment. National Academy Press; 2003.
3. Havranek EP, Mujahib MS, Barr DA, et al; American Heart Association Council on Quality of Care and Outcomes Research, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, Council on Lifestyle and Cardiometabolic Health, and Stroke Council. Social determinants of risks and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2015; 132(9): 873-898.
4. Braveman, P. Social conditions, health equity and human rights. Health and Human Rights. 2010;12:31-48.
5. UN General Assembly, Universal Declaration of Human Rights, 10 December 1948, 217 A (III), available at: https://www.refworld.org/docid/3ae6b3712c.html [accessed June 16, 2020]
6. World Health Organization. Available at https://www.who.int/ [accessed June 16, 2020]
7. Wolff J. The Human Right to Health. (New York, NY: WW Norton and Co.), 2012.
8. Medical Professionalism in the New Millenium: A Physician Charter. Ann Intern Med. 2002;136:243-246.
9. Braithwaite R, Warren R. The African American Petri Dish. J Health Care for Poor and Underserved. 2020;)April 15):1-12.


Education
Covid-19 and Face Masks: Who Is Responsible for Educating the Wearer?
Cynthia Sheppard Solomon and Glen D. Solomon | Wednesday, June 24, 2020

Comic book heroes of our youth, Batman and the Green Hornet, knew how to wear their masks (1). Today, the public is not as secure. Have you been watching? Have you seen what we have at gas stations, on TV, at the grocery and in the garden center???

Some people wear masks, some don’t. Some wear them below their nose, some wear them on their necks, some have them hanging off one ear…. But when the gal making my bagel sandwich reached to pull her mask up when it fell below her nose the fourth time, I decided not to purchase the already placed order.

Whose responsibility is it to help this young lady properly protect herself and consumers? Her boss? Her corporation? The Surgeon General? The state? Should there be written procedures for management? What about a medical receptionist or patient when handed a mask to wear? Should there be some education?

I know many who do not know masks should cover their nose. Some pull their masks down to talk with me. One thanked me, the pharmacist, for making recommendations regarding tightening the elastic ear holders with a paper clip to hold the mask higher for comfort and safety. Why aren’t medical managers giving in-services? Whose responsibility is it?

When I see profound misuse, it is easy to espouse my opinions. Touching the outside of a mask without washing or sanitizing one’s hands as soon as possible afterward can cause harm. The virus can stay on the mask, on hands or on other items that have been touched. Being careful not to touch one’s face and covering one’s nose with the mask are essential to successful protection. But people who are unaware of the benefits of mask wearing may respond negatively to being provided tips from bystanders. Most bystanders have a personal vested interest in everyone wearing masks properly. I have heard wearers complain that the masks are too big or they slide down. And frankly, some wearers could just care less!

We really do not want to be face mask police, but for our safety, we prefer others use masks, handling them properly. But, most people are not informed, and rightfully, they deserve some useful information.

Yes, the Surgeon General has done public service announcements. This spring, he said using masks, especially when used improperly, cause more harm than good – then later, he said masks could help.

There has been no surge in public service announcements clarifying what proper mask management entails. Doesn’t the government have a role? Couldn’t the public health system take up the banner? The CDC has good information about face mask use on their website (2, 3). But government websites are not always easily accessible to consumers. A recent JAMA patient page (4) covers the why, the what and the how, beautifully. This pictorial piece shares the priorities of lengthy hand washing, donning and doffing masks without touching the front of the mask or face, and washing masks to prevent contamination. Can we get this information to consumers???

We must not assume people understand the seriousness of the virus, nor should we assume they will know how to properly use a mask. Health care officials and politicians on TV often do not safely manage their own masks. Putting contaminated masks in a pocket, pulled down on a neck or placing them in a purse, can jeopardize one’s health and the health of others. Touching a mask without sanitizing one’s hands can cause droplets and aerosolized particles to spread.

In response to Governor Cuomo’s 22-year-old daughter telling him he was not communicating clearly about masks, they came up with a contest for all New Yorkers to create an educational 30 second ad on mask wearing. Although focused on getting the public to wear masks, the concept could be extended to focus on proper use. Creativity and fun can be a part of educating others!

Although the politicization of government agencies has been seriously questioned during this pandemic, experts agree the best way to prevent COVID-19 spread is by wearing masks. We suggest prevention is linked to proper use. Masks work – neither Batman or the Green Hornet, nor their sidekicks, Robin and Cato, ever tested positive for coronavirus.

Who should be responsible for educating the public about masks? Many medical professionals are taught to handle masks, but ancillary medical personnel, patients and consumers require education on safe proper use. Boxes of face masks may not come with instructions – and finding evidence-based YouTube videos on the topic may be impossible.

While no one is overtly taking responsibility, isn’t it our ethical duty as health care professionals to be part of the solution by promoting safe use in our communities? Isn’t this part of professionalism?

Cynthia Sheppard Solomon, BSPharm, RPh, FASCP, CTTS, NCTTP, is Clinical Assistant Professor, Department Internal Medicine and Neurology, Wright State University Boonshoft School of Medicine, Dayton, Ohio. Glen D. Solomon, MD, MACP, is Professor and Chairman, Department of Internal Medicine and Neurology, Wright State University Boonshoft School of Medicine, Dayton, Ohio.
References
1. Disclaimer: Batman and the Green Hornet are fictional characters, as are Robin and Cato. While their eye masks obscured identities, they did not prevent disease.
2. https://www.cdc.gov/coronavirus/2019-ncov/communication/print-resources.html
3. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-to-wear-cloth-face-coverings.html
4. Desai AN, Aronoff DM. Masks and Coronavirus Disease 2019 (COVID 19)-JAMA patient page. JAMA 2020323(20):2103. Published online 4/17/2020.doi10.1001.jama.2020.6437.


Professionalism
Statement on Racism and Racial Violence
Board of Directors, Academy for Professionalism in Health Care | Wednesday, June 24, 2020

The recent deaths of George Floyd, Ahmaud Arbery, Breonna Taylor and many others killed or harmed are tragic and stark reminders of the historical injustices that many African Americans and other people of color in the United States have experienced and continue to experience daily.
APHC is a non-profit organization dedicated to enriching professionalism across the full spectrum of health care. Its mission is to optimize patient care through professionalism education, scholarship, policy and practice in all health-related fields. Most APHC members provide patient care and teach and lecture on topics of medical professionalism and ethics, including the character and values of being health care professionals. The Board of Directors of the APHC recognizes that the suffocating effects of structural racism and injustice stand contrary to health care professionalism and the mission of the APHC. To remain silent on these matters would be a form of moral complicity.

Racism and all other forms of racial, cultural, sexual and religious discrimination, intolerance and bigotry have no place in moral societies. Sadly, we know this is not the reality for many of our colleagues, students, patients and members of our local communities.

The eruption of protests we are witnessing around the country and the world are the result of people calling for accountability and justice for those murdered and harmed. All people have inherent moral value and should be treated equitably, unlike the experiences of those who are treated differently because of their ethnicity, culture, sexual orientation, gender, spiritual beliefs or the color of their skin.

The APHC stands with those who wish to use their voice and actions to heal the wounds of systematic racial injustice. To quote Dr. Angela Davis, “In a racist society, it is not enough to be non-racist, we must be anti-racist.” We applaud demonstrations like those in Michigan, in which police and community members marched together in a demonstration of human solidarity.

The APHC values diversity and inclusivity of all who are committed to its mission. We recognize more can and should be done to address historical and systematic racism and all forms of discrimination and bias in the U.S. and throughout the world. As you read this statement, please join the leadership of the APHC as we recommit ourselves to the mission of our organization and to being an agent of change to address the wrongs of systematic racism, discrimination, and intolerance and their negative impacts on the health individual persons and of our communities. We encourage all health care institutions and academic medical learning environments to make a similar commitment by structing their teaching, patient care and research programs to end health disparities and the structural elements that contribute to them.

Each of us has much work to do and as an organization committed to excellence in professionalism, we ask for your guidance in helping the APHC support our fellow health care professionals, trainees, patients and the communities we serve. The Board encourages our members to reach out to us with their recommendations on how we can work together in support of one another.


Education
APHC Hosts First Virtual Conference
Preston Reynolds | Thursday, May 14, 2020

In early March, the Academy for Professionalism in Health Care (Academy or APHC) leadership grappled with news of a global pandemic. When the Board voted to cancel our scheduled annual meeting, we proposed to launch our first virtual conference, Promoting Professionalism Amidst COVID-19.

This virtual venture proved to be tremendously valued by the 297 individuals who attended from around the world (10 countries on five continents). The APHC is grateful to our sponsors: Drexel University and Professional Formation for the virtual platform and technical expertise, and seven sponsors for their financial support: the AMA Journal of Ethics, Johns Hopkins Berman Institute of Bioethics, American Association of Colleges of Osteopathic Medicine, Loyola Center for Bioethics, American Board of Medical Specialties, Loma Linda University Center for Christian Bioethics and Penn State College of Medicine.

Ten experts addressed relevant topics. Preston Reynolds, APHC Board Chair, opened up with a discussion on professional accountability, weaving together principles of professionalism and human rights to deepen our responsibility to address social justice as the highest calling for the health professions. As she highlighted, pandemics find niches created by economic and health disparities, now exposed with skyrocketing death rates among communities of color and vulnerable groups. Tom Harter, incoming APHC Board chair, described ethical principles concerning risk and duties. How we weigh risks is a personal journey that all health professionals must resolve. At the same time, being a health professional comes with duties to patients and communities that are inherent in the work we do, even if this responsibility exposes us to potential harm of illness and death.

Lynne Kirk, Chief Accreditation and Recognition Officer of the Accreditation Council for Graduate Medical Education (ACGME), and Alison Whelan, Chief Medical Education Officer of the Association of American Medical Colleges (AAMC), addressed changes in medical student and resident training in response to COVID-19. Both emphasized the need to balance our responsibility to educate competent health professionals with the duty to protect patients and health staff from the risk of infection while also ensuring adequate personal protective equipment to front-line workers. COVID-19 is accelerating ACGME’s and AAMC’s move to competency-based education and team-based care while also pushing educators into innovate around telehealth. Similarly, elements of professionalism have shifted with greater attention on social justice and just distribution of finite resources, commitment to maintaining trust by managing conflicts of interest and commitment to professional responsibilities, while maintaining a commitment to scientific knowledge as a driver of professional and community responsiveness.

Kelly Michelson, professor of pediatrics at Northwestern Lurie Children’s Hospital, addressed organization professionalism amidst COVID-19 by first pointing out that even within one hospital or health system, there are many organizations operating simultaneously, such as the emergency room, intensive care unit, ambulatory clinics and the larger organization itself. COVID-19 has stretched different institutions and different elements of an organization in completely different ways, some being overwhelmed, while others remain closed. As the pandemic unfolds, what is the responsibility of the larger organization to the community it serves? Is one life saved the same as addressing the social determinants of health that put many people at risk for death? How can one balance the duties of justice as we shift from conventional care, contingency care and crisis care? In the end, concepts of duty to care with the duty to solidarity are essential to understand.

The next group of speakers described resources and strategies to delivering health and learning virtually. Steven Locke, founder of iHope Network, described tips and techniques for communicating with patients via telemedicine. He shared insights on how to create an effective “clinical space” virtually as well as rules and regulations surrounding telehealth encounters from licensing to billing to confidentiality. Pamela Duke, Associate Director of Clinical Skills and Professionalism at Drexel University College of Medicine shared her years of experience creating a virtual platform to facilitate longitudinal small group learning with the students at Drexel as they move from campus to campus in their distributed network of hospitals and clinics. She highlighted effective techniques for maximizing the value of virtual small group discussions and the value of peer reflection for professional identity formation.

Dennis Novack and Clare Marash described two valuable resources for educating students, residents and practicing clinicians on principles on professionalism. After several years in development and testing, Professional Formation will soon be available to educators around the world. Founded by Dennis Novack and colleagues with many APHC members as module authors, research demonstrated this resource to significantly increase trainees’ understanding of core professionalism principles and enhance their professional identity formation. The Medical Professionalism Project (MPP), developed by researchers and clinicians at Duke University, emphasizes that while we may believe we are demonstrating professionalism, often this is not the case. Each module opens with self-reflective questions and then weaves case discussion with comments by experts, allowing the viewer to reflect on their own behavior and what is expected as professional norms. All APHC members receive a 20 percent discount when signing up for MPP.

The conference closed with two of the most moving presentations. Steven Rosenzweig took us on the journey of reflection and renewal as we embraced the stress of the pandemic not only on our colleagues serving on the frontlines, but also on our patients, our communities, our families and ourselves. Building tools for resilience are foundational to all of our work, all of the time. Timothy Quill, master clinician and educator on end-of-life care, provided us with tools for communicating with patients and families, now faced with very difficult decisions. His years of experience enrichened the discussion and role play as he illustrated how to balance patient autonomy with beneficence, non-maleficence and just use of finite resources.

At the close of the APHC’s first virtual conference, we believe we accomplished our goal: provide our colleagues in the field of professionalism with insights into what this pandemic can teach us, tips on educating trainees through virtual platforms, information about on-line resources and skills in helping colleagues, patients and families as they struggle with stress, exhaustion and death. Solidarity reminds us that we are one profession as we confront and embrace this pandemic and build a future together.

P. Preston Reynolds, MD, PhD, MACP, is Immediate Past Chair of the APHC Board of Directors and Professor of Medicine and Nursing at the University of Virginia.

Here are a few comments that we received about the conference:

“This was the BEST webinar I have ever attended. It was personal, people were very engaged in their topics, the topics were EXTREMELY relevant. I had planned to only stay for part of it, but I could not pull myself from any of the talks! It was amazing.”
“This has been a really informative and useful conference.”
“Thank you for a wonderful virtual conference!”
“This has been very valuable.”
“It was fantastic.”
“It was terrific, and I appreciated that I could attend free of charge!”

The five-hour recording, which can be accessed at https://bit.ly/APHC2020Conference, includes a table of contents, to easily access specific topics. Please support our community by joining APHC or making a donation to ensure that we can continue to bring you virtual conferences and other programs.


Ethics
Ethical Communication During a Pandemic:  First Do No Harm
Emma J. Kagel, Jeffrey Gruenglas, Busi Mafanya Mombaur and Elizabeth Sivertsen | Thursday, May 14, 2020

The COVID-19 pandemic is stressful, overwhelming, and scary for everyone around the world, regardless of profession and level of exposure. As healthcare professionals, we join the multitudinous in the war against COVID-19. As bioethicists, we are equally concerned with how ethical communication can progressively inform our response and navigation of COVID-19 especially from the lessons learned lens. While the alarmist approach taken by many has intentionally raised awareness of the need for PPE accessibility and public access to evidence-based working understandings of contagion control, we caution our healthcare provider colleagues to consider the implications of employing such language due to the ongoing novelty of the global virus that resists contagion. We hope to serve as canary or a mentor to all other sectors involved in communicating evidence-based, thoughtfully transparent yet compassionate communications, and support advocacy momentum without inciting through fear and threats

In the initial weeks, healthcare providers shared, more than ever, personal narratives that were informative and essential to understanding the needs the general public could help address (e.g., PPE, abiding by social distancing and complying with masking initiatives) but equally motivated by exposing poor health administration, political soapboxing and questionable policy decisions within their institutions. Healthcare providers are faced with, on too many levels, the daunting obligation to manage tensions between two conflicting principles: caring for patients and adhering to responsibilities toward the public.

Responsively, The Hastings Center has published and called upon colleagues to assist the Presidency, state Governors and Mayors, various governmental branches and their associated advocacy organizations in the absence of a Presidential Bioethics Commission (which was disassembled when President Trump took office) to focus on three duties owed by healthcare leadership: plan, safeguard, guide. Accurate and fairly represented communication to the public must carefully balance two key tenets of medical ethics, namely promoting the good of others (beneficence) and preventing harm (non-maleficence). When communicating with the public, healthcare workers have the right to be transparent about their personal knowledge and experience within the healthcare settings. That right, however, should be weighed against the rights of the public to have trust that healthcare institutions offer a safe place to seek care during a pandemic.

It has not been uncommon to find articles written by healthcare providers who opine that current conditions at hospitals might threaten the availability of nurses and physicians. Reports such as these threaten to undermine trust in the public and exploit the public’s faith in the stewards of healthcare. We support and implore healthcare providers to exercise their voice to advocate for sound medicine and patient safety. Likewise, those in the position to do so ought to advocate for robust governmental and institutional initiatives to improve and ensure safe working conditions. Advocacy is the skillful garnering of public awareness and support for a cause. To successfully advocate for the patient and medical community, rather than coerce out of fear, one must thoughtfully navigate educating, empowering and engaging their audience. Those who disseminate or publish such work ought to consider the optics of both the climate and potential misinterpretation by the public.

Given the daily inundation of panic-driven or unqualified information, the public struggles to discern fact from fiction. Oregon Health and Science University reinforces this philosophy by requiring medical students to complete a mandatory evaluation of compassionate communication skills prior to commencement. Communication by healthcare providers transcends empathy to be mindful of how word choice, medium and context impact perceptions for the public. Healthcare providers must balance their duty to the public with accurate and fair representation.

Many physicians and scientists have emerged as examples of transparency, honesty and realism. One such example is Dr. Anthony Fauci and his “truth-telling” approach, in which he may not always give resolute answers, but his words are never minced. He consistently admits that we are dealing with an unknown pathogen and that the impact, presentation, measures needed to fight it are of infinite possibilities. It is expected and reasonable that some information-sharing will later be retracted as inaccurate due to retroactive evidence-based findings. Transparent real-time communication should not cease but baseless claims and communications to incite action out of fear are not acceptable.

The public is inundated with conflicting information — at times feeling as though they are watching a tennis match about how to protect their health. Rather than acknowledging the inherent uncertainties of the current pandemic wherein honest scientific information may be delayed or even redacted later as incorrect, statements are made to shock and infuse reactionary behaviors. Balanced and non-alarmist input from geneticists, virologists and immunologists healthcare professionals would be invaluable in helping the general public understand how and when the answers will come as we work to inform ethically charged policies and procedures. In a time when we are asking the public to trust us, we need responsible discourse to steadily hold a lantern against the darkness of the unknown.

Throughout the COVID-19 crisis, people in all roles have had to rally for action from global authorities, national governments, local governments, public health authorities, employers and healthcare institutions. Healthcare providers are the public’s most trusted profession when it comes to the dissemination of health information. Calm and thoughtful communication from the profession has never been more important. Transparency and effective, ethical communication can unify all toward the greater good.

Emma J. Kagel, JD, MBE, HCE-C is the Manager of Clinical Ethics at Mayo Clinic; Jeffrey Gruenglas, MBE, MA, NREMT is a Lecturer of Bioethics and Health Policy at Boston University and Busi Mafanya Mombaur, MD, MPH, MBE is a neurologist and Elizabeth Sivertsen, MBE, BSN, CCRN is the Medical Ethicist at Grady Memorial Hospital.


Ethics
Ventilators:  Moral Obligations of the State
Raul Perez | Thursday, May 14, 2020

The job of the state (1) for justice is to secure the well-being of its citizens. “Well-being is best understood as involving plural, irreducible dimensions, each of which represents something of independent moral significance.” Among those dimensions, two now salient, are COVID-19 related: Health, that is flourishing through biological or organic functioning of the body and Personal Security closely related to health - workplace safety and personal protection equipment issues.

There was ample forewarning (2) of an unavoidable viral pandemic that should have brought about governmental anticipatory measures to offer critical care to large populations of patients. It is hardly surprising that this society, which has largely cast aside Judeo-Christian perspectives on the value of human life in favor of productivity or quality, is not promoting life-sustaining interventions at end of life. The notion of too many lives, population control and lives-not-worth-living; advanced directives and palliative care, influence individual decisions and public health policy.

In this view, it seems, that being intubated and attached to a ventilator is an “indignity” that must be avoided even at the cost of one’s life. Forgotten is the fact that Intubation/ventilation, regularly used in surgery, is safe (3). Many professionals and lay people believe in good faith that there are lives not worth living (4). These beliefs pervade everyday life in a multicultural, pluralistic (5) and democratic society.

Public health policy acknowledges those preferences and promotes compatible social structures. Elected officials can apply the tools the state uses for regulation of commerce, taxes, reimbursements from CMS, FEMA and healthcare insurance, tax relief and others to directly influence and decrease the production of medical devices and critical care facilities. States fiscal constraints disincentivize companies from either manufacturing or having large stocks of life sustaining equipment. A hospital trying to expand its critical care capacity would have to face some issues.

First, polls, media and the bioethics literature may reflect a tendency towards forfeiting critical care by patients. Second, saving the environment through population control and a “death with dignity” are frequent subjects of public discourse and do shape personal decisions. Third, fiscal constraints such as certificate of need, medical device tax (2.3 percent), inventory tax and the expense of keeping facilities and devices ready to go.

End of life decisions may lack information and comprehension (6) and are very likely to change. End of life seems dignified only if life sustaining is forgone (7) and patients meekly cease to be “burdens.” For this COVID-19 pandemic, a highly infectious agent, useful data is scarce, specific treatment and vaccines are non-existent and diagnostics tests unreliable or not available.

Patients suffer from a mostly reversible “diffuse alveolar damage” (8), which requires mechanical ventilation (9) until patients are able to breathe by themselves. In severe cases, ECMO (10) may be used.

Provide reliable data to drive the decision-making process or inform of lack thereof. Afterwards, “… listen to all, then align, communicate and repeat” (11).” Design fair, COVID-19 specific protocols, emphasizing care for the most vulnerable. Monitor for embolic phenomena and treat accordingly. Try all non-invasive supplemental oxygen devices prior to intubation. Have enough ventilators built for the population at risk. Make ECMO widely available. Have the states provide a fiscal environment conducive to manufacture medical devices and maintenance of critical care facilities. Congress could enact legislation to safeguard professionalism promoting medical practices.

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

References
1. Social justice, Powers & Faden, Oxford University Press 2006 pp. 3-49
2. … (Influenza: The Once and Future Pandemic, Public Health Rep. 2010;125 (Suppl3) ;16-26.) (“The next deadly disease that will cause a global pandemic is coming.” Bill Gates, Liberia 2015) (Preparing for the Next Pandemic, Scientific American, Sharon Guymipas July 20, 2018)
3. Originally manual, now mechanical. At the end of the procedure, before the patient can breathe on his own, manual ventilation is used. As well as in emergent medical care.
4. Permitting the Destruction of Life Unworthy of Life, Binding & Hoche 1920
5. Physician & Philosopher, Pellegrino Ed.
6. The Belmont Report
7. Self-effacement for the survival of humanity.
8. 2020 COCA Pod Cast, ECMO: Extra Corporeal Membrane Oxygenation
9. “microvascular thrombosis “… all about respiratory therapy support.” david.reich@ mountsinai.org
10. Ibid 7
11. telehealth@providence.org


Professionalism
Ventilator Scarcity and Euthanasia
Raul Perez | Thursday, April 23, 2020

The COVID1-19 pandemic in Italy and other countries has prompted frequent testimonials in the media from physicians about the moral stress they suffer when having to decide which patients are to be intubated and placed on a ventilator to save their lives and which are not. The fateful decision is prompted by life sustaining equipment scarcity. In more extreme scenarios, the life sustaining equipment must be removed from the older patient, who will also be provided pain control and comfort measures to be used in the younger one. Many of the accounts attempt to explicate the moral anguish on having to “play God” and probably, unwittingly, promote its acceptance as standard ethical medical care. The role of ideologies foreign to medical practice and failed state or government health policy is not emphasized. Several moral agents could be complicit in this scheme – the physician, the hospital, the state and others.

The physician is faced, first with a quality of life decision – what is the morally good and technically right thing to do now, for this particular patient to save her life. For both of the above patients the answer is: intubation and mechanical ventilation. Explains Keown (1) in “distinguishing from ‘quality of life to Quality of Life’...to avoid any misunderstanding here, quality of life” will be used to refer to an assessment of the patient’s condition as a preliminary to gauging the worthwhileness of a proposed treatment and Quality of Life to refer to an assessment of the worthwhileness of the patient’s life.”

It seems that medical device scarcity allows physicians to seamlessly forfeit quality of life decisions for Quality of Life (2) decisions, that is euthanasia as “intentional or foreseen life shortening.” For there to be euthanasia there must be a shortening of life or in Keown’s words: “… a decision to shortens a patient’s life by a doctor and that death is thought to benefit the patient (1).” This shortening of life can be accomplished in medical settings by removing life sustaining care (expert personnel and medical equipment) or by failing to provide life sustaining care. Beauchamp and Childress assert (3); “We conclude that the distinction between withdrawing and withholding is morally untenable and can be morally dangerous…The felt importance of the distinction between not starting and stopping procedures undoubtedly accounts for, but does not justify, the speed and ease with which hospitals and health care professionals accepted no code or DNR orders and formed hospital policies regarding cardiopulmonary resuscitation (CPR).”

Regarding the moral obligation of both physician and hospital Pellegrino explains, “The physician is the final common pathway whose assent is required for whatever is done for the patient. The physician's covenant is with the patient. It is the patient’s interest that should be primary, not societal interests. The physician is primarily the advocate for his or her patient and not an instrument of social, institutional or fiscal policy. There will be times when physicians may have to refuse to comply with law or public policy (4).”

The hospital (5) must carry the moral obligations it incurs by virtue of its own declaration as a “Hospital” – a setting, a place for the sick to be healed (6). It must provide the setting in which medicine can be practiced safely and competently: a building, trained personnel, facilities, medical devices and personal protection equipment (PPE). The hospital has the moral obligation to inform the public, all who work within it walls, future patients and their families or caretakers if it lacks any or all of the above so as to ease “… free and rational choice well beyond informed consent” and stakeholders be able to avoid unsafe and life threatening environments.

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

References
1. Euthanasia, Ethics and Public Policy 2nd ed. Keown John Cambridge University Press 2018 pp. 37-49
2. “Patients who have the best chance of getting better are our first priority.” Kasie @
“Patients who have ventilator or ICU care withdrawn, will receive pain control and comfort measures.” @Nicholas _bag_ “Letter was in preparation for worst case scenario, but has not been enacted as policy.”
3. Principles 7th Ed pp. 161, 2013 Oxford UP
4. Mayo Alumni, ethics at the bedside Pellegrino Ed.
5. Physician and Philosopher
6. Physician & Philosopher Pellegrino Ed. (Hospital as moral agent)


Education
A Call to Arms: In COVID-19 Crisis, a Sustainable and Resilient Professionalism Demands EMOTIONAL PPE
Janeta F. Tansey | Thursday, April 23, 2020

Provider burnout and physician suicide had already been a well-documented public health crisis before COVID-19. Now, as hospitals are stretched beyond normal space and employee usage patterns, as resources and PPE are inadequate or inaccessible, as neighbors, patients, families and colleagues are threatened nationwide, the impact on provider health is amplified. Recent COVID-19 studies out of China report that a considerable proportion of frontline health care workers experienced symptoms of depression (50.4 percent), anxiety (44.6 percent), insomnia (34 percent) and distress (71.5 percent). We are seeing these same symptoms roll out across the United States in our providers. On an unprecedented level, they are and will be exposed to high levels of horror, anguish, vulnerability, sorrow, moral distress, self-doubt and even helplessness. In my own specialized practice, physicians from around the country are telling me that they are resolved to be courageous and responsive, but they are already fatigued, hurting and strained by unrelenting moral triage.

Society has been focused on the PPE of masks and gowns, but providing EMOTIONAL PPE is critical to managing burnout, demoralization, moral distress, and both direct and secondary trauma.

The wave of trauma is beyond the typical training and preparation of healthcare teams and providers, despite their preparation for courage, excellence and professionalism under duress. As society asks for and applauds providers for being heroically sacrificial, the providers are quietly experiencing shame and guilt when they reach their own limits as human beings. Healthcare providers are drafting wills, self-quarantining from their families, video-recording messages for their children in case they die, watching others succumb to devastating respiratory distress and trying to decide whether to rush to the epicenters and help their colleagues, or to hold the line in their own communities. The terrible risks of this distress must be addressed immediately to fortify the critical resource of our healthcare providers. There is no doubt that we will find the impact of this traumatic stress on our healthcare professionals will last far beyond the immediate circumstances. We need them. They need us.

A Call to Arms: I encourage our APHC members and colleagues to creatively design empirically supported interventions for healthcare providers and first responders to foster responsive and adaptive resilience. This is critical to a lasting and steady professionalism during and following crisis.

These are our hard questions:
What does just-right courage look like in the battlefield ethics of medical crisis? Are the military-war metaphors the right ones for this time, or do they miss something important?
Is there any possibility of peace (let alone sleep) when no matter how hard we try, our limitations result in others’ possible or actual suffering? What do we do when we can’t help but imagine the harms coming from tasks undone?
How do we triage emotional labor when the whole world needs care? Is there any cure to compassion fatigue?
How do we cope with this terrible grief? In all of this direct and secondary trauma, how can we think about and nurture a semblance of post-traumatic growth, or at least prevent trauma disorders?

How do we cope with all the righteous anger we are feeling about everything that has gone wrong? Who is our “neighbor” when our many communities are all at risk simultaneously?
How do we map a path through this sense of overwhelming futility? What do we do when being smart and well-educated doesn't actually bring us the guidance we really need for what to do NOW?

My faculty and I are working on tackling these hard questions directly and honestly in a Resilience Mini-Bootcamp that will begin by livestreaming on Sunday evenings, April 19, and will also be recorded and posted for 24/7 availability. This empirically supported intervention invites healthcare providers and first responders from every sector across the country to stop, breathe and implement immediate practices for resilience. In a moving act of solidarity, I am seeing my local departments sponsor their residents and fellows out of professional funds. I will offer aggressive discounts to help any program access this for their teams.

I am offering APHC Members and their friends/colleagues to immediately receive $125 off the Resilience Mini-Bootcamp by using the coupon: APHCFRIEND
https://virtuemedicine.com/resilience/

At Virtue Medicine, we have also pulled together a Doctors for Doctors Program of interdisciplinary providers, all senior and experienced Mind-Body specialists who are working as a team on rapid-response care to activate the Defiant Power of the Human Spirit in healthcare professionals, to use Viktor Frankl’s term. My team is completely on a telehealth platform offering care across the entire country. In my call to arms, I am asking APHC members and colleagues to support and offer similar services. If your providers need our services, contact us. We have opened up 100+ hours including evenings and weekends. https://virtuemedicine.com/doctors-for-doctors/

You can reach me at jtansey@virtuemedicine.com. Or use our 24/7 inquiry and new client portal at www.virtuemedicine.com to get a question to us.

Godspeed, friends.
Janeta

Janeta F. Tansey, MD, PhD is a Psychiatrist, Bioethicist, Specialist in Physician Care and Secondary Trauma; Principal, Virtue Medicine PC; Adjunct Clinical Associate Professor, University of Iowa


Education
Commentary:  The Coach and The Medical Student
Teresa Hunter-Pettersen | Thursday, February 13, 2020

Professionalism is a word that has synonyms like expertise and adeptness. The art of professionalism can be overlooked until an overt unpleasant circumstance presents itself. In education, there is much effort placed on applied skills and tiers of knowledge that integrate into achieving goals and establishing learning objectives for students. Medical education is not any different in today’s complex societal norms. Medical educators face challenges in translating the art of professionalism into taking a history and performing a physical examination.

At times, there is an awkwardness that is observed when a first-year medical student, who has had no prior clinical experience, begins to translate details from learning objectives to documenting a history and performing a physical examination during standardized patient encounters. On occasion, a medical student is encouraged to put the cellphone away; and to modify, to a degree, some personal grooming towards an attire that is polished and well-primed in order to meet the standard that is incumbent upon medical professionals.

After an observed encounter is completed, medical educators coach to give feedback to medical students. The coaching approach is a conceptual framework that defines measurable constructs using tools, such as an assessment form. A medical student can tangibly learn from these transitional encounters which may lead to improved outcomes.

The challenge from a coaching perspective is how to communicate effectively the notion that professionalism is integrated into the art of history taking as well as the quality of performance during a physical examination. After receiving feedback, it is hoped that the medical student’s perceptive is one that is appreciative. Retrospectively, medical students have purported that coaching should be a part of medical education, because they feel that it is a natural precursor to coaching patients.

The transference from an awkward approach to an adept one is subtle. Principles reminiscent of par excellence are ingrained in the thinking of the medical educator who fosters ethical standards and confidentiality. Medical students can be steeply enwrapped in emotional constraint that inhibits collecting historical data and/or completing a physical examination. Under timed and stressful conditions, the medical student may disengage from the standardized patient who demonstrates perceived maladies in a portrayal of a clinical presentation. The interaction between the two can be intense during an encounter. Under such conditions, a medical student may become somewhat uncomfortable and lose focus which may create deficiencies in the history or physical examination. The coaching approach is one that is conducted with a thoughtful assessment so that there is time to reflect, make adjustments, implement a goal plan, address the deficiency, manage time/stress and personal energy as it relates to a feeling of optimism for the next encounter. Overall, the coaching experience augments the formal rigor of medical education in comparison to traditional practices at so early a juncture in the curriculum.

The art of coaching is a dynamic one between the medical educator and the medical student. It incorporates aspects that engage qualities of trust, reliability, emotional engagement and acceptable professional behavioral standards. The medical student becomes adept at the practice. The process is a trans-formative rite of passage from pre-clinical to clinical practicum. History and physical examination skills evolve so that the medical student can create a list of assessments/differential diagnoses to then move on to contemplate assessments that are ruled in or ruled out through formulating a well-developed plan. A constructive plan is configured through medication(s), lab workup, imaging, osteopathic manipulative treatment, counseling, referrals, admission or a follow-up visit that represents tiers of knowledge building.

The impact of coaching early in medical education in a longitudinal curriculum opens portals to establishing ground work for self-improvement. There evolves an indelible influence between medical educator and medical student through coaching. The coaching approach can raise the level of confidence and a renewed sense of what expertise is expected as the medical student prepares to embark upon the dynamic relationship with clinical preceptors in the subsequent years ahead.

Teresa Hunter-Pettersen, MD, is Associate Professor of Medical Education at Lake Erie College of Osteopathic Medicine in Bradenton, Florida

Resources
1. Cameron, D., Dromerick, L., Ahn, Jaeil, & Dromerick, A.W. (2019). “Executive/life coaching for first year medical students: a prospective study, BMC Medical Education, (2019) 19:163; Retrieve from: https://doi.org/10.1186/s12909-019-1564-4.
2. Deiorio, N., Carney, P., Kahl, L.E., Bonura, E.M., & Juve, A. M. (2016), Coaching: a new model for academic and career achievement, Medical Education Online, 2016, 21:33480, Retrieve from: https://dx.doi.org/10.3402/meo.v21.33480.
3. Sim, J. H., Aziz, Y.F.A., Mansor, A., Vijayananthan, A., Foong, C.C., & Vadivelu, J. (2015), Students’ performance in the different clinical skills assessed in OSCE: what does it reveal? Medical Education Online, 2015, 20:26185- Retrieve fro: https://dx.doi.org/10.3402/meo.v20.26185.
4. Polak, R., Finkelstein, A., Axelrod, T., Dacey, M., Cohen, M., Muscato, D., Shariv, A., Constantini, N. W., & Brezis, M. (2017), Medical students as health coaches: Implementation of a student-initiated Lifestyle Medicine curriculum; Israel Journal of Health Policy Research (2017) 6:42; DOI 10.1186/s13584-017-0167-y.


Professionalism
Implicit Bias:  Where do you stand on having it?
C.S. Solomon | Thursday, February 13, 2020

As a pharmacy practitioner, I must confess I have been known to make more than a few ridiculous public acknowledgments. In teaching clinicians, I have, at least once or twice, recommended health care professionals work on recognizing their implicit biases in order to miraculously erase them.

Implicit bias has to do with the subconscious judgments we make that are often based on stereotypes (1). Using the example of tobacco use, implicit bias exhibited by clinicians can negatively affect implementing proper screening or supporting adequate quit attempts. Research now demonstrates that clinicians offer tobacco cessation treatments more often to sicker patients and to patients of higher socioeconomic status. Nicotine dependence and tobacco abuse disproportionately impact disaffected populations. And implicit bias has been shown to contribute additively to the issue of health disparities, potentially creating more negative circumstances for patients to overcome.

Part of my practice is working as a tobacco treatment practitioner; as such, it is impossible not to deal with patients with social and health disparities. Medicaid recipients, the impoverished, the mentally ill, HIV patients, those who self-identify as LGBTQ, those with lower socioeconomic status, pregnant women under the age of 20 and numerous other special interest groups are associated with higher incidence of tobacco use disorder.

But other medical conditions are affected by implicit bias as well. Twenty-five percent of all Americans with diabetes do not know they have it. Sadly, the rate among Asian-Americans is even higher, with approximately 50 percent of diabetic Asian-Americans not aware of their diagnosis. They are two times more likely than whites to develop diabetes, despite lower obesity rates (1). Elizabeth Tung, MD, internist at University of Chicago, recently studied the disparities in diabetes screening between Asian Americans and other adults. Her group found that Asian Americans had 34 percent lower odds of receiving diabetes screening than whites (1), explained only by unconscious bias parameters.

The National Academy of Medicine reported that racial and ethnic minorities receive lower-quality health care than white people, even when insurance status, income, age, and severity of conditions are comparable (2). Where are you on this and other issues in the unconscious bias paradigm? What can each of us do to identify where we stand on perceptions that may have been embedded over a lifetime of experience and learning?
Concrete suggestions to evaluate one’s specific biases are available using several recent resources (3). First, implicit bias cannot be measured with standard survey type, self-report questions (3). One instrument designed specifically to measure one’s implicit bias is the IMPLICIT ASSOCIATION TEST (IAT). Examples of this format are available at https://implicit.harvard.edu (3).

Considerations for clinicians, researchers, policymakers and patients are included in Irene Blair’s research in The Permanente Journal, 2011 (3). For clinicians, these include: considering “gut” reactions to specific individuals/groups as potential indicators of implicit bias, assessing how these might affect your work (4), looking at the situation from the patient’s perspective (5), acknowledge and reappraise (6,7) rather than suppress uncomfortable feelings and thoughts (8). These and many other suggestions have been confirmed to add value to eliminating and reducing biases. The Institute for Health Care Improvement at www.IHI.org also has numerous recommendations for minimizing bias.
Neglecting someone’s medical needs or giving them less than the best care is reality when clinicians ignore the role of implicit bias in the patient’s care. If the clinician harbors deep seated negative feelings about the way the patient appears or some aspect of their background, it characterizes unconscious actions in response to bias within their patient base.

What can you do about the baggage you may carry into an examination room? How about what you bring into a conversation with a family in crisis? I urge you to investigate your own feelings more. We can all improve on how we carry out our life’s experience as we work with patients.

C.S. Solomon, RPh, FASCP, CTTS, NCTTP, Assistant Clinical Professor, Department of Internal Medicine and Neurology, Wright State University-Boonshoft School of Medicine, Dayton, Ohio

References
1. Quinn, C. ‘Implicit bias’ may account for glaring disparity in health care screening. THE WORLD. https://www.pri.org/stories/2017-02-09/implicit-bias-may-account-glaring-disparity-health-care-screening accessed 01-25-2020.
2. Bridges,KM. Implicit Bias and Racial Disparities in Health Care. https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the_state_of_healthcare_in_the_united_states?racial_disparities accessed 01/25/2020.
3. Blair,IV, et al. Unconscious Bias and Health Disparities: Where Do We Go From Here?. PERM J. 2011 Spring; 15(2):71-78.
4. Ranganath KA, et al. Distinguishing automatic and controlled components of attitudes from direct and indirect measurement methods. J EXP SOC PSYCHOL 2008 Mar;44(2):386-96.
5. Todd AR, et al. Perspective Taking Combats Automatic Expressions of Racial Bias. J PERS SOC PSYCHOL 2011. Mar 7[epub ahead of print].
6. Monteith MJ, et al. Putting the brakes on Prejudice on the development and operation of cues for control. J PERS SOC PSYCHOL 2002. Nov;83(5):1029-50.
7. Murphy MC, et al. Leveraging motivational mindsets to foster positive interracial interactions. SOC PER PSYCHOL COMPASS 2011 Feb;5(2):118-31.
8. Macrae CN, et al. Out of mind but in sight: Stereotypes on the rebound. J PERS SOC PSYCHOL 1994;67:808-817.


Education
The Integration of Professional Identity Formation in a Medical School Curriculum
Mark Clark | Thursday, February 13, 2020

In the past eight years, I have had the good fortune to participate in two particularly rewarding projects. The first was to serve on a University of Texas Task Force that sought to define Professional Identity Formation and propose curricular strategies for implementing such a formation in medical education. In a 2015 Academic Medicine article, our team described the work we accomplished (1). My second project was to serve on the founding faculty of the University of the Incarnate Word School of Osteopathic Medicine. This role afforded me the opportunity to implement some of the strategies that our UT Task Force had proposed, and to do so in the building of a curriculum from the ground up.

One of the challenges I have encountered in implementing the formative dimension in the curriculum is clarifying the difference between Professional Identity Formation and Professionalism. The latter, as it is often conceived and addressed, relates to behaviors deemed appropriate in the eyes of traditional wisdom. The former is a process devoted to cultivating those virtues and elements of character that result in the behaviors associated with Professionalism. For the purposes of helping to develop the medical curriculum at my institution, I adopted the definition of Professional Identity Formation that our Task Force derived, though I did provide my colleagues with this “elevator speech” abridgment: Professional Identity Formation is the transformative journey through which one cultivates those virtues and elements of character necessary to becoming a fulfilled, humanistic physician of excellence.

Our Task Force distinguished six Domains and 38 Sub-Domains of virtues and elements of character we hoped to find in a fully-formed physician, then suggested broad educational experiences that could foster longitudinal development in each dimension. One of the Domains, for example, is Habits: in a fully-formed physician, we would expect to see certain acquired habits, and these would include (Sub-Domains) Self-Directed Learning, Critical Thinking, Self-Care, Empathic Labor, Reflection of the Meaning of Experience, Self-Awareness, Regard for the Human as an integration of Mind-Body-Spirit, and Aesthetic and Spiritual Experience (2). How might we foster longitudinal development in each of these dimensions? (3) At my present institution, I have sought to incorporate specific educational experiences that do just this. Of note is that we regarded the formation as a “curricular thread” that is woven into and throughout the curriculum, not something to be addressed as a Friday afternoon add-on. A basic scientist, a clinician, and a medical humanist team-teach whole-class sessions and integrate formation concerns in the lesson. This doesn’t take extraordinary amounts of time, and it enhances the quality of the educational experience.

In addition, one should recognize that a particular educational experience may address development in multiple Sub-Domains. Say I was team-teaching a large group session (Socratic, not lectures) related to breast cancer. I might show students the photo of a woman’s torso, post-mastectomy, from a medical textbook, then show an illustration depicting the same circumstance, then show a self-portrait of an artist who had undergone a mastectomy. I would ask students to reflect, in writing, upon what they thought was being communicated in each representation.

Obviously, there is a “reflection on the meaning of experience” occurring here, as well as an “engagement in aesthetic experience.” As students meditate on that artist’s work, though, they engage themselves in a labor of empathy that attunes itself to the feeling of what it is to lose a breast, and they learn something about the integration of a spirit with body and mind that is absent in the textbook illustration and the photograph. In broaching the emotions that empathy brings about, they develop self-awareness, and they deepen such awareness, as well, in experiencing the different kinds of knowing brought about by the different representations. They learn something about non-verbal communication. Because the faculty has included the artist’s/patient’s representation, the students receive a role-modeling that valorizes the patient’s perspective and insists that compassionate, truly ethical care—rooted in a regard for the Human Other as sacred—demands our understanding of it. All of this in an educational experience that runs maybe 30 minutes: an experience not deemed some form of intellectual recess or decorative add-on, but as something essential in the evolution of achieving an identity of professional and moral excellence.

Mark Clark, PhD, is an Associate Professor of Medical Humanities at the University of the Incarnate Word School of Osteopathic Medicine.

References
1. Holden, MD, et al. (June 2015) “Professional Identity Formation: Creating a Longitudinal Framework Through TIME (Transformation in Medical Education).” Academic Medicine 90, 6: 1-7.
2. I added the Sub-Domains “Regard for the Human as an Integration of Mind-Body-Spirit” and “Spiritual Experience,” which do not appear in the Task Force document. These elements reflect dimensions of the identity sought at a school of osteopathic medicine and a Catholic university. The additions suggest an important point: an institution has a role in the shaping of professional identity and ought to address this through the development of Sub-Domains unique to the program.
3. As our Task Force had noted and which I have sought to address in depth, the full scope of the challenge becomes (1) to determine what is called for in promoting development, longitudinally, with respect to each of the Sub-Domains; (2) to design and deliver educational experiences that promote such development; and (3) to design and implement modes of assessment that track development. A suitable discussion of addressing this challenge is beyond the scope of this article.


Education
The hidden curriculum: Undergraduate nursing students’ perspectives of socialization and professionalism
Susan Harrison Kelly | Tuesday, February 04, 2020

Background and aim: Nursing students form a professional identity from their core values, role models, and past experiences, and these factors contribute to the development of their professional identity. The hidden curriculum, a set of ethics and values learned within a clinical setting, may be part of developing a professional identity. Nursing students will develop a professional identity throughout school; however, their identity might be challenged as they attempt to balance their core values with behaviors learned through the hidden curriculum. The purpose of this project was to educate students on the hidden curriculum in the development of their professional identity.

Materials and methods: A sample of 112 senior nursing students was recruited from a northeastern university in the United States for this study. Pre–post survey design was used, and an educational session was administered prior to the post-survey. Descriptive statistics and a valid percentage were used to describe the data within the surveys.

Ethical consideration: Study was approved by the author’s University Institutional Review Board.

Findings: A significant finding was for advocacy as students would speak up if witnessing inappropriate behavior toward patients or families with a mean score increase from 2.50 (pre-survey) to 1.45 (postsurvey). Also, over 95% (n ¼ 106) found the educational session beneficial as they learned they had the ability to advocate and speak up for their patients.

Conclusion: Students were able to use their core values and advocate for their patients and families which allows for safer patient care.

Published in Nursing Ethics.


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 age