Some of the toughest decisions any of us will ever make will take place in a doctor’s office. But before those decisions ever come up, doctors must often wrestle with the options themselves. And those options are growing more complicated every year. In this next to last episode in our series Future Docs, we ask how today’s medical students are learning to grapple with tomorrow’s ethical questions.
Maybe you remember a television show called St. Elsewhere - a medical drama that ran on NBC in the early eighties. It was one of the first such shows to peel the curtain back on medicine and portray doctors not as infallible, all-knowing gods, but real people struggling with real conflicts. Maybe the ethical issues doctors were dealing with back then weren’t any less gut wrenching, but they seem somehow a bit less complicated, like in this episode from 1983. A doctor’s patient dies of cancer. He thinks it’s pretty clear. But his boss wants him to ask the family’s permission to do an autopsy just to make sure.
Doctor 1: “That’s the family I’ve got to get the release for the autopsy from.
Doctor 2: “I don’t envy you.”
Widow: “No! He’s been through enough.”
Doctor 1: “It’s a very simple procedure.”
Widow: “I don’t want a bunch of strangers cutting James up!”
Doctor 1: “An autopsy could help us understand the cancer better.”
Widow: “He’s dead, doctor. That’s all I need to know. Now let the dead rest in peace.”
Doctor 1: “Ordinarily I would agree with you, but in this particular case….”
Widow: “Two years I watched my husband suffer. No more. Do you hear me? No more!”
The ethical dilemma there? Whether to cheer harder for scientific understanding or a grieving family’s wishes.
Doctors still have to wrangle with that one. But a lot has changed since then. Advances in medicine have given us a dazzling spectrum of options to prolong or alter life. The rising cost of health care and the growing number of uninsured are forcing us to make increasingly difficult decisions about who gets care and what kind. The speed of change and discovery is quickening and in many ways we’re still pressing the creases out of the map, trying to figure out where we are.
“We are entering sort of in this new frontier. And it’s placing greater demands on physicians to be prepared to have these types of conversations.”
Doctor Jay Baruch teaches emergency medicine at Brown University’s Warren Alpert Medical School, where he also helps coordinate what students learn about medical ethics. He says medical students need training and practice before they encounter ethical dilemmas with their own patients.
“Once students get on the wards, once you enter into clinical practice, you realize that so much of medicine is sort of wrapped up in messiness and ambiguity,” says Baruch.
But how do you teach future doctors—students who often excel at soaking up information and having the right answers—to unwrap so much messiness and ambiguity? Baruch says you give them tools.
“Part of the education in educating residents and young physicians and medical students,” Baruch says, “is often times not necessarily giving them skills that they don’t already have.”
Because hopefully, Baruch says, the school has already admitted smart, sensitive people.
“It’s the fact that we’re all human beings. And we need a framework,” says Baruch. “We need an approach to think through these issues when we’re in it.”
For first and second year medical students at Brown University, that means weaving ethics into classroom lectures and discussions. It also means giving students the chance to work through examples – or case studies. That’s what they did in this recent workshop.
In a conference room in Brown’s medical school, a group of students looks over a packet of information about a fictional patient. He’s got a terminal illness. He speaks very little English. And his wife seems not only to be undermining his care but possibly looking forward to profiting from his death. The workshop leader frames the issue.
Leader: “So, how can you address that as a physician…end-of-life decision-making?”
There’s a group of students, some in short white lab coats, sitting around a conference table. And this second year medical student tries out an answer.
Student: “I guess I would address it with really open-ended questions, but also possibly ask if he’s thought about what might happen after that point…”
The workshop leader nods. He’s on the right track.
“And what’s that called?”
His answer? An advance directive.
An advance directive is a legal document that tells health care professionals and loved ones how you’d like to be cared for in an emergency, especially if you can’t make decisions for yourself. Here’s what’s sticky about this one: doctors swear an oath to do no harm. And usually that means trying to save someone’s life, no matter the consequence. But the more ways we invent to keep people alive, the longer we’re living. Trouble is, that living can come at a great financial cost… and without the quality of life we might prefer. The workshop leader says that’s a tough conversation to have with a patient at the very end.
Leader: “So, practically speaking, if you’re the outpatient physician or the palliative care physician and you have someone who has a progressive neurodegenerative disease, it behooves you to go over that information with the patient.”
Student: “Do you do that early on, as one of the first sessions?”
The group of students tackling this case study included some nursing and social work students. You wouldn’t have seen them in a medical school 30 years ago. But their participation is a sign of another shift in health care that’s bringing more new ethical issues into focus.
“We’ve moved from sort of a Marcus Welby focus on what it means to be a doctor to a much more team approach to health and health care,” says Mildred Solomon, president of the Hastings Center, which in 1969 became the first bioethics think tank in the country.
Working more often as part of a health care team, rather than a lone wolf practitioner, means doctors will have to adjust the way they make decisions, or how they approach an ethical question. And Solomon says there’s another new role doctors are being asked to play in our changing health care system: cost controller.
“That’s a challenge to medical ethics. You want your doctor to be there as your advocate,” says Solomon. “But doctors also need to integrate into their sense of professionalism a leadership role in helping to fix our health care system. And a sense of responsibility for community health, population health, as well as for the patient across the desk.”
Solomon says introducing medical students to these conundrums is critical. Because future doctors will be the gatekeepers of all the new medical technology and advances in care we have to offer that community. Learning how to dole it out responsibly, she says, is the new frontier for physicians in training.