Balancing Ethical Issues in Medical Education

"If You Never Feel Anything, What's the Meaning of What You are Doing?"

(May 2, 2011) Here is a fictional case study given to first-year CU medical students last year:

Some of the (first-year class) had a wonderful party last Friday night while wearing their "I love CU Medical School" sweatshirts and posing for pictures in various states of intoxication. They then wandered up to the anatomy lab and taped a really cool music video with the cadavers. Many of the pictures were posted on Facebook. The video was posted on YouTube. The next day one of the students looked up and befriended through Facebook a really cute guy who was a patient at her preceptor’s clinic.

Clearly this is not a good scenario.

But, as Wendy Madigosky, MD, puts it, "One of the questions we learn to ask is, ‘Why would a reasonable person do that?’ It’s important to know that. If we can build in students a growing capacity to make the right choices, then we have met the goal."

Madigosky, an assistant professor in family medicine and director of the Foundations of Doctoring curriculum, is part of a growing effort to incorporate professionalism and ethics into coursework and conversations at the medical school.

This comes in part out of the understanding that medicine can be a highly personal interaction that leads to great rewards but also pitfalls. This may be especially true as physicians increasingly adopt a patient-centered approach to health care.

The example of Marilyn Manco-Johnson, MD, and her patient, and friend, Nicole Bond (see accompanying article), shows how that connection can grow over decades and nurture both doctor and patient.

Several studies have established that a closer doctor-patient relationship can benefit the patient and the physician as well.

"You burn out quicker if you wall yourself off," says Marilyn Coors, PhD, associate professor in psychiatry at the Center for Bioethics and Humanities. "If you never feel anything, what’s the meaning of what you are doing? At the other extreme, if you have no boundaries then every death is of a friend and patient."

Different doctors set boundaries in different places, as researchers at Massachusetts General Hospital found when they surveyed U.S. physicians’ attitudes toward three types of personal relationships with patients.

"Comfort with social relations with patients is highly variable," the researchers said in the journal Medical Care in 2010, "but most agree that social ties with patients can be compatible with professional conduct. Fewer physicians believe it is appropriate to treat patients they are connected to financially. Consistent with earlier studies, fewer than 10 percent feel sexual relations with patients are ever acceptable."

Another study, published in 2005 in the New England Journal of Medicine, made the case for emphasizing ethics early on, stating, "Disciplinary action by a medical board was strongly associated with prior unprofessional behavior in medical school."

CU’s medical school keeps evaluating the way it teaches professionalism and has been expanding that part of the curriculum. Social media pose the newest challenge to relationships and other aspects of professionalism.

Among many recent studies on social media, researchers in New Zealand surveyed Facebook use by recent medical graduates there. Sixty-five percent had Facebook accounts, according to a paper published in 2010 in Medical Education. Of that group 63 percent kept their information private. But among those who did not restrict access to information, more than a third revealed such details as sexual orientation and religious beliefs, and nearly half posted photographs of themselves drinking alcohol and, in a few cases, clearly intoxicated. One announced membership in a group called Perverts United.

"This area [of ethics] is growing in terms of emphasis," says Jackie Glover, PhD, who directs the Humanities, Ethics and Professionalism thread that spans all four years of the medical school curriculum. "We require an ethics course, which isn’t unusual, but we also emphasize ethical behavior as a competency in all our professional schools.

"We have obligations as human beings, professionals and friends. Sometimes they align and sometimes not."

Health Sciences Librarian Peggy Cruse, MLIS, contributed to this article.