- Email: [email protected]
Medical Students Mirror and Hold Mirrors
MEDICAL STUDENTS MIRROR AND HOLD MIRRORS Jeffrey A. Nisker, MD, FRCSC Editor-in-Chief
Medical students' observations of their clinical instructors are reflected in their choice of specialization, 1 their manner of medical practice,2 and likely their capaciry to care. Medical students, like all young people, become what they see. This metamorphosis is both cognitive, just as we tried (and still try) to assume the "best" attributes of our "best" medical school teachers and residency program mentors, and subliminal, just as we assume without realization or acknowledgement the attributes of the mentors we admire, but also of those we do not admire. The letter in this issue of fOGe from medical student Shelby H~que,3 responding to a letter published in the September fOGe 4 regarding doulas providing obstetrical care, segues to physicians providing obstetrical care and to current medical education producing sensitive future physicians. In this letter, Shelby Haque holds a mirror to us at the end of 2003; a mirror whose image is both encouraging and disturbing. The mirror is encouraging when Shelby Haque writes that he has seen "brilliant physicians manage complex labours,"3 reflecting the beaury, complexity, and importance of obstetrical care, and that this beaury, complexity, and importance are still perceived as such by medical students. The mirror is also encouraging in that it reflects a medical student's sensitiviry to the importance of compassionate care. Although this sensitiviry likely accompanied Shelby Haque to medical school day 1, this finalyear medical student was able to retain his sensitiviry along the "miles of medical ink"5 and amidst the consuming call schedules of medical education. 6 Perhaps some of Shelby Haque's medical school instructors promoted preservation of sensitiviry through their seminars and personal examples. It is also encouraging that Shelby Haque, a male medical student, felt compelled to write on an issue of inadequate provision of health care to women, an issue more frequently identified and addressed by women. The mirror is further encouraging in that it reflects that this medical student has retained his courage beneath7 the "tonnes of tutored words"5 of medical education; courage to submit his reflections, unencumbered by pseudonym, for publication in a national medical joumal that he is well aware his clinical teachers, reference writers, and selectors for residency programs may read. I would like to think all medical educators would applaud the sensitiviry and KeyWords Education, medical, undergraduate; ethics, medical; students, medical; internship and residency; obstetrics, education; physician-patient relations; professional role; obstetrics, standards
JOGC
courage of this student, and accolade a letter selected for publication by an "indexed, " peer-reviewed medical journal, but many students have confided in anonymous surveys8-10 (and in my office) their fear about speaking out on any issue of medical education or treatment of patients.9 However, Shelby Haque's letter is also disturbing. He writes, "As a first-year medical student at my wife's bedside during the birth of our first child, I remember the physician on call quickly entering the room, making some convoluted, incomprehensible mention of'PIH,' and then leaving as quickly as she had entered."3,!! Referring to his clinical clerkship "rotation in obstetrics,"3 he writes: "I also saw obstetricians deliver several women in one day as if they were came at a factory farm. My experiences, and the experiences of my medical school colleagues, lead me to believe that the factory farm approach is more widespread than physicians would like to admit."3 Although we can focus the angst ofShelby Haque's observations on Canada's insufficient "human resources" for compassionate obstetrical care, and add our own experiences to heighten the heat of this focus on the government under-funders responsible for this inadequacy, it remains that the perceptions of medical students like Shelby Haque lessen their regard for obstettical practice and the physicians who provide obstetrical care. The lessening of this regard cannot help but occur, even though our colleagues who still deliver babies are well-intentioned physicians doing the best they can under the stressful circumstance of time constraint. Indeed, Shelby Haque's letter reflects the overwork and dissatisfaction of many of the professionals who provide obstetrical care, just as much as it reflects the suboptimal care and dissatisfaction of many of the women receiving obstetrical care. These reflections may contribute to the difficulties in recruiting medical students to residency programs that provide training in obstetrics, as indicated in a study of Canadian medical students in which "sixry-two percent were influenced by experiences both before and during clerkship"!2 in considering residencies in obstetrics and gynaecology. Shelby Haque's letter is further disturbing when he writes, "My med-school training in pregnancy and childbirth has focused exclusively on the medical aspects of labour. Spiritual and emotional aspects are given little more than a sarcastic chuckle during teaching rounds and lectures."3 This observation suggests that this student's medical education, and likely that of many medical students in his and most medical schools, is fraught with the demeaning of non-science seminars, such as those that promote sensitiviry to the needs of the person inside DECEMBER 2003
the patient l3 or explore ethics and social issues. As either diseasebased learning or problem-based learning (PBL) remains the focus of most medical school curricula, rather than person-based learning (a better PBL, in my opinion),6 and most medical students remain exam-pressured to be closeted in science-studying, how can we expect students to be open-minded to the study of ethics and psychosocial issues? As long as non-science continues to be perceived as nonsense, the "sarcastic chuckle"3 to "spiritual and emotional aspects"3 and the "ethics-eyelid reflex"6 will continue to be infectious. Although decanal championing may be required to refract the perception that "spiritual and emotional aspects"3 are unimportant, we can help by including seminars on compassion and psychosocial issues during medical students' "rotation[s] in obstetrics."3 Such seminars may even assist in the revisiting of obstetrics by these students and ultimately their recruitment into residencies in obstetrics and gynaecology and family medicine. Finally, Shelby Haque's comment that "the fact that patients would pay such high fees for labour support [by doulas] should be a clear indication that something is missing in our medical management of pregnancy"3 needs to be repeatedly reflected to planners and funders of obstetrical care to refract the distorted view that adequate numbers of obstetrics practitioners and adequate funding of obstetrical services currently exist. Obstetrics practitioners should acknowledge these inadequacies to their patients, to refract any perception that they and their colleagues are callous and uncaring. Acknowledging to the patient that the clinician has no choice but to spend less time with the individual patient than she deserves, because of the many patients requiring care at that moment, helps patients and their families appreciate the increasingly time-constrained conditions of obstetrical practice. This appreciation may encourage public insistence that policy makers plan a large increase in the numbers of physicians and nurses providing obstetrical care, rather than continuing to emphasize an increase in efficiencyl4 of obstetrical care provision. For as Nuala Kenny contends, "Medicine is a moral enterprise, not a business venture." 15 As Neil MacGregor writes in his Foreword to Jonathan Miller's book, On &flection, "Perceptual confusion rapidly becomes moral, and in this looking-glass world, language mirrors the ambiguities oflooking."16 It is fine that medical students sometimes perceive obstetricians as "brilliant physicians [who] manage complex labours,"3 but more important that medical students perceive obstetricians as compassionate human beings. This perception will only be possible when obstetricians have the time to truly care for each patient, which includes time to demonstrate their compassion for each patient to each patient and each student; compassion the obstetrician feels and would like to express, but does not have time to express or, indeed, time to provide. It is fine that medical students perceive hard-science seminars as important, but essential that medical students perceive non-hardscience seminars as important. This will only occur when medical students are encouraged to see the person inside the patient l3 JOGe
and the person inside the physician. It is necessary for medical students to accurately view inadequacies in health-care provision and education, and like Shelby Haque, take umbrage with these realities. For what awaits their pass through the looking-glass of graduation is not Alice's fantasy world,17 but the real world where many women choosing to journey through what they feel should be the wonderful experience of pregnancy and birthing l8 are not adequately supported, and where clinicians wanting to provide optimal assistance are not permitted. If clinicians do not feel that they are providing the best obstettical care possible - not just the best they can provide under time constraints - it is difficult to feel good about our professions and ourselves, a reality essential to being good role models for students and good ambassadors for our professions.
J Obstet
Gynaecol Can 2003;25( 12):995-6.
REFERENCES I.
2.
3. 4. 5. 6.
7. 8.
9. 10.
I I. 12. 13. 14. 15.
16. 17. 18.
Althouse LA, Stritter FT, Steiner BD. Attitudes and approaches of influential role models in clinical education. Adv Health Sci Educ Theory Pract 1999;4(2):111-22. Kenny Np, Mann KY. See one, do one, teach one: role models and the CanMEDS competencies. Ann Royal Coli PhYSicians Surg Can 200 I ;34(7):43S-8. Haque S.The newest team member? J Obstet Gynaecol Can 2003;2S( 12): I003. Gruneir R.The newest team member? J Obstet Gynaecol Can 2003;2S(7):S64-S. Nisker J.The yellow brick road of medical education. Can Med Assoc J 1997; 156(5):689-91. Nisker J. Narrative ethics in health care. In: Storch JL, Rodney P, Starzomski R, editors. Toward a moral horizon: nursing ethics in leadership and practice. Toronto: Pearson Prentice Hall; 2004 [in press]. Referring to Hermann Hesse's critique of the education process in Hesse H. Beneath the wheel. New York: Bantam; 1968. Hicks LK, lin Y, Robertson Ow, Robinson DL,Woodrow SI. Understanding the clinical dilemmas that shape medical students' ethical development: questionnaire survey and focus group study. BMJ 200 I;322;709-1 O. Coldicott Y, Pope C, Roberts C.The ethics of intimate examinations teaching tomorrow's doctors. BMJ 2003;326;97-9. Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students' perceptions of their ethical environment and personal development. Acad Med 1994;69(8):670-9. Permission to publish this incident received from Charlene Smith. O'Grady T. Decision factors regarding choice of obstetrics/gynaecology as a career [abstract].J Obstet Gynaecol Can 2001;23(10):926. Nisker J. Chalcedonies. Can Med Assoc J 200 I; 164( I):74-5. Stein JG.The cult of efficiency. Toronto: Anansi; 200 I. Kenny N.The continental divide: comparing U.S. and Canadian values in health reform. Joint meeting of the American Society for Bioethics and Humanities and the Canadian Bioethics Society; 2003 Oct 23; Montreal, QC. Miller J. On reflection. London, England: National Gallery Publications; 1998.p.9. Carroll l. Lewis Carroll: the complete illustrated works. New York: Modern library; 1979. Bergum V. A child on her mind: the experience of becoming a mother through birthing, adopting and placing a child.Westport (CT): Greenwood Publishing Group; 1997.
DECEMBER 2003
Medical students' observations of their clinical instructors are reflected in their choice of specialization, 1 their manner of medical practice,2 and likely their capaciry to care. Medical students, like all young people, become what they see. This metamorphosis is both cognitive, just as we tried (and still try) to assume the "best" attributes of our "best" medical school teachers and residency program mentors, and subliminal, just as we assume without realization or acknowledgement the attributes of the mentors we admire, but also of those we do not admire. The letter in this issue of fOGe from medical student Shelby H~que,3 responding to a letter published in the September fOGe 4 regarding doulas providing obstetrical care, segues to physicians providing obstetrical care and to current medical education producing sensitive future physicians. In this letter, Shelby Haque holds a mirror to us at the end of 2003; a mirror whose image is both encouraging and disturbing. The mirror is encouraging when Shelby Haque writes that he has seen "brilliant physicians manage complex labours,"3 reflecting the beaury, complexity, and importance of obstetrical care, and that this beaury, complexity, and importance are still perceived as such by medical students. The mirror is also encouraging in that it reflects a medical student's sensitiviry to the importance of compassionate care. Although this sensitiviry likely accompanied Shelby Haque to medical school day 1, this finalyear medical student was able to retain his sensitiviry along the "miles of medical ink"5 and amidst the consuming call schedules of medical education. 6 Perhaps some of Shelby Haque's medical school instructors promoted preservation of sensitiviry through their seminars and personal examples. It is also encouraging that Shelby Haque, a male medical student, felt compelled to write on an issue of inadequate provision of health care to women, an issue more frequently identified and addressed by women. The mirror is further encouraging in that it reflects that this medical student has retained his courage beneath7 the "tonnes of tutored words"5 of medical education; courage to submit his reflections, unencumbered by pseudonym, for publication in a national medical joumal that he is well aware his clinical teachers, reference writers, and selectors for residency programs may read. I would like to think all medical educators would applaud the sensitiviry and KeyWords Education, medical, undergraduate; ethics, medical; students, medical; internship and residency; obstetrics, education; physician-patient relations; professional role; obstetrics, standards
JOGC
courage of this student, and accolade a letter selected for publication by an "indexed, " peer-reviewed medical journal, but many students have confided in anonymous surveys8-10 (and in my office) their fear about speaking out on any issue of medical education or treatment of patients.9 However, Shelby Haque's letter is also disturbing. He writes, "As a first-year medical student at my wife's bedside during the birth of our first child, I remember the physician on call quickly entering the room, making some convoluted, incomprehensible mention of'PIH,' and then leaving as quickly as she had entered."3,!! Referring to his clinical clerkship "rotation in obstetrics,"3 he writes: "I also saw obstetricians deliver several women in one day as if they were came at a factory farm. My experiences, and the experiences of my medical school colleagues, lead me to believe that the factory farm approach is more widespread than physicians would like to admit."3 Although we can focus the angst ofShelby Haque's observations on Canada's insufficient "human resources" for compassionate obstetrical care, and add our own experiences to heighten the heat of this focus on the government under-funders responsible for this inadequacy, it remains that the perceptions of medical students like Shelby Haque lessen their regard for obstettical practice and the physicians who provide obstetrical care. The lessening of this regard cannot help but occur, even though our colleagues who still deliver babies are well-intentioned physicians doing the best they can under the stressful circumstance of time constraint. Indeed, Shelby Haque's letter reflects the overwork and dissatisfaction of many of the professionals who provide obstetrical care, just as much as it reflects the suboptimal care and dissatisfaction of many of the women receiving obstetrical care. These reflections may contribute to the difficulties in recruiting medical students to residency programs that provide training in obstetrics, as indicated in a study of Canadian medical students in which "sixry-two percent were influenced by experiences both before and during clerkship"!2 in considering residencies in obstetrics and gynaecology. Shelby Haque's letter is further disturbing when he writes, "My med-school training in pregnancy and childbirth has focused exclusively on the medical aspects of labour. Spiritual and emotional aspects are given little more than a sarcastic chuckle during teaching rounds and lectures."3 This observation suggests that this student's medical education, and likely that of many medical students in his and most medical schools, is fraught with the demeaning of non-science seminars, such as those that promote sensitiviry to the needs of the person inside DECEMBER 2003
the patient l3 or explore ethics and social issues. As either diseasebased learning or problem-based learning (PBL) remains the focus of most medical school curricula, rather than person-based learning (a better PBL, in my opinion),6 and most medical students remain exam-pressured to be closeted in science-studying, how can we expect students to be open-minded to the study of ethics and psychosocial issues? As long as non-science continues to be perceived as nonsense, the "sarcastic chuckle"3 to "spiritual and emotional aspects"3 and the "ethics-eyelid reflex"6 will continue to be infectious. Although decanal championing may be required to refract the perception that "spiritual and emotional aspects"3 are unimportant, we can help by including seminars on compassion and psychosocial issues during medical students' "rotation[s] in obstetrics."3 Such seminars may even assist in the revisiting of obstetrics by these students and ultimately their recruitment into residencies in obstetrics and gynaecology and family medicine. Finally, Shelby Haque's comment that "the fact that patients would pay such high fees for labour support [by doulas] should be a clear indication that something is missing in our medical management of pregnancy"3 needs to be repeatedly reflected to planners and funders of obstetrical care to refract the distorted view that adequate numbers of obstetrics practitioners and adequate funding of obstetrical services currently exist. Obstetrics practitioners should acknowledge these inadequacies to their patients, to refract any perception that they and their colleagues are callous and uncaring. Acknowledging to the patient that the clinician has no choice but to spend less time with the individual patient than she deserves, because of the many patients requiring care at that moment, helps patients and their families appreciate the increasingly time-constrained conditions of obstetrical practice. This appreciation may encourage public insistence that policy makers plan a large increase in the numbers of physicians and nurses providing obstetrical care, rather than continuing to emphasize an increase in efficiencyl4 of obstetrical care provision. For as Nuala Kenny contends, "Medicine is a moral enterprise, not a business venture." 15 As Neil MacGregor writes in his Foreword to Jonathan Miller's book, On &flection, "Perceptual confusion rapidly becomes moral, and in this looking-glass world, language mirrors the ambiguities oflooking."16 It is fine that medical students sometimes perceive obstetricians as "brilliant physicians [who] manage complex labours,"3 but more important that medical students perceive obstetricians as compassionate human beings. This perception will only be possible when obstetricians have the time to truly care for each patient, which includes time to demonstrate their compassion for each patient to each patient and each student; compassion the obstetrician feels and would like to express, but does not have time to express or, indeed, time to provide. It is fine that medical students perceive hard-science seminars as important, but essential that medical students perceive non-hardscience seminars as important. This will only occur when medical students are encouraged to see the person inside the patient l3 JOGe
and the person inside the physician. It is necessary for medical students to accurately view inadequacies in health-care provision and education, and like Shelby Haque, take umbrage with these realities. For what awaits their pass through the looking-glass of graduation is not Alice's fantasy world,17 but the real world where many women choosing to journey through what they feel should be the wonderful experience of pregnancy and birthing l8 are not adequately supported, and where clinicians wanting to provide optimal assistance are not permitted. If clinicians do not feel that they are providing the best obstettical care possible - not just the best they can provide under time constraints - it is difficult to feel good about our professions and ourselves, a reality essential to being good role models for students and good ambassadors for our professions.
J Obstet
Gynaecol Can 2003;25( 12):995-6.
REFERENCES I.
2.
3. 4. 5. 6.
7. 8.
9. 10.
I I. 12. 13. 14. 15.
16. 17. 18.
Althouse LA, Stritter FT, Steiner BD. Attitudes and approaches of influential role models in clinical education. Adv Health Sci Educ Theory Pract 1999;4(2):111-22. Kenny Np, Mann KY. See one, do one, teach one: role models and the CanMEDS competencies. Ann Royal Coli PhYSicians Surg Can 200 I ;34(7):43S-8. Haque S.The newest team member? J Obstet Gynaecol Can 2003;2S( 12): I003. Gruneir R.The newest team member? J Obstet Gynaecol Can 2003;2S(7):S64-S. Nisker J.The yellow brick road of medical education. Can Med Assoc J 1997; 156(5):689-91. Nisker J. Narrative ethics in health care. In: Storch JL, Rodney P, Starzomski R, editors. Toward a moral horizon: nursing ethics in leadership and practice. Toronto: Pearson Prentice Hall; 2004 [in press]. Referring to Hermann Hesse's critique of the education process in Hesse H. Beneath the wheel. New York: Bantam; 1968. Hicks LK, lin Y, Robertson Ow, Robinson DL,Woodrow SI. Understanding the clinical dilemmas that shape medical students' ethical development: questionnaire survey and focus group study. BMJ 200 I;322;709-1 O. Coldicott Y, Pope C, Roberts C.The ethics of intimate examinations teaching tomorrow's doctors. BMJ 2003;326;97-9. Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students' perceptions of their ethical environment and personal development. Acad Med 1994;69(8):670-9. Permission to publish this incident received from Charlene Smith. O'Grady T. Decision factors regarding choice of obstetrics/gynaecology as a career [abstract].J Obstet Gynaecol Can 2001;23(10):926. Nisker J. Chalcedonies. Can Med Assoc J 200 I; 164( I):74-5. Stein JG.The cult of efficiency. Toronto: Anansi; 200 I. Kenny N.The continental divide: comparing U.S. and Canadian values in health reform. Joint meeting of the American Society for Bioethics and Humanities and the Canadian Bioethics Society; 2003 Oct 23; Montreal, QC. Miller J. On reflection. London, England: National Gallery Publications; 1998.p.9. Carroll l. Lewis Carroll: the complete illustrated works. New York: Modern library; 1979. Bergum V. A child on her mind: the experience of becoming a mother through birthing, adopting and placing a child.Westport (CT): Greenwood Publishing Group; 1997.
DECEMBER 2003