Phil Wolfson’s Last Lecture

EDITORIAL

Phil Wolfson’s Last Lecture In Memory of Phillip J. Wolfson, MD ASE President, 2007 Barry D. Mann, MD Acting President, Association for Surgical Education Philip J. Wolfson, 57, of Haddonfield, a pediatric surgeon and medical school professor, died Wednesday 8/29/07 at Kennedy Memorial Hospitals-University Medical Center/Cherry Hill. Dr. Wolfson suffered fatal injuries when he was hit by a truck while jogging near his home. He had jogged every morning around 4:30 a.m. for the last 20 years, his brother, Robert, said. (Philadelphia Inquirer 8/31/07) Sometimes life is just so random. Why was this giant of a man and truly wonderful person taken from us and from his family at this time? I have been advised that the best we can do is to remember what Phil himself would have wanted us to remember about him and to heed the lessons he was in the process of teaching us. Phil Wolfson played many roles in life. In each of his many roles, he was a model for all of us. In 1982, Dr. Wolfson joined Jefferson Medical College as Chief, Section of Pediatric Surgery, where he had a productive career for nearly a quarter century. In 1985, Phil started the Neonatal ECMO program at Jefferson, one of the first of its kind in the country. As a pediatric surgeon, Phil spent his adult life caring for premature babies, anomalies, atresias, and the physical consequences of random genetic rearrangement. Doing his best in the arena of the operating room to right developmental wrong, he was renowned for his ability to deal with the associated human pain of both parents and children in the more private arena of one-toone relationships. “He followed his patients as if they were his own children,” is how his long-time nurse had put it. “He loved those babies.” Phil was passionate in his commitment to medical student education. He was truly the educator’s educator. For nearly a decade, he served as the Chairman of the Curriculum Committee for the Jefferson Medical College. He served on the National Board of Medical Examiners and most recently became President of the Association for Surgical Education in April 2007. Yet, even as his clinical and administrative commitments abounded, he continued to devote an incredible amount of time to students. As educator, he made the most of every “chance” encounter. He met with students and counseled them. He worked “behind the scenes” to help the struggling student repair and the unhappy student regroup. He arranged for mentors and took the time to be a mentor himself. Since his passing, so many notes have been circulated from students about how their chance encounter with

Dr. Wolfson set them into a profoundly satisfying life course! Phil worked publicly to acknowledge students as adult learners, to empower them, and to have their opinions taken seriously by the medical establishment. Phil had written very recently for FOCUS on Surgical Education, which is a publication of the Association for Surgical Education, about the “hidden curriculum,” the violations of professional behavior by residents and attendings. Phil pointed out that students feel trapped and unable to speak up. Phil’s hope was to empower students. He believed fundamentally that the hierarchical system needs to change. To him, this was not just a better educational model, but also the key to patient safety and better patient care. It has come to my attention that a common practice on college campuses these days is to invite popular professors to deliver a lecture as part of what is termed a “Last Lecture Series.”1 Popular professors are asked to think deeply about what really matters to them and to give hypothetical final talks. The question to be mulled is this: What wisdom would we impart to the world if we knew it was our last chance? It seems appropriate to publish herein an essay Phil Wolfson had prepared for the Summer Issue of FOCUS on Surgical Education in his role as the President of the ASE. I believe it truly represents what Phil would have chosen as his “Last Lecture.” The editors of FOCUS and of the Journal of Surgical Education have agreed to publish Phil Wolfson’s important message in the context of this tribute. “Of Course There Was Nothing I Could Do” Phil Wolfson, MD. Jefferson Medical College What does a medical student do if she sees a resident falsely documenting physical examination findings in a patient’s chart that she knows he did not perform? If a student discovers an incidental perforated eardrum on his own physical examination in a preoperative patient and is told to keep quiet about it because otherwise it will need to be worked up and it might delay surgery? If she is sent to draw arterial blood gases on a postoperative patient with shortness of breath when she feels she has not been adequately instructed to perform this procedure? If he is asked to misidentify himself as “Dr” in order to obtain

Journal of Surgical Education • © 2008 Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery

1931-7204/08/$30.00 doi:10.1016/j.jsurg.2007.11.005

1

medical records? If she discovers that her attending surgeon does not tell a patient whom she has become close to that his colon cancer has spread to his liver because the patient’s family members do not feel the patient can handle the news? If the highly regarded attending surgeon with whom she is rotating makes crude and derogatory remarks about an overweight patient’s body habitus when that patient is anesthetized in the OR and many of the OR personnel laugh, some of them nervously? If he sees a resident inadvertently break sterility during an operative procedure and that resident does not tell the attending? If the spleen is injured by a retractor during a left colectomy and the patient is told that the spleen needed to be removed “as part of the operation”? Unfortunately, it is very likely that the student involved will do nothing. In a recent article in the New York Times, In a Hospital Hierarchy, Speaking Up Is Hard to do,2 Dr. Barron Lerner describes how medical students, at the bottom of the heap in the established medical hierarchy, are inhibited from speaking up when they witness their supervising physicians committing errors or acting unprofessionally. Even when such acts jeopardize patient care, students (and to a lesser extent, residents) remain quiet due to an intimidating environment and the fact that they know these same physicians will be grading them. And even when students do bring such matters up, they are often ignored. Although we often assume that the process of medical education with exposure to us and our residents as role models will strengthen our students’ moral values, there is evidence that frequently the opposite occurs and students’ ethical principles are actually eroded during medical school. One study examined six medical schools and demonstrated that 98% of students had heard physicians refer derogatorily to patients, 61% witnessed unethical behavior by team members, and 58% of students reported having done something unethical themselves.3 The most frequent reasons given for what the students considered to be their own complicity were fear of a poor evaluation and to “fit in” with the team. Another survey of 16 US medical schools found that 42% of students reported harassment and 84% experienced belittlement, especially related to Surgery.4 Such an environment is hardly conducive to students speaking up! I believe that these situations in which medical students feel unable to address unprofessional behaviors they witness, are inhibited from reporting events that compromise patient safety, or are themselves mistreated are all interrelated, and have enormous adverse effects. In addition to the fact that many medical errors, estimated to be the third leading cause of deaths in the United States, go uncorrected and patients in many instances receive less than professional care, there are also serious consequences to the medical students themselves. 2

In the first study above, a majority of the students felt guilty and considered that some of their ethical principles had been lost.4And in fact, the students who reported witnessing unethical behavior were more likely to have acted unethically themselves. In the second survey, students who reported they had been mistreated were significantly less satisfied with their career choices and showed numerous adverse psychological ill effects.4 What can be done? I believe we need nothing less than a radical change of the culture in which we educate medical students and residents in the clinical environment. Although some shifts have already occurred, we have a long way to go. The aviation industry is way ahead of us. In that culture any crew member, no matter how junior, is obligated to call attention to any area in which they have a concern, and they will be listened to with no adverse consequences to themselves. I do not claim to know how we can fully bring about such a culture change in medicine, where professionalism issues as well as safety concerns are at stake, but I will offer some of my own suggestions. I would very much like to hear from you, and can hopefully start a dialogue. For the past several years I have held an “Ethical Dilemmas” session with each block of my Surgery students. Early on I presented what I thought were provocative cases to discuss, but it mostly fell flat! Now I have each student submit a dilemma they have personally encountered and we sit around a table and discuss them. All the examples in the first paragraph above were from actual cases that have been submitted. In addition, students have described instances where residents have told them to predate notes in patients’ charts to the day before; instructed them not to tell a patient after an improper medication was administered with significant side effects; and told them not to let an attending know that the resident had done a PAP smear incorrectly which could not be repeated because the patient had already left the clinic. Attendings have not been present in the OR when patients had specifically requested that they perform the operation themselves; an attending told a student to scrub in when the patient had made it clear that no students should be there because the “patient would never know;” patients have been unnecessarily coerced into having procedures performed; patients who speak no English have not received the same level of care because it was “too much trouble” to obtain consent through an interpreter for things such as an epidural catheter; “Do Not Resuscitate” requests of patients and family members have been ignored; and much more. The title of this essay was in fact taken directly (with permission) from a student’s submission. Another student noted, “As a third year student I have been made to feel that my opinions are valueless.” Although I make it clear I do not have all the answers

Journal of Surgical Education • Volume 65/Number 1 • January/February 2008

(and sometimes the students’ perception of unprofessional behavior may not match my own criteria), we discuss what the student felt, what the student did, what the student could have done, and the barriers for them to have perhaps acted differently. The other students around the table invariably bring up similar situations in which they have been involved and are quite thoughtful and passionate. At the very least I hope that by soliciting and listening to students’ dilemmas in a safe environment these sessions provide a forum to legitimize their concerns and possibly give them the courage to act as they feel they ideally should the next time, or at least when they themselves are residents or attendings. But until I started asking, I almost never heard about any of these situations. Our medical school has conducted a yearly inter-clerkship Session on Professionalism for the entire third year class in which video clips of students dealing with controversial ethical issues encountered with their residents and attendings are shown. Students register their opinions on what they believe should have been done on an audience response system, discuss the issues portrayed in small groups with key physician facilitators, and then have an “Oprah” style open discussion with the whole class together with active participation by the Dean. We try to make it very clear that students can and should have a strong voice. Most importantly, I believe we can empower our students (and residents) the most when we are secure enough to explicitly open ourselves up to their questioning of our own practices and possible shortcomings. For example, the “time out” at the beginning of an operative procedure is an excellent opportunity for us to openly invite any member of the team to vocalize any concerns they may have at any time. When we make it clear to our students and residents that excellent patient care and their own education are our highest priorities and that their contributions are welcome and will be rewarded, we may be able to truly change the culture. A review of malpractice claims against surgeons demonstrated that status asymmetry between individual care givers was the most frequent factor that led to communication breakdowns resulting in patient injury.5 Medical students, although viewed as being at the bottom of our food chain, are bright, thoughtful, eloquent, and care deeply about our patients with whom they often spend a great deal of time and can identify with.

Rather than a system that intimidates students into silence we must foster their idealism and treat them as junior colleagues. Patient care and their professional development demand it. Phil Wolfson lived a life of doing good deeds quietly, and he shunned the spotlight. When the Jefferson Medical College Class of 2002 honored him for his commitment to students by commissioning his portrait as a gift to the university, he was grateful for the honor, but he was embarrassed to be in the spotlight. When he stepped down from the Curriculum Committee at Jefferson after years of service, he simply arose and announced that this would be his last meeting. When his aides said, “But Dr. Wolfson, why didn’t you mention this before? We would have made you a party,” Phil answered appreciatively, “That’s why.” Quintessential Phil. Surgical Education Week in Toronto next April was to be Phil Wolfson’s well-deserved time in the spotlight. In his unexplained and random disappearance at this time, I see him shunning the spotlight once again. It is as if Phil is reminding us of what was the hidden curriculum of his own life: It is the deeds behind the scenes, the no-credits, the ones that do not get recorded on the CV that are truly the important ones in life. May memories of Phillip J. Wolfson remain a blessing for all those whom he touched, particularly for his wife Ginny and his daughters Erin and Carrie. May we all learn from the true inner curriculum of Phil’s life.

REFERENCES 1. Zaslow J. A beloved professor delivers the lecture of a life-

time. Wall Street Journal On-line. September 20, 2007:D1. 2. Barron HL. In a hospital hierarchy, speaking up is hard to

do. New York Times. April 17, 2007:F5. 3. Feudtner C, Christakis DA, Christakis NA. Do clinical

clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development. Acad Med. 1994;69:670-679. 4. Frank E, Carrera JS, Stratton T, et al. Experiences of belit-

tlement and harassment and their correlates among medical students in the United States: Longitudinal survey. BMJ. 2006;333:682. 5. Greenberg CC, Regenbogen SE, Studdert DM, et al. Pat-

terns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007;204:533-540.

Journal of Surgical Education • Volume 65/Number 1 • January/February 2008

3