Human Dimensions of Medical Education (Dr. Michael Plaut).

There is fairly wide agreement that the 3-day experience has deviated from its original intent to help prepare incoming students for the anxieties, responsibilities and changes they will face in Medical School. Course directors in the pre-clinical years think that much more could be done in this experience to emphasize better the issues of entering the profession, what it means to be a physician and the general principles of medical professionalism: e.g. to subordinate their own interests to the interests of others, adhere to high ethical and moral standards, respond to societal needs, and their behaviors reflect a social contract with the communities served, evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others, and trustworthiness, exercise accountability for themselves and for their colleagues, demonstrate a continuing commitment to excellence, exhibit a commitment to scholarship and to advancing their field, deal with high levels of complexity and uncertainty and reflect upon their actions and decisions as well as the responsibilities of the physician as a lifetime learner) if it was made clearer what the purpose of the retreat is. Faculty members also agreed that we should more clearly focus on the shift the participants are undergoing from undergraduate student to graduate/medical student and what they are “getting into,” as well as the privileges and opportunities that bring with them responsibilities and obligations.

One senior student suggested that at least one small group session (with at least one upper-class-person present) should be devoted to the topic of HELPERS-PRO, which could be introduced by a vignette, followed by a free-flowing discussion. Because only 50% of students attend, consideration should be given to 1) making it a mandatory experience and 2) providing more scholarship support. There is also a need to refocus the process from the more leisure-sportive to interpersonal-relational, which would accelerate the process of understanding the general principles of HELPERS-PRO. Several persons deplored the tendency for participants to avoid self-disclosure and personal details about their backgrounds.

I also recommend that some “summer reading” be suggested to the entering students. This could include such short works (Appendix 5) as Tolstoy’s “The Death of Ivan Ilyich,” Conrad’s “The Secret Sharer,” and Orwell’s “Shooting an Elephant.” These short pieces can serve as a jumping-off point for many of the group discussions during HDME, the Orientation Week and beyond.

The First Day (Dean Wilson) and Orientation (Dr. Jack Gladstein).

During Dean Wilson's welcoming address, special emphasis can be placed on the entire area of HELPERS-PRO in a way that emphasizes the positive rather than negative aspects. In addition, thought should be given to ways of minimizing the verbal/interactive and maximizing the electronically available aspects of operational/administrative issues (e.g. Campus Police Chief) while maximizing time spent on the personal/professional aspects of entrance into the profession with all that it implies. There is a need from day one to be sure students recognize the importance of respect for others, timeliness, dress and comportment different from that which may have been expected of them in college.

To emphasize the Dean and the School's commitment to the area of HELPERS-PRO, it would be very, very impressive to have the Dean lead off with (1) some prepared remarks, then (2) interview a patient with simultaneous TV feed to small groups in the lab rooms, followed by (3) their very first small group devoted to the subject of “What is Professionalism” rather than to CPR. Indeed, several faculty members suggested the entire first day be devoted to an overview of the entire area of HELPERS-PRO, with both lectures and small group discussions around case examples. to introduce what it means to be in the Profession of Medicine. At this time, all the areas and aspects involved in HELPERS-PRO could be introduced in small groups. (The effectiveness of open ended questions discussing terminology; e.g. what does Aprofessionalism mean, was nicely demonstrated in a recent New Yorker article on focus groups entitled “Annals of Marketing; The Word Lab” N. Lemann, Oct 16 & 23, 2000, pps 100-112.]

Promotion of Organizations (Student organized).

Faculty noted that if directed towards students= cultural/etc interests, they do and could continue to augment aspects of the areas under concern throughout the four years.

Medical Informatics (Dr. David Mallott).

It is possible to include in the hands-on parts (e.g. learning to make power point slides) examples that would deal with the area, e.g. making slides to illustrate a talk on AWhat is Professionalism.

Structure and Development (Dr. Larry Anderson).

The course could also deal with human research such as human experimentation, treatment of research subjects.

Principles of Human Behavior (Dr. Bruno Anthony).

Dr. Anthony believes they could cover the other general principles of the physician’s need to subordinate their own interests to the interests of others, respond to societal needs, and their behaviors reflect a social contract with the communities served, and physicians reflect upon their actions and decisions as well as aspects of professionalism such as accountability, appearance, demeanor, duty, excellence, following through with recommendations made to patients, honor, integrity, judgement, language (appropriate), sensitivity to culture, gender and religion and spirituality, respect towards physician and non-physician colleagues and sexual harassment.

Dr Anthony also thinks that more focus could be placed on the areas of Professionalism, etc by emphasizing the importance of including them through a meeting of all the instructors involved in the course before it begins.

The White Coat Ceremony (Dr. Jack Gladstein).

Without dictating to anyone else what they might say, it might be interesting to see if all the aspects of the area (not currently mentioned) could be mentioned by one or another speaker (in a positive way).

After Human Behavior and The White Coat Ceremony.

There is a need for some kind of follow-up. It was suggested that periodic seminars on various subjects could be added as “booster shots.” Ideal venues for these include the ICP groups and the PBL cases.

Autopsy Experience (Dr. Raymond Jones).

Currently as much as possible students are told before viewing the autopsy of the varying reactions students have ad the opportunity to talk 1-1 to someone afterwards if they wish. This could be made mandatory so that exploration of the areas of death and dying, respect for the patient, the intimate relationship they will have, physicians’ adherence to high ethical and moral standards, social contract with the communities served, core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others, and trustworthiness, accountability for themselves and for their colleagues, continuing commitment to excellence, commitment to scholarship and to advancing their field, and reflection upon their actions and decisions are once again explored.

Cell & Molecular Biology (Drs. Giuseppe Inesi, Jerry Barcak).

They thought that the course could also cover the General Principles of Professionalism such as the physicians need to respond to societal needs, and their behaviors reflect a social contract with the communities served, evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others, and trustworthiness, demonstrate a continuing commitment to excellence, exhibit a commitment to scholarship and to advancing their field and deal with high levels of complexity and uncertainty as well as aspects such as accountability, decency, demeanor, duty, honesty, honor, integrity, judgement, putting the patient first, reporting colleagues’ errors, skills, telling the truth; unprofessional behavior such as abuse of power, in interactions with patients or colleagues, bias and sexual harassment, breach of confidentiality, arrogance, greed, misrepresentation of credentials and certifications, education and training, impairment, lack of conscientiousness, lying, conflicts of interest, self-referral, acceptance of gifts, over-utilization of services, collaboration with industry, compromising the principles of clinical investigation; humanism including caring for patients’ needs and psycho-social aspects, compassion, empathy; sensitivity to age, culture, gender, socio-economic status, religion and spirituality, sexual orientation, confidentiality, transfer of responsibility, aspects of human research such as aspects of human experimentation and treatment of research subjects; and MD-industry relationships including common sense and conflicts of interest when seeing patients, peer-reviewing research or articles.

(Genetics Component) (Dr. Miriam Blitzer).

In addition, she and Dr. Cowan felt more emphasis could be placed on the following, among the General Principles, the physicians need to: adhere to high ethical and moral standards, respond to societal needs, and their behaviors reflect a social contract with the communities served, demonstrate a continuing commitment to excellence, exhibit a commitment to scholarship and to advancing their field and reflect upon their actions and decisions as well as aspects such as demeanor, duty, excellence, honesty, integrity, judgement, language (appropriate), skills, telling the truth, abuse of power in interactions with patients or colleagues, lack of conscientiousness, over-utilization of services, collaboration with industry, compromising the principles of clinical investigation, sensitivity to culture, gender, socio-economic status, religion and spirituality, proper record keeping, confidentiality, ethical obligations under managed care structures and areas of human research, such as aspects of human experimentation and treatment of research subjects, self-assessment, and recognition of conflicts of interest when seeing patients, peer-reviewing research or articles.

Intimate Human Behavior (Dr. Michael Plaut).

In addition Dr Plaut believes he could also deal with issues such as honor, reporting colleagues’ errors, telling the truth, breach of confidentiality, arrogance, misrepresentation of credentials and certifications, confidentiality, physician impairment, including: alcohol and drug impairment and physical aggression.

Neuroscience (Drs. Marshall Rennels, David Smith).

They think in the future they could also cover aspects such as the need for physicians to respond to societal needs and exercise accountability for themselves and for their colleagues as well as arrogance, greed, impairment, conflicts of interest such as self-referral, acceptance of gifts, over-utilization of services, collaboration with industry, compromising the principles of clinical investigation, sensitivity to age, culture, gender, socio-economic status, religion and spirituality and sexual orientation, proper records, transfer of responsibility, , double-agency, fees, billing, reimbursement, ethical obligations under managed care structures, human research such as human experimentation, treatment of research subjects, physician impairment, including alcohol and drug impairment, other impairment of cognition, on call alertness, sexual-aggressive behavior, including body and mental boundaries, physical aggression, remediation and physician-industry relationships, including the AMA Guidelines, common sense and conflicts of interest when seeing patients, peer-reviewing research or articles.

In Neuroscience, it is also possible to emphasize aspects such as ethics (e.g. the decision whether to present in person, patients with Alzheimer’s), respect for patients (with cognitive/mental impairment), and treatment of research subjects (with cognitive/mental impairment).

Functional systems (Dr. Michael Selmanoff).

Dr. Selmanoff believes it would be suitable to stress issues, such as: the principles that physicians need to exhibit a commitment to scholarship and to advancing their field and deal with high levels of complexity and uncertainty as well as areas such as sensitivity to age, culture, disability, gender, socio-economic status, religion and spirituality and sexual orientation, human research and within the need for life-time learning: self-assessment and using primary source reading. Additional steps include: having some replace Dr. Grozman who oversaw the whole first year, adding family members to clinical correlate interviews and going over the cases for places where areas and aspects of humanism/professionalism/etc., could be added.

Introduction to Clinical Practice (Dr. David Stewart).

Dr. Stewart in the future they could also cover aspects such as: not impugning the reputation of others, greed, misrepresentation of credentials and certifications, education and training, lack of conscientiousness, lying, over-utilization of services, collaboration with industry, compromising the principles of clinical investigation, double-agency, fees, billing, reimbursement, ethical obligations under managed care structures, avoidance of exploitation (financial, sexual, self-aggrandizement), aspects of human research such as human experimentation, treatment of research subjects, on call alertness sexual-aggressive behavior, including body and mental boundaries, sexual harassment, life-long commitment to education (e.g. CME), using primary source reading, physican-industry relationships, including the AMA Guidelines and conflicts of interest when seeing patients, peer-reviewing research or articles.

In addition, in Dr. Silverman’s portion, he thinks he could also include the following: the physician’s need to respond to societal needs, and their behaviors reflect a social contract with the communities served, exercise accountability for themselves and for their colleagues, following through with recommendations made to patients, honor, judgement, knowledge, language (appropriate), not impugning the reputation of others, reporting colleagues’ errors, service (devotion to a lifetime of), skills, telling the truth, cheating, greed, misrepresentation, credentials and certifications, education and training, conflicts of interest, self-referral, acceptance of gifts, over-utilization of services, collaboration with industry, compromising the principles of clinical investigation, sensitivity to sexual orientation, ethical behavior such as confidentiality, proper records, transfer of responsibility, double-agency, and avoidance of exploitation (financial, sexual, self-aggrandizement).

Consideration should also be given to spending more time in the 3 meetings with the 18 faculty members reviewing what material relating to the area and aspects might be stressed in each section of the course. In addition, in discussing the pairing of teachers with Dr. Donald Thompson, it was apparent that currently psychiatrists are paired with psychiatrists and non-psychiatrists are paired with non-psychiatrists. It would be interesting to have 9 mixed pairs and 9 homogenous pairs and see if there is a difference.

Finally, it has been suggested that the community visit to Planned Parenthood, the soup kitchen, etc. occur too early in the student’s career and should be scheduled later (eg in Years 2, 3 or 4). The reason behind this is that at this point the students are still developing their sense of what a physician is and are not yet ready to consider the physician’s role in society and the community.

PBL (Dr. David Mallott).

PBL presents another opportunity where cases all have some aspects of the areas of HELPERS-PRO. At issue is how to get every group to focus on these issues, however, since it is antithetical in principle to the way that PBL should work. In addition, there is a need for a re-examination of the cases to see if more such “twists” can be inserted without lengthening the content. A senior student also suggested that (1) at least one senior student (some already participate) be included in each group and (2) one entire vignette be dedicated to the area. At a minimum, each case should be scrutinized for insertion of material that could be discussed as group leaders alerted to which issues are highlighted in which cases.

Second year

Host Defenses and Infectious Diseases (Abdu Azad).

A New Course

Dr. Jordan Warnick feels that the pace of 26 weeks straight was too much and breaking it up with two weeks (after weeks 8 and 16) of seminars on subjects such as "Becoming a Physician" and/or Ethics and Ethical Behavior which could incorporate many aspects of HELPERS-PRO would be a win-win. Dr. Warnick suggested this be done in early November between HDHI and P&T.

Pathophysiology & Therapeutics (Drs. Jordan Warnick & Gary Plotnick).

They note that they could cover: death and dying, self-assessment, recognition of deficits in knowledge, skills or attitudes, re-mediation, life-long commitment to education, e.g. CME, use of evidence-based medical skills and using primary source reading. The course is structured so that different systems are covered different weeks. Thus, the first hour(s) of each week could be devoted to an introduction to the ethical and human dimensions of Pulmonary Medicine, the Reproductive System, Cognition, etc. This way everything from mercury poisoning to cancer could be gain this perspective.

Physical Diagnosis (Dr. Raymond Flores).

Dr Flores also thinks it could deal at greater depth with other issues of in the area of HELPERS-PRO, through some sort of training of and phase-specific checklists for preceptors to make sure they’ve covered in the course of the year. One senior student suggested that there was a role for senior students in helping out during the course and that they could contribute to the student-student transmission of values.

The Ex-PBL Segment (Dr. Raymond Flores).

Several persons have suggested that this segment could be the nidus for a special effort in HELPERS-PRO. In addition to the current emphasis on Professionalism, Sexual Harassment, Spirituality and Ethics – the course could be expanded to 8 weeks and include panels of patients and physicians, to make the subjects come “more alive” and it could cover the treatment of research subjects and professional behavior not covered elsewhere (e.g. gifts to physicians, treating the VIP and our relationships to industry.) Dr. Parker’s Cultural Diversity segment could also expand the discussion of diversity to include impairments (e.g. loss of vision and mobility) and ethnic/cultural groups not now covered (e.g. Asian) as well as the need for physicians to demonstrate a continuing commitment to excellence, respect towards physician and non-physician colleagues and death and dying including pain, palliation, possibility of recovery. Also, I think portions of what Dr. Brian Berman deals with could well be adapted to a newly structured ex-PBL time-slot course.

Orientation (Dr. Dorothy Snow).

Dr. Snow thinks that in the future they could cover many of the HELPERS-PRO aspects more formally and Nancy Barzak also thinks she could cover: the physicians need to subordinate their own interests to the interests of others, adhere to high ethical and moral standards, deal with high levels of complexity and uncertainty and reflect upon their actions and decisions. as well as accountability, duty, honor, integrity, not impugning the reputation of others, putting the patient first, reporting colleagues’ errors, skills, lying, caring for patients’ needs and psycho-social aspects, compassion, empathy, transfer of responsibility, and respect towards patients and family members and towards physician and non-physician colleagues.

It was also suggested that the course include a "booster shot", to that provided in ICP, on physician-patient communication to be given in the form of a skills workshop by Dr. Alan Hemani (Bayer Institute and VAMC).

All Clinical Clerkships.

In addition it was suggested that a periodic meeting of the clerkship directors could explore which aspects of the areas are common and which are different to seek a comprehensive coverage of all.

It was also suggested that since the 3rd year students are most closely taught and influenced by their 4th year peers and senior residents, that during the orientation to each clerkship, the Chief Resident reinforce our commitment and concern about teaching aspects in this area and encourage the senior residents and 4th year students to try to remember to constantly keep these areas in mind while teaching. It was also suggested that the Office of Medical Education offer all residents training on teaching medical students.

Clerkship in Internal Medicine (Dr. Philip Mackowiak).

Dr. Mackowiak thinks that in the future they could also cover aspects of human research such as human experimentation, and the treatment of research subjects.

Clerkship in Family Medicine (Dr. Yvette Rooks).

Dr. Rooks also believes they could include, the physician’s need to adhere to high ethical and moral standards, reflect a social contract with the communities served, evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy and trustworthiness, exercise accountability for themselves and for their colleagues, deal with high levels of complexity and uncertainty and reflect upon their actions and decisions as well as not impugning the reputation of others, service (devotion to a lifetime of), skills, telling the truth, abuse of power, in interactions with patients or colleagues, bias and sexual harassment, arrogance, greed, misrepresentation of education and training, lack of conscientiousness,, self-referral, compromising the principles of clinical investigation, transfer of responsibility, sexual misconduct and boundary violations, avoidance of exploitation (financial, sexual, self-aggrandizement), body and mental boundaries, physical aggression, sexual harassment, recognition of deficits in knowledge, skills or attitudes, re-mediation, use of evidence-based medical skills, and conflicts of interest when seeing patients, peer-reviewing research or articles.

Clerkship in Surgery (Drs. Bruce Jarrell, John Colonna).

They think that in the future they could also cover aspects such as the need for physicians to respond to societal needs and exercise accountability for themselves and for their colleagues as well as arrogance, greed, impairment, conflicts of interest such as self-referral, acceptance of gifts, over-utilization of services, collaboration with industry, compromising the principles of clinical investigation, sensitivity to age, culture, gender, socio-economic status, religion and spirituality and sexual orientation, proper records, transfer of responsibility, , double-agency, fees, billing, reimbursement, ethical obligations under managed care structures, human research such as human experimentation, treatment of research subjects, physician impairment, including alcohol and drug impairment, other impairment of cognition, on call alertness, sexual-aggressive behavior, including body and mental boundaries, physical aggression, remediation and physician-industry relationships, including the AMA Guidelines, common sense and conflicts of interest when seeing patients, peer-reviewing research or articles.

Clinical Clerkship in Pediatrics (Dr. Robert Englander).

He also believes they could deal in greater depth with the General Principles, such as the physicians need to subordinate their own interests to the interests of others, adhere to high ethical and moral standards, respond to societal needs, and their behaviors reflect a social contract with the communities served, evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others, and trustworthiness, exercise accountability for themselves and for their colleagues; demonstrate a continuing commitment to excellence, exhibit a commitment to scholarship and to advancing their field, deal with high levels of complexity and uncertainty and reflect upon their actions and decisions as well as bias and sexual harassment, cheating, greed, misrepresentation, credentials and certifications, education and training, impairment, conflicts of interest, self-referral, acceptance of gifts, over-utilization of services, collaboration with industry, compromising the principles of clinical investigation, ethics such as sexual misconduct and boundary violations, confidentiality, avoidance of exploitation (financial, sexual, self-aggrandizement), death and dying, including pain, palliation, possibility of recovery, physician impairment, including alcohol and drug impairment, other impairment of cognition, on call alertness, and sexual-aggressive behavior, including body and mental boundaries, physical aggression, and sexual harassment.

Clerkship in Neurology (Dr. Neil Porter).

Dr Porter states that since the clerkship teaching is performed by many faculty members from both within and without, he is not sure which areas and aspects of professionalism are covered and that it might be helpful to distribute a guideline or list of topics to try to cover.

Clerkship in Psychiatry (Dr. Don Thompson).

Dr. Thompson thinks that the course could also cover: the need for physicians: to subordinate their own interests to the interests of others, physicians adhere to high ethical and moral standards, to respond to societal needs, and their behaviors reflect a social contract with the communities served, exercise accountability for themselves and for their colleagues, demonstrate a continuing commitment to excellence, exhibit a commitment to scholarship and to advancing their field, altruism, appearance, decency, demeanor, duty, excellence, honor, integrity, putting the patient first, reporting colleagues’ errors, service (devotion to a lifetime of), telling the truth, abuse of power, in interactions with patients or colleagues, bias and sexual harassment, breach of confidentiality, impairment, lack of conscientiousness, lying, conflicts of interest, self-referral, acceptance of gifts, over-utilization of services, collaboration with industry, compromising the principles of clinical investigation, ethical behavior including confidentiality, proper records, transfer of responsibility, sexual misconduct and boundary violations, confidentiality, respect towards patients and family members, respect towards physician and non-physician colleagues, physician impairment, including alcohol and drug impairment, other impairment of cognition, on call alertness sexual-aggressive behavior, including body and mental boundaries, physical aggression, sexual harassment, the need for life-long learning, including self-assessment, recognition of deficits in knowledge, skills or attitudes, re-mediation and the life-long commitment to education (e.g. CME).

Draw-the-Line Project (Organization of Student Representatives).

The Draw-the-Line could usefully be expanded to also deal with Respect towards Patients and family members.

The Ambulatory (AHEC) Experience (Dr. David Stuart).

There are no guidelines on what to cover concerning the areas and aspects, which perhaps there should be. To reinforce issues emphasized in the third year, once again it would be possible to devote attention to issues such as: ability to communicate, accountability, altruism, appearance, decency, demeanor, duty, excellence, following through with recommendations made to patients, honesty, honor, integrity, judgement, knowledge, appropriate language, not impugning the reputation of others, putting the patient first, reporting colleagues’ errors devotion to a lifetime of service, skills and telling the truth. This is also another opportune time to deal with high levels of complexity and uncertainty and reflecting upon one’s actions and decisions as well as humanism, including caring for patients’ needs and psycho-social aspects, compassion, empathy and sensitivity, including sensitivity to age, culture, gender, socio-economic status, religion and spirituality and sexual orientation. Dr. Stewart also thinks in the future they could also cover aspects of not impugning the reputation of others, cheating, misrepresentation of credentials and certifications, collaboration with industry, compromising the principles of clinical investigation, human research such as human experimentation, treatment of research subjects. Physician-industry relationships, including the AMA Guidelines, common sense and conflicts of interest when seeing patients, and peer-reviewing research or articles.

A suggestion was also made to have each student follow one patient and his/her family during the AHEC experience.

Anesthesiology Subinternship (Dr. Brenda Fahey).

Dr. Fahey believes they could include the need for physicians to exhibit a commitment to scholarship and to advancing their field, as well as aspects such as decency, demeanor, excellence, not impugning the reputation of others, putting the patient first, keeping proper records, and the need for self-assessment, recognition of deficits in knowledge, skills or attitudes, re-mediation, life-long commitment to education (e.g. CME), use of evidence-based medical skills and using primary source reading.

The Mentoring Project (Dr. Donna Parker).

Dr. Parker’s workshops to the faculty could be used to suggest areas and aspects of HELPERS-PRO, etc. that would be suitable for being dealt with in this special opportunity.

Evaluation (Dr. David Mallott).

The introduction of OSCE's into the evaluation process offers a fine opportunity to evaluated all the areas and aspects of HELPERS-PRO that have been introduced in each segment evaluated.

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