Duke University School of Medicine - Aesculapian Yearbook (Durham, NC)

Page 31 text:

and dying, a five-minute negative contact of that physician with a terminal cancer patient can leave an horrendous emotional problem in the lap of the nursing staff on that ward. The physi- cian can leave expeditiously, but the nurse assigned to the patient has to cope with the problem for hours on end. A fatigue syndrome of nursing personnel on cancer wards has evolved. Many of the complaint letters I receive are due exam- ples of poor physician-patient communications and indicate the need for humanism in medicine in the form of more empathy and understanding for patients by future medical students and residents. William G. Anlyan l'Directory of Residency Training Programs for 1979-80. Pub- lished by The American Medical Association. Feb. 1980. H190 .19 'VXI 9U! ,- :ft CD -1 .swf r-P 3 F7 Young adults in medical school are a heterogeneous group of talented, highly motivated, unique individuals who have already accomplished a great deal during their undergraduate years. There can be no doubt that the diverse backgrounds of the students contribute a great deal to the interactions of the stu- dents with each other and with the faculty. One of the rewarding aspects of being a teacher in the Duke Medical School environ- ment is observing the mutual respect which students have for one another. During the third year of medical school when more time is available for thinking and integrating information, it is delightful to see the student interactions as they share informa- tion with one another and learn by discussions with their peers. The Duke Medical School curriculum is unique. The first year provides a vocabulary and exposure to an insurmountable quantity of information. The second year clinical clerkships then expose the student to disease processes and people. The variability of diseases, the sometimes overwhelming sadness of illness, and the frustrations and pleasures of caring for people become a strong motivating force for integrating basic science information and returning to obtain additional facts from the basic sciences when necessary. The relative freedom of the third and fourth years at Duke provide the opportunity for further enhancement of the basic science background of our students, as well as for continued acquisition of clinical skills. This time allows the student to develop a critical approach to acquiring information, to assimilate further facts, and to develop the ability to solve problems relevant to the practice of medicine. The development of these skills is far more important then the individual facts which are acquired during medical school. The education of students can be successful only if they develop this ability and acquire confidence in solving each problem as it presents itself. The factual foundation provided by medical school must be built upon during the productive lifetime of the student. This obligates the medical school to provide the factual background but even more importantly, to help students understand the need for continuing acquisition of knowledge. Not only do students need to continue learning from the literature, but also from their own experiences in medicine. The guiding principle must be the ultimate concern for providing optimal health care to the individual patient. There are mutiple pathways which can be pursued within the broad framework of medicine. For example, a student may elect sub-speciality training or may elect to become involved in health care administration, either choice narrows his or her focus in medicine. Such decisions are the province of the student, but based on experiences occuring during their four years in medic- al school. Most of us have chosen medicine as a personally satisfying occupation. It is constantly stimulating, sometimes terrifying, and always interesting. This commitment to medicine as a pro- fessional career requires great understanding on the part of other persons sharing our lives. Medicine is not an eight hour a day job. Under no circumstances can responsibilities be dis- carded at the end of a Working day. There are ways in which responsibilities can be shared, but the time commitment and anxieties of caring for other persons will consume the majority of the waking hours of most persons in medicine. This is a difficult responsibility to integrate with family life and personal obligations. In particular, for women who elect to have a family and be in medicine, time commitments are sometimes extreme- ly difficult to manage. The biological role of women in bearing children may require compromise with other commitments and certainly requires emotional support. The physiological needs of infants are relatively simple when compared to the emotional needs and demands as they grow and develop daily. This is often not appreciated until such development is observed within the individual home. The joys are more than enough compensation for the difficult times, but unanticipated compromises may occur in the amount of time or the direction of training of individual physicians. Assistance within the household often becomes a necessity for homes with two working persons, parti- cularly two physicians. The quality of love and care within the home are far more important than the number of hours spent within a home. Thus, with planning, compromise, and hard work, it's possible to reap the enjoyment ofa happy personal life as well as the fulfillment of a satisfying career. Finally, a personal note of gratitude to the students who provide the motivation to continue teaching. Perceptive ques- tions, refreshing novel approaches to problems and enthusiastic interest in learning are constant stimuli to me to continue learn- ing in order to teach. Catherine Wilfert PHILOSOPHBRS 2 5

Page 30 text:

in a laboratory doing research rather than taking care of sick fellow human beings. I have no clear solution to propose and will continue to agonize about this issue. The Medical School Experience Clearly, the elective curriculum instituted in 1966 at Duke has been successful at this institution. It is the way of the future as useful medical information increases exponentially. We rec- ognized in the 1960's that it was no longer possible to expose medical students to all pertinent medical knowledge. The first two years were tailored to acquaint the student with the lan- guage of biomedicine and the process of problem solving. The last two years provided the opportunity to sample specific areas in depth. An additional dimension will have to be added - the changing process of decision-making as well as the changing information base. The evolving physician-computer interface is constantly a changing process. The Myocardial Infarction Re- search Unit CMIRUD instituted at Duke in 1967 is a splendid example of how decisions will be made in the future regarding the care of patients with coronary artery disease. Human mem- ory becomes increasingly fallible. The clinical experience of one physician is an insufficient data base for decision-making. The MIRU model is already being adapted to the field of cancer. In succession, other diseases will be managed with the same pro- cess and will be used by medical students, residents and clini- cans. The data base will be made available to community physi- cians by satellite terminals. Already proven to be cost-effective, the computer-physician process should be supported by third party insurance as a mechanism for a higher quality of care and for cost containment. Having an objective basis to sort out patients with myocardial infarction who can be discharged in 5-7 days instead of 21 days will be increasingly important as the per diem in coronary care units climbs up to 351000 per day in the 1980's. Changes Anticipated in Residency Training Because of the interdependence of clinical services, institu- tions will need to be accredited for graduate medical education. The patient with heart disease coming to a teaching hospital requires a spectrum of bench strength in medicine or pediatrics, radiology, surgery and anesthesiology. Each is an important link and quality cannot be unacceptable in any one. Today, Residen- cy Review Committees and the various specialty board tend to look at individual programs. The patient may be in jeopardy if one residency training program is on confidential probation unbeknownst to the others. Some mechanism such as the Liaison Committee on Graduate Medical Education will need to have muscle at the national level to accredit teaching hospitals aspiring to provide residency training. As a second set of teeth, the Joint Commission on the Accreditation of Hospitals should not accredit hospitals with residency programs that are not certified by the LCGME. Other issues that will evolve in the 1980's will be the problem of accomodating the larger crop of graduating MDs into avail- able Year I Residency Programs. As the LCGME improves quality by accreditation, some residency slots may be discon- tinued. It is possible that we may see a situation comparable to France and Spain where the number of Year I slots are less than the number of graduating MDs. A clear trend is already in view to correct speciality maldistributionf' Recent graduating classes have listed not only their preferred internships for the specialty of choice but for other less sought specialties as well. Finally, we can anticipate changes in the financing of residen- cy training. To date, each specialty board has designed the criteria for accomplishing residency programs. There is no 24 PHILOSOPHERS across the board consideration of whether the trainee is still a dependent highly supervised individual or if, indeed, he or she can be considered to be a relatively independent junior staff person - e.g., the 8th year resident in cardiac surgery. Residents are currently supported by the patient care budgets of teaching hospitals. It makes more sense to support the cur- rent more senior relatively independent residents on the same basis as the faculty, be it fee-for-service or some other basis. Collectively, residents do not have a comfortable national voice. They are being wooed by the AMA as future members thereofg they are sought by the unions as employees of hospi- tals. The medical educational associations need to incorporate the legitimate interests and membership of the 64,532' resi- dents in the teaching hospitals of the United States. Continuing Medical Education This is probably the biggest challenge of them all. Why? The average duration of compartments in the continuum of medical education is as follows: Premed - 4 years, medical school- 4 years, residency - 4 years, continuing education - 55 years. Given the 5-year half-life of useful information in biomedicine and the changing process of learning and practice, continuing medical education is a sleeper. In the 1980's and l990's, there will be a shift in the center of gravity of educational programs in the continuum of medicine, from medical school and residency training to continuing education. Fortunately, by our current tax laws, it is possible to be a self-financing area. How to do it? Unfortunately, at this time we know what works and what doesn't in continuing education at the extremes. We have no objective basis on which to judge the usmorgas- borg of offerings on the international scene. Evening lectures that follow long cocktail hours and massive dinners probably are inconsequential. Spending a month every two years with the house staff as a fellow in a given specialty at an academic medical center to learn new diagnostic and therapeutic skills is probably effective. Evaluating the net impact of a specific type of con- tinuing education program on the patient care of a given practi- tioner is lacking. Humanism in Medicine Of significant concern is the question: Does the increasing science and technology of medicine put it in an adversarial relationship with treating patients and their families as human beings? My answer is a hopeful, resounding no !! lwould not be honest if I did not express my grave concern in this issue. As the complexities of diagnosis and treatment increase exponen- tially, there has been a decrease in the ability of the physician to communicate with the patient and the family. The role models of faculty were never perfect. In the 1940's and 1950's, we still had professors who denied the patient the truth about having cancer, it put the patient and the knowledgable family in a difficult situation. Today, the problem with the clinician is not protecting the truth to avoid shocking the patient, but a lack of awareness of how to communicate effectively with the patient and the family. It behooves faculty members to behave as role models for the medical students and the residents. Furthermore, the subject of communication process should be incorporated in clinical rounds. What to say - how to say it - where to say it! The effectiveness of the physician in communication has a domino impact on other health professionals who have to deal with patients and their families. The poor physician communicator can have a devastating emotional impact on the patient, the family and the other health professionals. A striking example of the latter is the resident who is insecure and anxious about death

Page 32 text:

L C 2' 3 3 'FI DJ CD 1-P P+ fu 3 F AUTHORITY AND COMPASSION The experiences of medical school have helped you prepare to change roles - from being a well-educated young adult to becoming a physician. As a physician you will have unique authority- to physically intervene on behalf of a patient to help restore health. While others may have a deep concern for the causes of illness or for the delivery of health care, or may prescribe and perform certain forms of therapy, only you the physician will have legal authority to direct and participate in all aspects of comprehensive patient care. Your medical education prepares you to assume this new authority, but it must also prepare you to assume new responsi- bilities - those of providing informed and compassionate care to people. Rather than being on a pedestal, where one with your newly acquired authority might be found, becoming a physician means becoming immersed in all aspects of human experience while using your authority to benefit people. You will come to know thousands of individuals as they become your patients, and you may know them as no one else does. They may care very little about the science, i.e., the cause, prevention and therapy of their illness, but they will seek to reacquire health by benefit- ing from your authority and talents as a medical scientist. However, they will need much more than the science you have learned, since very few of your patients will be cured of all their ills by your intervention. In order to properly care for you patients, you must maintain a commitment to them, to science, and to yourself. The process of first detecting illness is currently a job primarily for the patient, but defining the illness, understanding its development, knowing how and when to intervene, and knowing when to modify care using new techniques are your responsibilities as a physician. This commitment to science, at least to that body of medical facts and practice which is currently accepted, is empha- sized in medical school and is apparent in the performance of medical students. Sometimes less apparent is an understanding of when to add new or different methods of care to the currently accepted therapeutic programs, when to experiment on hu- mans, or by what criteria new information becomes better in- formation. Concepts involved in logical decision making have been presented to you in both abstract and tangible forms. 26 PHILOSOPHERS u These concepts must be reviewed and consistently practiced in order to help you know when to reject a particular idea, or with what level of certainty a concept may be accepted. Caring for patients requires providing compassionate care, which includes having an understanding of what it is that the patient gives up by being ill. Caring also includes having a sense of how to help the patient reduce the sacrifice caused by illness. For many patients, this may simply mean your bending from a rigid schedule to consider their needs and responsibilities when you plan for their continued care. For the patient with progres- sive disease, this may mean your advising how to make today more important while not giving up hope for tomorrow - to focus on the near term, to help forget the bad moments and to learn to cherish the good. But to care and to continue caring, you must also care for yourself To risk emotional commitment to patients whose fate is unclear makes you vulnerable to loss. To frequently risk this loss is too intense for you to cope with alone. The tension must be shared with colleagues who can support you and occasionally relieve you of responsibilities. You must recognize not only your need to care for others but also your need to save some energy for yourself. Your life will change when you receive the physician's authority, but you will remain the same person you always were. People other than your patients will need you for matters often less intense than those you will cope with in medicine. You must learn occasionally to put aside the more dramatic matters so that you may tend to private matters and maintain interests outside of medicine. Giving by becoming immersed in human experiences can lead to one having nothing to give. Remember to save some for the giver. john M. Falletta l'l'l 4 93 L CD 'Pi cr CD 1 3 p PHILOSOPHY My own experience as a physician living and working in two countries, South Africa and the United States, spans a period of thirty years. During these years three communities have had the greatest impact on my professional and personal development. The first community was in Durban, South Africa. From 1946 to 1954 my husband and I Worked in an Institute of Family and