In 2002, the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine (MSU-CHM) celebrated its 25th anniversary. Originally known as the Medical Humanities Program, it was launched in 1977 under the leadership of the CHM’s founding dean, Dr. Andrew Hunt.
Since its origins within the CHM, the Center’s mission has expanded to include teaching obligations in a number of other colleges at Michigan State University. These include the College of Osteopathic Medicine (yes, Michigan State has two medical schools), the College of Nursing, the College of Veterinary Medicine, the College of Arts and Letters (primarily at the graduate level), the Detroit College of Law at MSU, and even occasionally the College of Agriculture and Natural Resources. The Center’s faculty are thus responsible for developing, administering and teaching a large variety of courses across a very broad mix of students.
The challenges and opportunities offered by such diverse responsibilities would itself be worth more discussion. For present purposes, however, we will confine ourselves to describing the challenges we’ve been facing just within the CHM. These are hard enough all by themselves.
A Course to Put Ethics in Context
In the first two years of a student’s four-year program, most of the ethics teaching we do is organized within a series of modules designed to give students a broad framework to help them understand the professional and ethical challenges they will be facing as caregivers. Now in its 11th year, the Social Context of Clinical Decision making (SCCD) is a required second-year course that extends over the entire academic year. It encompasses four modules, each six to eight weeks in length: Ethics (discussed in more detail in the next section), Epidemiology/Clinical Decision Analysis, Health Policy, and the Integrative Exercise. Most of the course is taught in small groups of eight in a problem-solving mode with faculty preceptors. The “take home” message to students is that they cannot expect to be “good doctors” if they fail to understand the social forces shaping medicine. Rather, they must understand these forces, and work with other physicians and the lay public to devise policies and practices aimed at protecting the integrity of the profession against corrosive economic and organizational forces (e.g., cost-cutting competition among managed care plans).
Ethical issues are woven throughout the course. It starts with three large-group hours that present a number of case scenarios challenging students to think about issues of health care justice, especially in relation to rationing and priority setting, in their role as loyal patient advocates. These issues are revisited in later modules in the course, especially the health policy module.
Perhaps the most distinctive module in the course is the Integrative Exercise. As its name suggests, it is a practical exercise aimed at integrating into a policy decision the perspectives from various disciplines introduced earlier. Each group of students has its own policy challenge, most often in the context of a managed care plan. For example, what policies ought a managed care plan adopt with respect to fast cardiac computed tomography scans? Or genetic tests for APOE (linked to Alzheimer’s disease)? Or for the BRCA1 mutations linked to breast cancer? Topics for the exercise change regularly to reflect real-world policy issues that physicians will need to address in their professional role.
Students must identify the relevant medical and policy literature for crafting a policy that they can jointly endorse, and that adequately addresses the ethical, economic, and epidemiological issues relevant to that policy. They then do a formal group presentation before their peers, course faculty, and outside policy experts, who will judge their work and direct critical questions to them. Though this exercise requires a considerable amount of work by the students, they rate it highly.
There are several ongoing challenges for the SCCD course. One of these is to keep the course as a whole thoroughly integrated, as opposed to being merely four modules strung together. Ideally, we would like to see ethics issues raised in the epidemiology module (just to be identified, not discussed at length). And we would like policy implications identified in the ethics module, even if they cannot be discussed at length. For example, if we think physician-assisted suicide is sometimes morally permissible, should we tolerate this as a matter of private conscience and leave in place policies that make the practice illegal? A second challenge for SCCD is both the magnitude and pace of change in the health care system as a whole, especially over the past ten years. The practical aspect of this challenge is keeping our readings in the policy module current. The pedagogical aspect is motivating students to learn about features of our health care system that might well change before they enter practice.
The SCCD course is also linked to another curricular experience that the Center faculty took a leadership role in developing, the Longitudinal Patient-Centered Experience. The overall goal of this experience is to allow students to see the health care world from the perspective of patients with a range of chronic illnesses. Over a period of 16 months, pairs of medical students will make a total of ten home visits with a patient and family living with a chronic illness. Each visit has a distinct purpose. Each visit is linked with another part of the curriculum, such as the SCCD course, which is where students will debrief the visit in small groups.
There are two visits specifically linked to SCCD. One visit is to discuss advanced directives with these patients, not in order to have patients execute a directive, but rather to find out whether they have thought about these matters, and, if so, how they have thought about them. The other visit discusses health care access and economic issues, the concrete complexities and frustrations associated with health care policy in the United States, whether Medicare or Medicaid or the details of a particular managed care plan. This visit makes very personal and concrete the consequences of what are otherwise abstract policy choices. For this visit students are also asked to do a two-page reflection paper in which they consider what they would do to reform a particular policy in the light of the difficulties their patient may have had to face.
The Longitudinal Patient-Centered Experience course is generally well received by the students. It is viewed by the faculty as a valuable part of the professional development of these students. In addition, our patients’ families are generally enthusiastic about playing this role in developing certain understandings and sensitivities in these future physicians. Faculty can meet with these patient/families over an “appreciation” lunch or picnic that we use to bring everyone together.
The Ethics Module
A six-week, 12-hour ethics module (mentioned in the previous section) has been taught as one component of the SCCD course since around 1990 (although there has been a required ethics course in the curriculum since the early 1980s). Currently, the entire 12 hours are devoted to small-group discussions with one faculty preceptor per group. Topics include treatment withdrawal from competent and from incompetent patients, newborn treatment decisions, abortion and reproductive decisions, control of information, and research ethics and other potential conflicts of interest. Evaluation is by group participation and by two required essays. The module syllabus can be viewed at http://www.msu.edu/course/hm/546/index.htm.
Two important changes are being implemented for the fall of 2003. The module is being expanded to eight weeks, and some large-group sessions are being planned to supplement the small-group discussion. The topics that will be added are genetics and medical errors.
Based both on student evaluations and some comparative research with other medical schools in the state, the ethics module has been seen as successful. Students value the small-group discussion format and the focus on clinical cases. They perennially complain about the amount of reading required, but complaints have decreased since we began to provide summaries of some less essential articles. The text used is well suited for clinical applications by student clerks and residents, and our students seem to keep and use the text in the third and fourth years of the curriculum.
A number of challenges remain. Perhaps of greatest concern is the historical fact that the ethics module and the evolving curriculum in professional behavior originated at different times and were lead by slightly different groups of faculty. As a result, there is far less than optimal integration and overlap between these two curricular offerings. The problem appears to exist at two levels. First, the faculty are not as yet unanimous about the conceptual linkages and the important differences between “ethics” and “professionalism.” At least some exchanges between staff and students around “professionalism” seem to take the form of telling students rules they must follow, which seems inimical to a curriculum in ethics, where one is required to provide good reasons for acting in a given way. Second, even where the faculty are agreed as to how ethics and professionalism relate conceptually--for instance, seeing professionalism as derived from a core set of virtues--students seem to perceive little connection between these disparate portions of the curriculum, and the curricular materials developed so far fail to reinforce the underlying connections. Some faculty have proposed a portfolio approach as one way to both enhance the evaluation of professional behavior and also make more clear how the ethics and professionalism curricula relate to each other.
Another challenge has been the optimal use of Web technology in the ethics module. Several years ago, faculty put as much content for the course as possible on a course Web site (listed above), assuming naively that the students would be hungry for any computer-based materials and would readily adapt to this format. However, the students already have to use two other sets of course materials--the textbook and a package of articles--as required reading. Going back and forth between these two sources is sufficiently daunting to discourage students from attempting the three-way integration of the text, the reading package, and the Web site. The students have therefore requested that as much of the course syllabus (e.g., reading list, discussion questions, article summaries) be printed out as hard copy and included in the reading pack. This prevents the great majority of students from using the special opportunities provided by the Web site, notably links to online bioethics resources. Another aspect of Web technology that so far remains unutilized is the opportunity to set up ethics discussion groups that will follow the students into their clerkship experiences in MSU-CHM’s network of community campuses.
The Humanities in Medicine Course
As the Center’s name suggests, we are committed to the usefulness of other humanities and social science disciplines for understanding the practice of medicine. For the past decade or so, second-year students have been required to complete an eight-hour course (four-week block) called Humanities and Medicine. They select one of three modules: Spirituality and Health, Literature and Medicine, or History of Medicine. Each consists of readings, group discussion led by a faculty preceptor, and two required essays, so that the format resembles the ethics module of SCCD that these students have had earlier in the year.
The Humanities and Medicine course is taught in late spring semester, just before students shift gears to begin studying for the National Board of Medical Examiners Part 1 examination. Initially it was feared that students would be too distracted by the need to review large amounts of basic science material to engage in the more reflective approach envisioned by the course. Although some students continue to express a preference for relocating this course earlier in the year, many state that they appreciate the opportunity to reflect on the social and cultural meanings of medical practice and their own values as developing physicians, just before immersing themselves in Board review and then proceeding into their clerkships. In general the course has received very positive student evaluations, with a number of students each year calling for it to be expanded.
Although each module within the Humanities in Medicine course arguably deserves to be required rather than selective, a special case can be made for the Spirituality and Health module. The curriculum has been designed around a model of spirituality that includes both religious and nonreligious approaches to fundamental life values; no student has yet appeared to feel excluded from discussions. The opportunity the module provides to reflect upon each student’s developing personal and professional values, and how these relate to the needs of their future patients, seems to provide a unique and usually highly valued experience for those students enrolled in the module. What is not known, however, is whether the fact that the module may be voluntarily selected has skewed the student population enrolled, so that the experience might be quite different if all students were required to participate. Evidence of required courses in spirituality and medicine in other medical schools, however, suggests that this would not necessarily diminish the effectiveness of the module.1-3
It can be argued with equal force, first, that students today graduate from medical school with an abysmal ignorance of the history of their profession; and second, that reading short stories and poems provides a uniquely powerful way for students to enter into the life world of patients who come from very different cultural backgrounds. There seems, however, to be little felt need among the leadership of the College to expand the Humanities and Medicine course beyond the (arguably token) eight hours that it now occupies. Although such a stance may seem odd for a medical school that explicitly proclaims human values and humanism as part of its central mission, MSU-CHM is not immune to the struggles for curriculum hours, and the need for concerted effort to prevent every available hour of student time from being scheduled with classes. One possible sign that the Humanities in Medicine curriculum has not yet reached its full potential is the absence of any student groups or clubs devoted to ethics or humanities, with the exception of explicitly denominational religious groups.
Fostering Professional Virtues
The Mentor Program at MSU-CHM is an introduction to the professional role of being a physician, as well as an opportunity for reflection, dialogue, and praxis about the students’ experience of their first two years of medical school, provided in the setting of a small group of students and an experienced faculty physician.
In this three-credit course, students meet approximately monthly for two hours in groups of six or seven students and one mentor during the first two (preclinical) years of medical school. Students individually or in small groups go into clinical settings to make observations. Each student is expected to be in a clinical setting to make observations at least once each semester.
Six themes of professional behavior have been identified for emphasis: Competence, Respect for Others, Compassion, Social Responsibility, Professional Responsibility, and Honesty. These core themes form the outline for student’s reflections on their professional development, and are addressed throughout the Mentor Program and into the clinical years, as discussed below. The group meetings provide opportunities for mentors and students to reflect on how they are living into these virtues, how they feel their experience of medical education reflects them, and how these experiences are preparing students to enter their professional role. The ethical boundaries of that new professional role are also part of this examination and reflection. Mentor Program students are guided into reflection on appropriate professional behavior in the medical profession. This is done by their mentor’s role-modeling as well as active facilitation of discussion about various dimensions of professional behavior. Mentor and students struggle together thoughtfully to address both professional and unprofessional behavior.
The Mentor Program is by design more flexible than typical medical school courses, even as it is less flexible than a typical mentor/protégé relationship. This tension between structure and freedom is both intentional and one of the greatest challenges for the program. By basing much of what takes place within the Mentor Program on clinical observations and current issues in medicine, the faculty mentor has the opportunity to respond to the professional developmental needs of individual students and the group. This makes the success of a small group in achieving the goals of the course particularly sensitive to the interest, energy, and skills of the faculty mentor.
The Clinical Years
One key feature of the curriculum at MSU-CHM is that our third- and fourth-year students perform their clerkships in community hospitals around the state. For many years ethics has been taught in these sites by volunteers from the community: sometimes faculty officially connected with MSU-CHM, sometimes not (usually physicians, but not always). There are six or seven two-hour sessions spread through the third year, part of a regular Wednesday afternoon “core competency” series that is attended by all students in a given community. (Except for the Wednesday afternoon sessions the students are often separated into smaller groups, doing different clerkships at different times.)
The ethics sessions have been kept relatively unstructured. Faculty are provided with copies of two or three articles on issues that arise from the medical student role,4-6 but are asked to focus their sessions around cases brought by the students. In some sites, faculty ask students to bring a brief written discussion of a case.
A few years ago we provided some optional material, primarily cases with questions, tied to some of the other “core competency” sessions: pain management, minority issues, and occupational health. Neither the ethics faculty nor the other “core competency” teachers made much use of the materials, and so we withdrew them. The last of these ethics sessions is always a meeting with members of a local hospital ethics committee. Students present two or three cases selected from their discussions during the year for discussion.
Circumstances in the various communities differ significantly. Marquette, for instance, is a small and isolated community 400 miles from East Lansing. Only six students each year do their clerkships there. Grand Rapids, however, is only 60 miles from Lansing and has roughly 25 students in each cohort. Some ethics faculty involve others in their sessions, perhaps chaplains, nurses, or social workers. In some sites ethics faculty work in pairs. Some prefer to have the sessions roughly monthly, whereas others want them weekly for an intensive two-month stretch.
Coordination and communication across such a diverse network is challenging. The sessions as described above have been relatively successful; the success, unfortunately, seems tied very closely to the personality of the particular faculty member involved. We have no control over who teaches most of the sessions because faculty are chosen by the assistant dean for each campus. In addition, it has been difficult to find ways to support those faculty who volunteer so generously. (No one has ever protested about the lack of pay, but some feel unappreciated, especially by central campus. This is an endemic problem at our far-flung clinical sites.)
A second problem is the scheduling of the ethics sessions within the year-long “core competency” sessions. These are of varying quality and interest, and often not valued by students or by their clinical preceptors, who resist having the students leave patient care. The “core competencies” were set up to accommodate curricular material that belonged in no particular clerkship (e.g., fluids and electrolytes, caring for the dying, cost containment strategies)
At the moment, however, fresh energy is arriving from the need to integrate the “professionalism” curriculum with the ethics curriculum. A professionalism program was initiated for third-year students that accidentally came close to duplicating what was already being done in the ethics core competency sessions. (This resulted from the endemic problems in communication mentioned above.) During the present academic year we are meeting with everyone involved in either kind of session in our community campuses, and at the end of the year we will have a retreat/planning session here in East Lansing, sharing the variety of ideas and plans people have tried. Afterward we will draw up a template for the newly named “ethics and professionalism” series, allowing a great deal of latitude from community to community, but articulating more fully the aims of the new series. Roughly speaking, these aims are both therapeutic (helping students deal with the “reality shock” of the third year) and educational (providing them with the tools they need in dealing with practical, real-life clinical ethics issues). The emphasis on student-generated material will remain, as will the final session with representatives of an ethics committee. What will be new will be explicit attention to the virtues around which MSU-CHM’s professionalism initiative has centered. Any list of virtues raises the danger of platitudes and preaching. We will be looking instead for thoughtful ways to help students respond to the pressures of clinical life and shape their professional identities.
Challenge and Excitement
At Michigan State as elsewhere, a medical humanities curriculum cannot stand still and continue to be successful. Keeping ourselves alert to problems and developing effective ways of responding to them is both an endless challenge and continuing source of excitement in our work.