Transcript The Hidden Curriculum Faculty Development UBC Family Practice Postgraduate Program Tammy Attia Faculty Development Coordinator Prince George Site.

The Hidden Curriculum
Faculty Development
UBC Family Practice
Postgraduate Program
Tammy Attia
Faculty Development Coordinator
Prince George Site
An Incriminating Question
Case 1
• Man in early 20’s, IQ 160, Dx: TB
• Psychologist noted subtle changes in mental status.
Feared TB entered CNS, alerted clinical clerk
• Clerk phoned attending: attending hung up
• Chased resident down the hall
“What’s the point? We did a neuro consult. They gave him a
clean bill of health. So some half-assed psychologist thinks
otherwise.”
• Next pt encounter: near-catatonic state… irreversible
» Charles LeBaron, Gentle Vengeance
Case 2
• On the third day post-op fractured hip repair a 72 year old
woman is switched from morphine to acetaminophen and
codeine for pain. (routine orders)
• Later that day the family practice resident notes that the patient
seems to be in a lot of pain with little relief from the T#3.
• The senior surgical resident sees the patient and finds no
infection or other problems and tells the FP resident that the
patient is fine.
• The FP resident checks the chart but avoids the patient because
she is uncomfortable and the encounter is unpleasant.
• The patient spends 6 days in uncontrolled pain before it
gradually settles on its own.
Outline
• Red flags (warnings) that our current
medical culture has problems.
• The history of these problems in our
medical culture.
• Implications of our medical culture on
intellectual and emotional development.
• Consequences of introspection and
dehumanization
Red Flags 1
Internal to the Profession
External to the Profession
• 40% of residents reported
impaired performance > 4 wks due
to poor mental health
~ 1/3 this sample had depression
• 5% of residents who require leave
do so after suicide attempts.
• ~ 40% of residents have
relationship problems with their
significant other.
• 31% of doctors would not go
through medical school again
knowing what they know now.
•Doctors described as cold,
uncaring, impersonal & distant
•Increasing trend toward alternative
medicine: most important reason is
how the patients feel they are
treated
• Patients let initially correctable
disease get out of hand (barrier to
seeking help is fear of doctor!)
History
• Education
Behaviour training at par with
teaching knowledge
• Patient
Perceptions
Deficiency in ability
Assumption that appropriate
behaviour follows
appropriate knowledge
Deficiency in character
Admission to Medical
School
• Intellectual Fitness FIRST
– Then screen for emotional fitness and
character.
Once admitted the student must then be
ACCEPTED into the medical culture.
Demonstrating our Values
Admitted but not yet Accepted
Proving your
“Intellectual Fitness”
Case 3: Intellectual Fitness
• Learning session on heart sounds
• Student A:
– “Well, I think I heard S1 and S2... There might have been a
systolic murmur...”
• Preceptor Response:
– “I’m not interested in your opinion. You are to report your
findings. Did you hear the heart sounds or did you not?”
• Student B: confident report
• Preceptor Response:
– “You know, I don’t even care if you’re wrong. That was
perfect.”
Admitted but not yet Accepted
Proving your
“Emotional Fitness”
Case 4: Emotional Fitness
I think it is very ugly that this lab should come along so
early in my medical education… Isn’t there
something wrong with starting off by causing pain
without an intention to cure?…
Meanwhile…the students… are beginning to say…
“How are you ever going to be a doctor if you’re too
sensitive to do dog lab?…” It’s a confirmation of all
my worst suspicions - this lab is intended to toughen
me, to divide me from ordinary normal people.
» P. Klass, A Not Entirely Benign Procedure p.30-33
Case 4: Emotional Fitness
I went upstairs… took a shower. But nothing could…
get that doggy smell out… I sat down on my bed…
And thought…You came to medical school to learn
how to heal people, save them pain…But if you do
wake up somewhere years from now and much to
your amazement they want explanations for why
you tortured and killed a dog today, you better get
your story all good and rehearsed because you’ll
have a lot of explaining to do.
» C. LeBaron, Gentle Vengeance, p. 191
Case 4: Emotional Fitness
“… I’m allowed little time to squander on
such mawkish reflections. In the
twinkling of an eye, it’s midterm week,
four exams in jackhammer succession.”
» C. LeBaron, Gentle Vengeance, p. 191
“Introspection and
reflection are terminal
diseases in medical
school.”
- Frederic W. Hafferty
Case 5: The Heirarchy
• 64 y.o. man, dicharged home after a triple bipass surgery
• Presents to Emergency room short of breath
• Medical student in ER takes history and physical
– Preceptor briefly stated suspicions of CHF and intent to
consult cardiology
• Cardiology resident takes thorough history and physical
– Preceptor announces suspicion of pneumonia. Consults
Infectious Disease
• ID resident spends good deal of time; repeats history and
physical
– Preceptor suggests diagnosis is Dressler’s Syndrome,
therefore, consults cardiac surgery
• Cardiac surgery resident takes history and physical
“We seem to prefer a cold or
even disturbed physician with
full command of current
medical science to the most
sensitive and compassionate
bumbler.”
- Dr. Melvin Konner
FIFE! Wait! I haven’t FIFEd you
yet!
?!
Case 6: Role Modeling
• Difficult, complex history
• Poor eye contact, standing at foot of
bed.
• Interview interrupted
• Preceptor response:
– “I’d be far more impressed if you made a
real connection with this person, than if you
got a perfect record of all her facts.”
Charles LeBaron:
• “It seems to me I had a little vial of sweetness and
kindness around stomach level. It’d been full when I
was born; half of it had sloshed out in miscellaneous
events since then, but I was hanging on for dear life
to those remaining couple of ounces…Anyhow,
serendipity had bailed me out on more than one
occasion… Maybe serendipity would do it again and
save that sloshing bit of enthusiasm and innocence.
But when it’s all over, years from now, will I know?”
Good luck with your teaching. The
next generation of doctors are
watching you!
References
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6.
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11.
12.
13.
14.
Allan D. Peterkin, 1998. Staying Human During Residency Training, 2nd ed
Jean-Charles Sourina, The Illustrated History of Medicine, Harold Starke Publishers Limited,
London, 1992.
Thomas Neville Bonner. Becoming a Physician - Medical Education in Britain, France, Germany,
and United States, 1750 - 1945, Oxford University Press, MY, 1995.
Montaigne, Essais, Extraits, Univers des Lettres Bordas, Bordas, Paris, 1985.
Moliere. Oevres Complètes I, Garnier-Flammarion, Paris, 1964
Melvin Konner. Becoming a Doctor. Elisabeth Sifton Books, NY, 1987.
Frederic W. Hafferty. Into the Valley, Yale University Press, NY, 1991
Attia, T. Personal Experience. 1997.
Merriam-Webster Online. 2005. http://www.m-w.com/
Klass, P. A Not Entirely Benign Procedure: four years as a medical student. Penguin Books. 1987.
Charles LeBaron. Gentle Vengeance, Richard Marek Publishers, NY, 1981.
Author Unknown. March 19, 2007. Debated Studies: Animal labs for medical student.
http://studentdoctor.net/blog/2007/03/19/debated-studies-animal-labs-for-medical-students. SDN .
Hands-on Clinical Rotations in the United States for international MDs
www.americlerkships.com.
Attia, T. Personal Experience. 2004.
Attia, T. Personal Experience 1999.
Thank You
• This module was written as an aid to the Preceptors
in the Postgraduate Family Practice Program at the
University of BC.
– Study credit is available to groups of preceptors
who complete the module
– Please give us your feedback on the module so
that we may improve it for others.
• Email your comments to Dr. Christie Newton,
Faculty Development, UBC Family Practice
• [email protected]
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