Philosophy, Psychiatry, & Psychology

Just over a decade ago, I began teaching medical students in the required preclinical course ethics and professionalism. The point of the course was to introduce basic ethical and professional norms through a small number of large group sessions, but mostly small group tutorials of 10 or 12 students engaging in weekly sessions combining readings from the literature and case scenarios highlighting real-life ethical tensions they either had, or would most likely, encounter in the future. The students wrote perceptively and thoughtfully each week, and class was topical and lively. Some students went on to complete longer essays for a school-wide ethics competition and even to win. By all accounts a resounding success.

Fast forward. Several years later, I began teaching in the third-year medical school longitudinal hospital-based clinical course as a section co-leader and then, subsequently, as a guest for ethics sessions in a number of the groups. Questions would arise and I would remind students of the readings and cases from the preclinical years. In response, blank stares. Even with prompting. Two-year recall: zero. What had happened to the engaged, thoughtful, interactive students when it came to medical ethics and professionalism? Surely they had not forgotten their physiology and pathology. How had the ethics disappeared?

As I reflected on these teaching and learning observations, I observed the students in their interactions and spontaneous discussions before and after sessions. I also observed their preoccupations during the meeting time itself. The students, in meeting the demands of their clinical years, had begun a process of professionalization. They were focused on the time-sensitive pressures of an ever-increasing pace of inpatient medicine. They had quickly and effectively assimilated the priorities, language, organizational, and clinical norms of each clinical rotation. They had begun to self-sort into self- and other-identification according to future role, training, and specialization. There was a fundamental tension. How could these students learn all they needed to learn from their clinical experience, take care of patients, learn systems, make critical decisions about their futures, and then think, explicitly, about the ethics of all that all at once? I came to realize that, as the students began the process of professionalization, however, they had not abandoned either ethics or professionalism. They did not keep particular [End Page 195] readings and named concepts at the forefronts of their brains or the tips of their tongues. But they had not abandoned ethics and the professional identity either.

Quite to the contrary, the students in their clinical years, by necessity, focused on the general demands of their education—call schedules, team responsibilities, exams, and the vicissitudes of supervising physicians. Yet they also brought forward topics squarely within the realm of ethics—without title or fanfare. Power dynamics between supervisors at different levels and students and finding voice without negative evaluative (grading) consequences; behaviorally challenging patients and how to conceptualize individual agency and responsibility both for patient actions and patient health; how to handle errors; privacy and confidentiality when the interests of others were at stake; and how to balance between medical interests and personal autonomy of patients to name a few. One could argue that rather than a momentous failure, the preclinical ethics and professionalism education had created a framework for student recognition of ethical challenges, even if they did not retain the particular knowledge about the nomenclature and reading material of those themes. The task on that view, then, would be to support medical students and physicians across all levels of training and practice to develop broad skills for identification of, reflection on, and careful engagement in the ethical complexities of medicine as an integrated part of learning and doing. In other words, we must work to ensure that ethics remains a front and center unifying core of medicine and medical practice. Medical education may begin to make ethics relevant. But individuals, organizations, and the profession itself must keep ethics relevant to maintain the integrity of our practice and our profession.

The deep strength of the Potter submission is its demonstrated success of the possibility...