The American Journal of Surgery has an interesting read - a qualitative look at medical student 'moral distress.' (Moral distress defined here as 'the negative feelings that arise when an individual believes he or she knows the morally correct response to a situation, but cannot act because of hierarchical or institutional constraints.) It looks at case summaries written by 3rd year medical students and analyzes them for themes surrounding descriptions of moral distress. Issues surrounding death, dying, hope, communication are a distinct part of the discussion. Some of the wisdom of these students is impressive. One wrote, 'But my observation was that more desperately than their need for answers was their need for kindness. And while we may not have had the ability to provide the answer, we certainly had the ability to provide the kindness.'
Thanks to Dr. David Weissman for alerting me to this.
2)
Age and Ageing has a systematic review on the natural history and prognosis of persistent delirium in older hospitalized patients. It adds to the literature on persistent delirium (see related post here) as a major marker of morbidity and early death in older patients. The data here are hampered of course by differences in definitions of delirium, follow-up, etc., and I wouldn't put a huge amount of stock in the actual numbers presented, but the finding that persistent delirium is a poor long-term prognostic sign seems irrefutable. Most interesting to me were the handful of studies which followed patients for multiple months suggesting that many older patients (mean age in these studies was in the early 80s) who are delirious during a hospital stay remain permanently cognitively altered afterwards (the way they define delirium here I hesitate to say they remain 'delirious' as opposed to permanently cognitively impaired, as well as there's a decent amount of variation in the studies between patients who presented delirious vs. those who develop it while hospitalized, as well as the data aren't broken down by who had dementia at baseline). Anyway - a few of the studies which followed patients for 6 months found a substantial minority (~10-30%) remain altered at 6 months. Yikes.
Thanks to Dr. Bob Arnold for alerting me to this.
3)
Pain Treatment Topics (a free, online collection of original publications - often very practical/clinically-oriented papers - along with other resources to do with all things pain), recently published a hard-look at what is known and not-known about the prevalence of opioid-abuse in patients receiving prescribed opioids for chronic pain (free pdf here - page 6), concluding more or less that what research is out there does not support the idea that prescribed opioids cause addiction or that opioid-abuse is inordinately common in these patients. Of course, and unfortunately, none of the research is definitive, but I think this is a good counter to publications such as this one in a highly influential journal: read the abstract (or the full article) which to the casual reader suggests a world of badness and then read my post about what the article actually says about abuse/addiction and chronic opioid therapy. No doubt that abuse/addiction is a problem in patients with chronic pain, but how much of a problem is not yet even well-defined, let alone the role of prescribed opioids in causing/maintaining the problem.
Image is a thumbnail from Pain Treatment Topics 'pain art' page.
4)
There's a new health policy blog out there which has been covering hospice and end of life issues quite well: Health Beat at http://www.healthbeatblog.org. Check out these recent posts about for-profit hospices and the new MedPac proposals to decrease hospice payments for a patient the longer they are enrolled.
Thanks, again, to David Weissman for letting us know about this.
3 comments:
I’ve been doing a lot of reflection lately on the hidden and informal curricula. This paper describes how this impacts upon our students in the form of moral distress and threatens to erode the values and ideals innate within our students which prompted them to choose medicine as a career. The authors have utilized this observation to prompt curricular change in the form of a longitudinal required reflective experience with a stable preceptor which spans the course of the formative third year. They utilize of student narratives in this reflective experience—a move that has provided them with a rich basis for study and quality improvement.
My reading this article was particularly timely as I had just finished facilitating a debriefing session with a group of 12 third year medical students at the end of their required geriatrics clerkship. This includes a week-long experience with the palliative care team. While I have facilitated such a debriefing on multiple occasions, this particular group struck a chord with me. Prior to reading the article, I wasn’t quite able to put my finger on it. They described feelings of guilt: guilt due to their own emotional reaction to a patient’s and/or family’s distress (“this was their [the patient’s/family’s] time to be emotional, not mine”); guilt due to a feeling of imposition as a team called in to achieve a specific goal (“Why can’t the primary medical/surgical team who’s been caring for the patient since his admission discuss prognosis with the patient? Why should we, who just met the patient, do this?); guilt of an erosion of “sincere” empathy (“I felt very sad for the patient on the first day we saw him and told him of his prognosis of 6 months or less, but then when we went to see him on the second, third, and fourth days, I found myself feeling less sorry for him and I felt bad about that. I wonder if the more you do this work, the less genuine empathy you feel for each patient.). After reading the article, I was able to frame all of this (and many of their other comments) as moral distress.
The question that remained for me after reading the article was whether they have faculty development sessions in preparation for the debriefing? I agree that just offering a setting in which students can feel safe and encouraged to share such thoughts and feelings is an important step. But it seems that our reaction as faculty to these reflections can be just as important as the role models that they witness on the wards. For the faculty, fighting the temptation to “fix” the problem or offer excuses for why things happened the way they did would seem exceedingly important. It seems that the most important thing from an educational standpoint is encouraging the habit of reflection in the clinical years—that is, helping the students become aware of their emotional reactions to the world and culture of medicine. Perhaps, by being able to reflect on the hidden and informal curriculum, we will help our students to hold fast to the values and ideals that brought them to our medical schools in the first place.
Lynn thanks for your thorough and spot-on comments. Your thoughts about faculty preparation for this type of 'teaching' is particularly interesting. My guess is that people attracted to this sort of teaching are 'naturally' inclined to the reflective side of things, but there are always those that aren't of course and the Need To Fix is one of the most irrepressible urges in medicine. Your students' comments and seem humblingly insightful and spot on. I'm curioius as to how you responded to them. The perennial question in palliative care (that I get from my family when and my medical students when I try to explain to them what we do): why do you need a group of specialists to do this? Isn't this what all doctors are supposed to do (this is regarding the medical decision/prognosis discussion/etc aspects of HPM practice not so much symptom management)? I haven't figured out a good, concise answer to that (I have a long laborious one) that doesn't sound self-righteous/like I'm slagging off my colleagues (by suggesting that yes in fact palliative care arose in part to fill a need that doctors overall weren't filling)....
RE: reducing payment for longer hospice stays. Because this is a family-oriented blog, I won't include my initial thoughts on this proposal. However, two printable things come to mind: (1) payment trends alone don't tell the story. So making a huge policy change, probably based on panic about the size of future CMS payouts, but obviously also based on limited and incomplete information, probably would be premature at best. There will always be economic opportunists. Perhaps for-profit hospices are among them. So lets take some serious in-depth looks at for-profits, how they differ from not-fors, and how not-fors may have changed in response to their presence in the marketplace. (2) There are already too many people who equate hospice with euthanasia. Seems to me that this proposed change would provide a not-so-subtle nudge in the wrong direction.
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