A Student’s Dilemma

Introduction:

Today’s class raises three related issues. First, we take another angle on the problem of responding to what you might consider improper instructions from a supervisor. Second, this is an occasion to investigate what has been called the “informal curriculum” of medical school. Much of your explicit training about professionalism presents and idealized version of what one should do. This perspective is sometimes expressed by the more jaded of Stony Brook students as the finding “the MCS answer” to moral problems. As the Hicks reading indicates, there is growing evidence that alongside of (or “under”) the overt curriculum taught in the texts, classroom and clinic, you are exposed to a covert curriculum “the real answer” – taught by example by your role models. Becoming aware of the difference and it’s impact on your habits and attitudes is important.

The difficulty that is the focus of today’s class is not one of moral ambiguity – frankly the misbehavior of the physician preceptor is reasonably straightforward, though don’t take this for granted. The harder problem is the one you face as the medical student. What do you do when you are asked by a superior to do something you consider wrong? The Caldicott article, published last month in Academic Medicine, discusses the attitudes of students at Upstate.

Finally there is ample literature regarding “conflicts of interest” faced by physicians (and medical students). The phrase is somewhat misleading because the conflict is sometimes about interests – economic, health, prestige, etc. – but also about duties – obligations to patients, to colleagues, to family, et al. Needless to say we all face these sorts of competing moral demands but they become especially acute when you assume the role of a professional, and even more critical when your profession is caregiving.

Objectives:

By the end of the class you should be able to do the following:

• Describe your strategy for responding to supervisors when they give you directions to do something you consider inappropriate.
• Give examples of the “informal curriculum” at medical school and the lessons you have learned therefrom.
• List the people whose interests a physician qua physician should consider in making clinical decisions.
• Suggest and justify a priority list, e.g. to whom is your primary obligation? the patient in front of at the time, to your patients generally, to your family, to yourself, to colleagues, et al. Whose interests should count in your decisions for how much?
• Explain the moral significance of the notions of universalizability and publicity for this case.
• Universalizability: You should be willing for everyone to do it. (for it to be a practice followed by everyone or done universally. What if everybody did that?
• Publicity: You should be willing to announce your action publicly. Would you be willing for everyone to know you are doing this?

Preparation:

• Read the articles in the study guide.
• Read the case of Dr. Hitchcock.
• Briefly answer the questions posed at the conclusion of the case. Though you need not write out your answers you will be expected to discuss your response in class.
• Written Assignment Suggestions: 
• The case for the week and the questions posed at its conclusion are apt for a position paper or analysis. 
• You might imagine this case coming to publicity and how you might respond in a letter to the editor. 
• Or perhaps an letter written to a dean concerning some specific facet of the “informal curriculum.”
• There are numerous articles in the resources for the week and you are welcome to research some of your own if you wish.

Process:

• We begin in section today.
• Discuss your analysis of the case and the questions posed at its conclusion.
• End discussion at 2:20 and proceed to lecture where Dr. Williams will present a concluding analysis of the case.

Study Questions:

• Describe your strategy for responding to supervisors when they give you directions to do what you consider inappropriate.
• Give examples of the “informal curriculum” at medical school and the lessons you have learned therefrom.