Close Reading, Improved Writing, and Service Learning: A Virtuous Circle!

I'm in Vermont at the Bread Loaf School of English, a Middlebury College program in which the students, primarily high school and middle school English teachers, can get a Master's degree in the course of five summers. My wife has been teaching here every summer since 1992 and I enjoy the potential for (a) telecommuting and (b) swimming and hiking in Vermont.

In the past four years I've been doing an annual workshop on "Making Ethics part of High School and Middle School English Class." Working with the students here is a great pleasure and privilege. There's very little that's more important than educating the next generation.The teachers are doing God's work!

There were 18 participants in the workshop I did a week ago, plus three members of the Bread Loaf faculty. The participants taught in settings ranging from the Navajo Nation to public schools in urban and rural settings to elite independent schools.

We focused the workshop around a question that came from a 10^th grade teacher, whose class does a service learning module that combines class discussion, a service project chosen by the student, and a research paper. She felt that the unit was well-intentioned, but many students experienced it as a burden, and it didn’t feel integrated with the rest of the semester’s work. She asked the group – did other teachers have ideas about how to make service learning more engaging for students? 

I’ve distilled 4 points from the wonderfully rich discussion:

1. English class is often asked to be the vehicle for humanistic goals in the school curriculum. Ideally, moral development and heightened humanism would be a goal for everycomponent of the school  – inside and outside of class. But this kind of full court press rarely happens, and English teachers are asked to take the lead. Being looked to for leadership in moral development is a challenge and an opportunity! I mentioned to the group that my medical specialty – psychiatry – is in a similar situation. We’re often asked to be responsible for the “understanding the patient’s point of view” component of the medical school curriculum. ..”

2. Several participants suggested that preparatory exercises can help students become more open to and engaged with reflection about values. A participant reported that hypothetical questions like “A lifeboat has 10 people but will sink from too much weight. Everyone will drown unless someone is thrown off. What should be done?” triggers lively discussion. Another participant described how she gives the class statements dealing with issues that come up in a book they are reading. Then she has them do “speed dating” – i.e., talking for 30 seconds with another student about their reactions to the statement. Another participant described how she did a similar exercise before reading Hamlet. She poses questions like “do you believe in ghosts?” or “if someone kills your father, should you kill that person for revenge” and asked students to stand up if they agreed. These teachers reported that like warming up before physical exercise, activities of this kind can help students “warm up” into a more reflective state of mind in which they are prepared to see ethics as something important to their lives.

3. When schools require service learning, unless students are prepared well they can cause harm when they enter into the space of those they are “serving.” And the very idea of doing “service for those in need” can create a noblesse oblige attitude (“the poor can’t help themselves – they need me to do this service for them…”) or cynicism (“this is just resumé padding…”). Some argued that requiring service learning and giving academic credit for it is corrupting. But others who agreed that these risks are real nevertheless felt that some students who would never get involved on their own might be turned on and transformed by the service learning experience.

4. Independent schools and public schools in wealthy communities are increasingly sponsoring “voluntourism” – programs in which students go for a short time to a poorer country to do “service.” With rigorous preparation, a strong relationship with local community partners, and opportunity to reflect on the experience, these programs can be excellent learning opportunities for the students and even if not helpful at the “service” site, at least not harmful. A participant contrasted “asset based community development” to “voluntourism charity work”.” ABCD involves identifying the strengths in a community and helping the strengths to be extended. Another participant questioned why “voluntourism” programs travel to other countries when there are valuable opportunities to contribute in their own or nearby communities.  With regard to the stance of noblesse oblige” I mentioned a favorite quote from Thoreau: “If I knew for a certainty that a man was coming to my house with the conscious design of doing me good, I should run for my life!”

The core idea that has emerged from the workshops is an understanding of a virtuous circle involving literature, writing, and social action, which I've represented in a diagram:

Close reading strengthens empathy and humanism by entering into the worlds that literature creates, and improved writing does the same by asking students to think about the audience they are speaking to and how they can best reach that audience. Understanding our values and biases and empathizing with perspectives of others even if we disagree with them increases “ethical sensitivity.” And when students identify values important to themselves and for their communities, they are primed for ethical activism on behalf of these commitments. Activism can create a virtuous circle by stimulating further learning opportunities that strengthen engagement with literature and writing. 

I hope the high school and middle school teachers learned as much as I did from the workshop!

Meditation and Medical Ethics

Medical ethics and mindfulness have a lot in common. I reached that conclusion after a recent conversation with my long-time friend Charlie Halpern about his effort to introduce mindfulness into legal education.

Charlie has been doing this at the UC Berkeley School of Law for the past several years through classes and elective retreats. He's an enthusiast and a believer. He feels, and many legal educators and law schools agree with him, that mindfulness practice increases empathy, compassion, and the ability to really hear what clients and others involved in negotiation and litigation are saying. He described how a professor at Berkely has taken to starting his classes with three minutes of silence. The professor reports that "sacrificing" three minutes of class time leads to a richer, more thoughtful class experience.

I've taught meditation to patients in a medical setting and have recommended meditation to many of my patients over the years. And I've written in this blog about how mindfulness practice can be woven into busy practitioners' lives. (See here and here.) But until the conversation I had with Charlie, I hadn't recognized the obvious connection between mindfulness and the way I've taught medical ethics.

In the semester-long course medical ethics course that I taught at Harvard Medical School, in addition to the topics that formed the intellectual content of the course, I encouraged the students to hone their skill at (a) observing their cognitive and emotional reactions to clinical situations that raise ethical issues, (b) treating these reactions as "data," not "truths," and then (c) reflecting on the "data" presented by their experience as one piece of ethical analysis before (d) reaching a conclusion. Over time, as demonstrated by clinicians who we regard as models of ethical action, this set of actions can become reflexive, done automatically and recurrently.

What I realized is that steps (a) and (b) are close cousins to what meditation teachers encourage their students to do. The setting is different - deliberate quiet and inwardness in meditation versus to what I'm inclined to call "meditation in action" in learning to be an ethically sensitive clinician. But the outcomes the teacher hopes for in the student - empathic connection with others, compassion, and seeing the truths that underlie complexity - are the same.

Recognizing the kinship between mindfulness and medical ethics is a valuable insight for ethics educators. An increasing number of students know something about meditation and respect the practice. Recognizing that skill at meditation can enhance their grasp of medical ethics, and, that skill at medical ethics fosters some of the key skills for meditation, enhances both domains.

Atheism, Humanism and Secular Ethics at the University of Miami

Between September 10, 2007 and today, I've written 82 posts about religion and spirituality. I've been especially interested in the moral underpinnings of the health professions. I've thought of health care as a calling throughout my career. But where does the call come from?

Historically, the call has been seen as coming from god and god's servants - saints, bodhisattvas and other benevolent beings who urge us to care for others. But what about health care workers who do not derive their calling from a theology?

I hope this question will be high on the list of research topics when the newly endowed chair of "atheism, humanism and secular ethics" at the University of Miami is filled. I learned from the New York Times article about the chair that it was endowed by Louis J. Appignani, an 83 year-old retired businessman who supports non-theist causes. The University was uncomfortable defining the chair as one of "atheism" studies, but Mr. Appignani insisted that the "atheism" be part of the title, and accepted the addition of "humanism and secular ethics."

In an increasingly secular population it's crucial to deepen public understanding of morality that is not based on religious theologies. Over the centuries, religious communities have been powerful advocates for good causes (e.g., abolition of slavery) but also for evil causes (e.g., "holy" war). For atheists and secular humanists to make a full contribution to the moral arc of the future, we need a deeper understanding of how the non-theological domain functions. Let's hope that the University of Miami chair contributes to this process.

When the chair is filled, there will be a great deal to learn from studying those who are called to the vocation of health care!

The Four "As" of Ethics

Here's a mnemonic I've found useful for thinking about the actions health organizations need to take to walk the talk of their values:

1. Analysis ("what is the right thing to do?") This is the activity most familiar to ethics committees and classes in ethics. When is it right to pull the plug? At what age should children make their own health care decisions? When the term "ethicist" is used it's generally associated with the analytic activity.
2. Advocacy ("let's do the right thing!") This is the charismatic leadership function. When  leaders are seen as admirable exemplars of the organization's values, bureaucratic position and natural authority coincide. This is a uniquely powerful configuration. But every group has members who others respect and want to emulate. Wise leaders look to these widely admired member of the group as strong influences on the organization's ethical culture.
3. Administration ("we need to create structures that make it easier to do the right thing.") Ethical behavior is strongly influenced by internal ego ideals, but it's also shaped by external factors like prompts in an electronic record that help us conduct and record advance care planning and nudge us when it hasn't been done.
4. Accountability ("how well are we living our ideals? how can we improve?") Many years ago, a primary care colleague had his assistant ask every patient after their appointment - "did Dr. X do what you needed him to do today?" If the answer was "no," the assistant was trained to intervene, either directly or by calling in to the office. Now we have well developed systems like Press Ganey to assist with accountability at the population level, but the basic function is the one Dr. X implemented on his own.

Ethically admirable health organizations need to cultivate all four of the "As". 

Two teaching cases about unneeded MRIs

Readers who teach may find these two cases useful. But I think they'll be interesting for most thoughtful adults. 

CASE I.  Many years ago I wrote a hypothetical case for a session on rationing for medical students.

Tension Headache

You are a primary care physician at a not-for-profit health maintenance organization (HMO) that serves 500,000 members, paid for by capitation, a monthly premium paid to the HMO by the members’ employer, Medicaid, or Medicare. The premium revenues create a budget to care for the entire HMO population. 

Susan Jackson, a 28 year old office worker, consults you about headaches. For the past month she has had frequent headaches at the end of the work day. The headaches are much less frequent on the weekends. She describes the headaches as a dull, mild to moderate pain, that feels like tightness or a band around her head. She is otherwise healthy. Her neurological examination is normal. She identifies clear stressors at work.

You explain that this is a classical pattern for tension-type headaches and give practical advice on what to do. You predict that the headaches will improve as Susan learns to master the stressors and to build more relaxation into her day. Susan thanks you, but says that a friend who had headaches received an MRI, which showed a tumor that required surgery. With some urgency she says “unless you can guarantee that there is no possibility whatsoever that I have a tumor, I want an MRI. What harm can an MRI do?”

You know that the likelihood of a tumor is vanishingly low, and that established standards of care do not recommend imaging studies in a situation like Susan’s. There is no medical contraindication to getting an MRI, but you know that it would cost between $1500 - $2000, which would come out of the budget for the HMO population. You reflect on what to do, and how to explain your thinking about the MRI to Susan.

CASE II. Today I read the following case on the excellent "Costs of Care" blog:

Doc, I need an MRI

By Patricia Czapp, MD

“Doc, I need an MRI for my back.”

I recognized the voice immediately and turned to greet one of my favorite patients, Mr. P. There he was, smiling, leaning on his walker.

Mr. P visits me several times a day in my primary care office that is essentially in his living room.  The practice itself, sized fewer than 1,000 square feet, is on the first floor of a high-rise apartment building that houses disabled and low-income adults.

My team and I provide primary care to the residents of the building  (a public housing unit) and the surrounding community, a diverse population that has in common these characteristics:  social isolation, low health literacy and low general literacy, a high prevalence of behavioral health problems, and limited transportation.

We came to practice in the building because our health system, Anne Arundel Medical Center, several years ago noted a high number of ED visits from individuals of one address. We visited the address to meet the residents of the building and their landlord, the local housing authority.

We found a population of individuals who were aged beyond their years, suffering from preventable complications of chronic disease and for whom a visit to the hospital met medical as well as nonmedical needs…individuals like Mr. P.

Mr. P is a man living a marginalized existence. He thrives when people take the time to listen to him, touch him, and show him that they care. For many decades , he found this comfort in the ED. When his landlord agreed to try an experiment with us, we came to practice in his building.  Mr. P was one of our earliest patients.

We provide a low-cost alternative to meet his needs and do so with kindness, tolerance and generosity.

“What happened to your back, Mr. P?” I asked.  “Did you fall or hurt yourself”?
“No Doctor, I Just woke up, got out of bed and it hurt real bad for a while.  I could hardly stand up. ”

Rather than lecture him about the lack of medical necessity for an MRI, I accompany him to his modest apartment where we review the condition of his bed and mattress and suggest alternative ways to use pillows to support his back.   Mr. P beams, “Thank you so much.”  And then shuffles toward the Community Room.

If we had not been there to intercept Mr. P, he would have dialed 911. It shocks many to learn that individuals use the ED for nonmedical needs. But for some, this is the only way they feel human.

Our practice has been open for two years. In that time, we have experienced a significant decrease in medical 911 calls, ED visits, admissions and readmissions of residents of the apartment building. They have an alternative now to the ED, and we meet their social needs in their living room – one visit at a time, sometimes multiple times a day…
“Doc, I need a CT scan for my head.”
___________________________________________________________________
Patricia Czapp, MD was contestant of  “The Best Care, The lowest cost: one idea at a time” – a collaboration between Costs of Care, Healthcare Financial Management Association, Strata Decision Technologies, and Yale-New Haven Health.

"Tension headache" works well with medical students and residents. It ends with a resource allocation dilemma. Ms. Jackson wants a guarantee of absolute certainty, which is virtually never possible. The MRI is not required for good clinical care, but if  it cost $15-$20, not $1,500-$2,000, should it be covered because of her understandable anxiety? And, however one thinks through the dilemma, what should the primary care physician actually say to Ms. Jackson?

The second case is a beautiful example of ministering to one's patient - clinical practice as a calling. It's invites learning about "hotspotting" - meeting the real needs of people who are "overutilizing" expensive medical care. Mr. P was suffering, but ED visits were not the best pathway to relief. Dr. Czapp's remarkable practice has the potential to reduce costs even as it provides vastly better care for the population she serves.

Political candidates continue to bash their opponents by accusing them of health care rationing. Cases like these allow us to understand how cost reduction and frank rationing can be conducted in an ethically admirable, clinically sound manner.

Talking about Suicide

Earlier this week my friend Steve Moffic wrote a powerful post about his experience as a psychiatrist dealing with suicide. He presents a moving discussion of how difficult it was to think and talk about the suicide of a patient he treated in residency. Here's the concluding paragraph of Steve's post:

Legal fears, confidentiality concerns, shame, and stigma are formidable obstacles. But talk we must, for talking—and listening—is a key to prevention and treatment. Any clinician knows that most who survive serious suicide attempts end up being glad they did, if they receive the help they need. They wanted to relieve the terrible psychological pain, not to die. Although the suicide will relieve the pain (as in the song from Mash, “Suicide is Painless”), it can cause intense pain in loved ones. Those left behind need the same forgiveness, relief of guilt, and community support that I received from my supervisors and fellow residents. Like a rock thrown into the river, the ripples of suicide can be mighty and wide. 

In my experience, learning to talk with patients about their suicidal ruminations posed more of an emotional than intellectual challenge. When I first encountered seriously suicidal patients I was tempted to try to "talk them out of it." There were three main ways I considered doing this: persuading them that their problems were solvable; emphasizing the reasons they had for wanting to be alive; and, imagining the impact of suicide on family and friends.

Luckily, wise supervisors pointed me in another direction. The task, they told me, was to find out what made suicide seem like such an appealing alternative. Over the years I learned to probe what I called the "logic" of suicide. What made suicide seem like the right thing to do? What was the source of its magnetism?

I found this approach easy to describe but hard to do. My own temperament is somewhat rigidly optimistic. Some aspects of my growing up were difficult, and in retrospect I believe I learned to see life's glass as half full rather than half empty as a way of warding off depression. My father's brother killed himself when I was 13. I didn't know him well, but I believe that even as a youngster I sensed the pain he experienced. When my two sons were teenagers they teased me about my determined attention to the bright side of life with the term "poptimism."

When I first read The Myth of Sisyphus in high school, I was transfixed by Albert Camus' opening sentence: "There is only one really serious philosophical question, and that is suicide." I thought - "this man gets it" - and underlined page after page. But it took me years of clinical practice to truly "get it." When is a patient's wish to turn off the ventilator a "competent refusal of treatment" and when does it represent a "irrational" suicidal impulse that should be impeded? These are great questions for an ethics seminar, but when I was called upon to make real decisions in real time I learned at a vastly different level.

Thanks to Steve Moffic for so vigorously bringing the importance of talking about suicide into open discussion!

From Faith to Atheism

What would you think was being talked about if you read the following:

"I got to come out...It used to terrify me, what people's reactions would be. But it's been so long now...I don't even care...I slept like a baby last night because I knew I wasn't going to have to live a lie any more..."

This isn't a young gay or lesbian person coming out to the family - it's Teresa MacBain, a Methodist pastor, telling NPR about "confessing " to her congregation that she has lost her faith and is now an atheist.

I interpreted the NPR interview and an article in today's New York Times in light of my Rosh Hashanah post about religion and medicine. Teresa MacBain stopped believing in God, but terribly missed the community solidarity, shared values, and supportive rituals that being part of a congregation provided. While she no longer believed in the divinity of Jesus, she had not lost faith in what she calls “the philosophy of Christ.” She averred that leaving religion did not mean she had left morality - she still adheres to the Ten Commandments, the Golden Rule and other moral teachings common to many world religions.(See this article in Religion News to learn more about how she gave up her theology but retained her moral perspective.)

Here's how MacBain described the loss of her religious community:

“For me, religion was everything, my entire world. All my friendships, connections, family,  all the places I went to deal with difficulties, to do good works, to find resources to raise kids — everything was contained within that environment. I miss that social connectivity, that network.”

Not surprisingly, like a divorced person who rapidly enters a new relationship, MacBain affiliated herself with new communities - such as the American Humanist Association and American Atheists. At a meeting she met Greg Epstein, the humanist chaplain at Harvard, who hired her to be a kind of apostle to help humanists/atheists around the country build a non-theistic form of congregational life. MacBain has left the church, but she's again in a role that is structurally much like the theistic pastoral role she occupied before the lost her faith.

Before I ended my beloved clinical practice five years ago I felt great anxiety. Even though the practice was only a portion of my work life, I felt that it was totally central to my identity. I described my fear in images like a becalmed sailboat or a car that was out of gas. In retrospect I see that it wasn't just ending my psychiatric practice that was triggering the anxiety - it was also fear of no longer being part of my equivalent of a religious congregation - the "congregation of medicine."

I chair the Harvard Pilgrim Health Care Ethics Advisory Group. Typically we have 25 - 35 participants. The group sits in a U and I sit and stand in the open segment of the U. From time to time when I'm calling the group together to start the meeting I have spontaneously and whimsically said "Dearly beloved..." I do have a feeling akin to love for the group and the process we follow. Sliding into language associated with religious practice reflects my underlying feeling that a group deliberating on the values that inform health care is first cousin to a religious congregation.

Insofar as shared religious beliefs provide the glue that unites a congregation in mutual support and a commitment to social justice I feel a kinship with it. But insofar as it claims a unique truth for its theology and condemns those who do not share its beliefs I see it as undermining the health of society.

[If you want to get a sense of Teresa MacBain's pastoral skills, put her name into YouTube and sample some of the videos of talks she's given since leaving the church.]

Religious Ethics and Medical Ethics

The Jewish New Year - Rosh Hashanah – starts this evening, and the New York Times featured a front page article on “Bar Mitzvahs Get a New Look to Build Faith.” The article touched a very personal nerve for me.

Both my parents and all of my grandparents were Jewish, but the family I grew up in was very non-observant. We didn’t belong to a synagogue and didn’t celebrate the Jewish holidays, other than a very perfunctory Seder at my father’s ailing mother’s home in Brooklyn. But at 11 or 12 I asked my parents to send me to Sunday School, an almost unheard of request for a child to make. As best I can recall, I wondered how the universe was created and what my purpose in life should be, and had the idea that religion might help me answer these questions.

They enrolled me in Temple Emanu-El, a large reform congregation that was founded in 1845. I quickly concluded that I’d made a mistake. In class we memorized prayers in a language I didn’t understand, studied holiday rituals, and learned about the history of the Jewish migration to the US. We didn’t touch the big questions I was interested in. When I said I wanted to quit my father asked me to stick it out for the sake of his mother, who was happy at the idea of my having some Jewish education, even if it ended in a confirmation ceremony and not a bar mitzvah.

It’s clear to me in retrospect that I was searching for a community that shared fundamental values and collaborated in actions based on those values. I didn’t find what I was looking for at Temple Emanu-el, but during the summer when I turned 16 (and in the two summers after that) I worked as a counselor at Felicia Madison, a camp that served poor children from New York City. When I got to college I was able to create a combined major in philosophy and psychology – a program that let me explore the kinds of questions I had in mind in asking to go to Sunday School. And I worked as a volunteer at a public mental hospital, which led to a career in psychiatry and medical ethics.

I believe that an anthropologist studying my affiliations would see the involvements with psychiatry and medical ethics as structurally similar to an involvement with religion. I consort with colleagues who share an outlook on the world, values, and a commitment to forms of action. There’s no theology, but it is a community of belief.

The New York Times article describes an initiative by 80 congregations to place more emphasis on values, community engagement, and social action, than on theology and ritual. The problem the congregations are trying to solve is family departure from the congregation as soon as the bar or bat mitzvah has been accomplished.

If I’m forced to define myself in terms of religion I identify myself as “a religiously-minded Jewish atheist.” In my clinical practice I found religious language natural to use – “that’s something to pray for,” “if it happens it will be a blessing,” “XYZ is your calling,” and more. When a patient with chronic schizophrenia asked me to remember him in my prayers I said I would, even though I don’t do anything a religiously observant person would call “prayer.” I felt that his request was for me to care deeply about him and his quest for well-being, and since I did, I felt it was truthful to say I would remember him in my prayers.

At the end of his life my father turned against all religions because he saw them as sources of hatred, slaughter and war. He was thinking of fundamentalist religion. In my view all “liberal religions” are comparably true and good, and all “fundamentalist religions” are comparably false and bad. As I examine the course of my adult life, it’s clear that the calling of medicine has been my version of liberal religion.

Should You Kill Your Disabled Child?

I've just read a remarkable book about this question: Rescuing Jeffrey, by his father, Richard Galli. I got to the book via "Calling It Quits: When Patients or Proxies Request to Withdraw or Withhold Life-Sustaining Treatment After Spinal Cord Injury," an article assigned to Harvard Medical School students for this week's class on end of life care in the required course on "Medical Ethics and Professionalism."

On July 4, 1998, Jeffrey Galli, 17 at the time, dove into the shallow end of a swimming pool and fractured his neck, injuring his spinal cord in a way that left him quadriplegic and unable to breathe without ventilator support. Richard saved his life by pulling him out of the pool and breathing through his nose. But when Jeffrey got to the Hasbro Children's Hospital in Providence, Rhode Island, and the extent of his injury became clear, Richard and his wife Toby considered whether the right thing to do would be to withdraw treatment and let Jeffrey die.

Galli renders the anguished flow of his thoughts and feelings in admirably spare prose. Not surprisingly for a 17 year old, Jeffrey had given no guidance about he would want to have done in a situation like the calamity he experienced. In his initial state of unconsciousness, and the next few days of impaired awareness, his parents had to make decisions for him. Galli initially felt that Jeffrey - a very physical boy who was not drawn to reading or other forms of "living in his mind" - would not be able to tolerate the helplessness and immobility of quadriplegia. But he recognized that he wasn't a reliable decision-maker. Perhaps he was the one who couldn't tolerate Jeffrey's condition. Galli conveys the way thinking about Jeffrey mixed with projection onto Jeffrey brilliantly. At one point he imagines pulling the plug on Jeffrey and then committing suicide himself!

When Jeffrey started to regain consciousness and began to fathom what had happened, his first reaction was "I want to die." But over the course of the ten days Galli's narrative describes Jeffrey first oscillates between wanting to die and wanting to live, gradually settling on the will to survive.

Galli provides a service to clear thinking by using harsh words to bring out harsh facts. For him the question isn't whether to "withdraw medical treatment from Jeffrey" but whether to "kill Jeffrey." In part, making that choice would have been an act of love - sparing his son from the suffering that he expected would be Jeffrey's fate. But in part the choice would have reflected his own suffering at the loss of a son with mobility. For that reason. "killing" wfelt to him like the right word.

The crucial help Galli received was from a physician whose name he does not give and who was not part of Jeffrey's ongoing treatment. The physician conveyed that the life vs. death decision didn't have to be made now. If Jeffrey decided in the future that life in a wheelchair with no use of arms or legs and no ability to breath on his own was not worth living, he could have the ventilator withdrawn. Galli concluded that letting the treatment proceed was not committing his son to a life of unwanted suffering.

The book is painful to read, but once I picked it up I couldn't put it down.

(Jeffrey completed high school and then college. For an article about him at the University of Rhode Island, see here. For a video of Jeffrey and his younger sister Sarah in 2012, 14 years after the accident, see here. And for a post I wrote about an adult patient with quadriplegia who elected to have his ventilator turned off, see here.)

Teaching Ethics in High School and Middle School

I'm in Vermont at the Bread Loaf School of English, a Middlebury College program in which the students, primarily high school and middle school English teachers, can get a Master's degree in the course of five summers. My wife has been teaching here every summer since 1992 and I've been enjoying the potential for (a) telecommuting and (b) swimming and hiking in Vermont.

This year the Bread Loaf program has a new format for elective workshops, and I'm doing one next Friday on teaching ethics in high school and middle school. I've never taught at that level, but I've taught medical ethics at Harvard Medical School for many years, and I wanted to see whether and how that experience could be extended to pre-college English classes. I hope the participants learn as much as I have in preparing for the workshop.

Since the content of the medical school course isn't relevant for pre-college English classes, I dissected out the underlying goals I have for the medical students. I identified five:

1. Strengthen ability to identify ethical issues, ideally combined with a zest for tackling these issues – a capacity that can be called “moral imagination” or “moral sensitivity.”
2. Impart systematic approaches to resolving ethical questions – approaches, not answers.
3. Enhance skills and attitudes that promote considering the views of others in a respectful manner – listening to those we’re talking with and, imaginatively, to the views of other stakeholders to the issue. 
4. Cultivate the habit of using our own "gut" reactions as “data” for ethical reflection, not necessarily as “truth.” This doesn’t come naturally to most adults, and is even more challenging for adolescents. 
5. Enhance capacity to reason to a justifiable conclusion and articulate the rationale for our conclusions.

In preparing for the workshop I came upon the work of Tom Wartenberg, Professor of philosophy at Mount Holyoke college, who teaches a course in which undergraduates (a) examine children's books through the lens of articulating the implicit philosophical content of the stories and (b) train to lead discussions for fifth graders at a nearby charter school. (The website is very worth a visit.) In an interview he described his objectives for elementary school children as essentially the same as my objectives for Harvard Medical students. His aim is to teach children how to "philosophize," not about the content of philosophy per se. The children dove into the discussions with the same gusto that makes teaching the course to medical students such  a privilege and pleasure.

Apart from the specific content focus of ethics education, the attitudes and skills required for reasoning about ethical issues are the fundamental requirements for democratic participation. I'll depend on the teachers who participate in the workshop for ideas on whether and how including ethics in high school and middle school English classes is (or is not) a promising practice in an era dominated by standardized testing.

Making Doctors more Ethical

The Association of American Medical Colleges (AAMC) has redesigned its Medical College Admission Test (MCAT) for the first time since 1991. For premeds, the MCAT is like the pearly gates - they have to pass through it to get to the promised land of medical school. It's more than 50 years since I took the MCAT, but as I wrote this paragraph I felt my pulse going up. Our innards don't forget major stressors from the past!

Starting in 2015, the MCAT will add a section on psychology and sociology and another on critical analysis, to the sections on the hard sciences and mathematics. The AAMC wants to send the message to premeds and colleges that medicine requires more than mastery of scientific knowledge. And they're right - taking good care of patients requires understanding the patient's psychology and social context, application of critical analysis to diagnosis and treatment planning, and the interpersonal skills for developing trusting relationships.

The MCAT section on psychology and sociology will be organized around five basic truths about human nature and society that the designers of the test call "foundational concepts":

• Biological, psychological, and socio-cultural factors influence the ways that individuals perceive, think about, and react to the world.
• Biological, psychological, and socio-cultural factors influence behavior and behavior change
• Psychological, socio-cultural, and biological factors influence the way we think about ourselves and others.
• Cultural and social differences influence well-being.
Social stratification and access to resources influence well-being.

The draft version of the new MCAT probes these basic truths with challenging questions. Some of them were tough to answer. I didn't get a perfect score.

At a welcoming event for first year Harvard Medical students in 1960, a distinguished scientist on the faculty asked me what I'd majored in at college. I told him - a combined major in philosophy and psychology. He responded - "philosophy and psychology - what are you doing in medical school?" 

The AAMC doesn't want that kind of "greeting" to happen in the future.

The AAMC is entirely right to extend the scope of what the MCAT examines. The new standards, however, are just a drop in the bucket for changing the culture of medicine. Doing well in psychology and sociology courses won't be hard for smart undergraduates. Course work matters,  but character can be refractory to book learning.

In a freshman philosophy course in college, the instructor asked "how many of you can refute Plato's argument for XYZ?" None of us raised our hand. "So am I right that you have all decided to change your lives in accord with XYZ?" Again, none of us raised our hand.

His point - the dissociation between what was on the page and what was in our hearts, was clear. In a similar vein, in the anatomy lab during my first year of medical school the instructor came to my table and asked our group about the course and branches of the femoral nerve (the major nerve going to the leg). Studious book learners that we were, we looked at the ceiling and tried to recall what we'd read in the anatomy text. The instructor suggested - "wouldn't it be better to look at the dissection you've just done?"

What premeds learn in social science courses is important, but what they learn from personal relationships, their jobs, teams, and volunteer activities has a deeper influence. I love leading a section of the first year Harvard Medical "Professionalism and Medical Ethics" course, but I think of it as trying to impart a framework that - with good luck and good mentoring - the students will be able to apply in their future clinical work. Albert Schweitzer taught that "Example is not the main thing in influencing others. It is the only thing." The example of what the AAMC is saying in its redesign of the MCAT is probably as important as what future students will learn in Psychology and Sociology 101!

Hand Washing,Teamwork, and Professional Ideals

Hand washing protects hospital patients from healthcare-associated infections. But on average, adherence to hand hygeine standards is under 40%.

In June, 2008, Northshore Hospital on Long Island started an experiment. It installed motion detectors in the doorways of ICU rooms to monitor entrance of staff, and installed cameras focused on the sink and hand sanitizer dispenser. Video auditors (in India) scored each event. The intervention tested the impact of (a) installing cameras and (b) feedback of results. No individuals were identified. Results were only reported in aggregate form.

In the 16 week prefeedback period, hand hygiene rates were under 10%! At that point, electronic boards were installed in the ICU hallway. Results were given on each shift. To my eye, the board looks cheerful. It shows the date, the target rate (>95%) and gives an electronic pep talk ("Sanitize Hands Upon Entry/Exit of Rooms!"). On May 17, 2010, the day displayed in the photo, it tells the staff: "GREAT SHIFT!!" and gives results for physicians and other health professionals.

Once electronic reporting of aggregate performance was given, adherence jumped from under 10% to the mid 80s. The results were sustained for two years.

The report in Clinical Infectious Disease doesn't speculate on what drove the change. There were no financial incentives and no monitoring of individual performance.

So what happened?

Here's my guess. Very few hospital workers doubt the importance of hand hygiene. But resolving to do better is like our New Year resolutions to lose weight or improve ourselves in other ways - easy to vocalize but hard to carry out.

The cameras without feedback accomplished nothing. But daily feedback reminded staff of where it stood relative to its ideals. And the aggregate reporting told staff that everyone was on board. In other words - an experience of unity in relation to professional ideals.

That's like the congregation singing a hymn together and praising the God they adhere to! The electronic board wasn't a voice from heaven, but it spoke to the flock every day on every shift. On a bad day it must have been like the chorus from Messiah - "All we like sheep have gone astray."

I hope a journalist or a qualitative researcher delves into the human side of the statistical story the article tells. We might learn important lessons about what helps us put our healthcare ideals into action.

What Business Schools Can Learn from Medical Education

The January-February issue of the Harvard Business Review has a column - "What Business Schools Can Learn from the Medical Profession" - by Harvard Business School dean Nitin Nohria.

Dean Nohria praises the way medical education addresses the "knowing-doing" gap by fostering hands-on experience in medical school and residency. In that spirit, this month, for the first time, Harvard will send 900 first year students to developing markets, where they will work in teams of six with a multinational or local company to develop a new product or service offering. At the end of each day students will gather with faculty members to discuss their experience.

I agree with the Dean's sense that immersion in field experience can be enormously educative. But the end-of-day sessions with faculty also play a crucial role. For the past ten years I've had the privilege of co-facilitating the "Patient/Doctor" seminar in the residency in Primary Care and Population Health that my department sponsors with the Brigham and Women's Hospital and Harvard Vanguard Medical Associates. This longitudinal seminar meets over the course of the three year program. Relationships with patients, self-understanding, professionalism and medical ethics are central topics for us.

Albert Schweitzer taught that “example is not the main thing in influencing others…it is the only thing.” Not every influence is positive, and our discussions often focus on how to deal with challenging circumstances, such as difficult patients or consultants who treat colleagues, students and patients badly. The faculty role in the HBS program will be crucial for helping students "process" what is sure to be a powerful but often confusing field experience.

Last year I reviewed notes I made (and kept) from clinical supervision I received as a resident more than forty years ago. Here's part of the note I sent to one of my teachers:

I've been reviewing notes that I kept from my residency at MMHC [Massachusetts Mental Health Center] 1965 - 1968. My clinical notes on the treatment of an especially difficult patient are interlaced with my summaries of what "Dr. X" said in supervision, and I wanted to tell you how excellent your teaching was. You consistently focused my attention on the therapeutic alliance and being very clear for myself and with the patient what the work to be done was. What I took from your teaching was practical, empathic and deep. Reading notes from 45 years ago is a fascinating experience, for a view of myself as a 26 - 29 year old and for a view of what psychiatry looked like through the lens of MMHC in the late 1960s.

Excellent teaching stays with us through a lifetime. Thank you for being such an important teacher and friend to me during those formative years of residency!

Here are some excerpts from the note I got back from Dr. X, who was living in a retirement community:

Good morning Jim! You have made my day with that message...I hope that over the years my teaching has at least held its own and not corroded; what I do know is that teaching has been a mainstay of my life and that it will be the last thing I give up if I have any choice in it.  

...Practical, empathic, and deep--now that is a motto for a life.

Old teachers, like the moon, bask in reflected light from the achievements of their students.

Every good thing to you for 2011, and thank you very much for writing me this splendid note.

The field experience is sure to be an important educational opportunity for the 900 first year HBS students. But it will also be an important educational opportunity for the faculty, especially with regard to ethics education. Before he became dean, Professor Nohria proposed a code of ethics for business. But we know from centuries of medical education that codes don't shape behavior. I look forward to hearing from HBS faculty and students about the ways in which the new field experience program does, and does not, influence the values orientation of the planet's future business leaders.