Teaching Crucial Conversations: The Curse of Knowledge & the ASK Problem

4 09 2012

One of the most interesting conversations that I had recently was at the ABIM Foundation Summer Forum Open Space Sessions.  The ABIM Foundation Summer Forum is a summit of thought leaders and experts representing healthcare organizations, policymakers, patients, payers, doctors, and trainees who come together to tackle a major problem in healthcare.  The topic of this year’s forum was in keeping with the launch of the new ABIM Choosing Wisely Campaign and aptly named “Choosing Wisely in an Era of Limited Resources.”

The Forum has a unique format, employing a mix of routine panel discussions, but also “Open Space” conversations where participants actually drive the agenda, deciding what they want to work on.  One of the Open Space topics that I ended up joining was on how to train physicians to have crucial conversations with patients.   After forming this group, there were some immediate questions raised– why only physicians?  What about other members of the care team, including the patient?  Moreover, individuals in our group each had a different definition of what  “crucial conversations” were.  One clear theme was around end-of-life conversations with patients, but that was not the only one.  For example, how to talk to a patient who is asking for a medical test that is not indicated?

As I returned home, I reread some of the literature I have become acquainted with on why we (humans) don’t communicate as well as we should.  Using this framework, it’s worth considering why doctors and patients may not communicate as well as they should.  Drawing from the knowledge communication literature when an ‘expert’ is communicating to a ‘decision maker’, two distinct problems can arise:

  • Curse of Knowledge– The curse of knowledge, otherwise known as the paradox of expertise, represents the difficulty of experts to use commonplace jargon to communicate their ideas to those that are not experts.  Because experts tend to surround themselves with other experts, it can be very difficult for an expert not to use technical jargon when communicating with people who not experts.  This is easily evident in a variety of scenarios – most notably in the first few seconds of the trailer for the movie Contagion when doctors try to tell Matt Damon that his wife, played by index case Gwyneth Paltrow, is dead.  The doctor starts by saying “I am sorry…she failed to respond”.  On cue, Matt Damon responds, “OK can I go talk to her?” clearly missing the meaning of what the doctor has just tried to communicate.  Likewise, one of the patient advocates at our table shared the story of how she came to know she had cancer – “It’s malignant” …so she deduced from “Mal” and all the words that start with “mal” are bad (malice, malpractice…to name a few) so she thought “Mal … bad”.
  • ASK Problem – the ASK Problem stands for the Anomalous State of Knowledge.  This is a problem that arises when the decision maker does not have the knowledge that it takes to ask questions, since asking questions often relies on having intimate knowledge of the subject at hand.   This is particularly salient since we have major campaigns that often are directed at patients to “ask more questions” of their doctor.  However, it may be very hard for a nonexpert to ask a question of an expert if they don’t have a set of common knowledge to go on.  Asking questions is so difficult that our work shows its rare for even physicians to ask other physicians questions, and instead they opt for what is known as “back-channeling” or saying “Uh-huh” to indicate their agreement.  The only problem with this is that back-channeling is that it can be exhibited by demented patients so it is not necessarily a confirmation of comprehension or understanding.  To make matters worse, a recent study shows that patients may not ask questions for fear of being labeled “difficult”.

How can we get around these problems? Well, improving a conversation requires training on all sides. Patients can also be coached to take a more active role in their care. However, healthcare personnel also need to be prepared so that their newly empowered patients are not an unwelcome surprise. Physicians and other healthcare personnel need to be trained in how to speak to patients about difficult decisions in a sensitive way.   One model curriculum we can learn from has been developed by oncology fellowship directors and is called OncoTalk.  One of the key tenants is the principle of NURSE, which describes how to respond to patient emotions during complex decision-making.

  • Naming the emotion “It sounds like you are afraid of X”
  • Understanding the emotion  “I can understand the fear that goes along with X.”
  • Respecting  “You are asking the right questions…”
  • Supporting  “I am here to support you through this decision…”
  • Exploring  “What are you thinking about now?”

Of course, the age-old question is can you teach empathy? Well, according to one recent study, empathy wanes throughout medical school.   So we should, at the very least, try to at least preserve it.

Vineet Arora MD





Help Debunk A Medical Myth About Patients Leaving AMA

11 07 2011

This week at FutureDocs, we are working with our friend and colleague Glass Hospital as well as one of our medical students and a recent residency graduate to bring to light a medical myth about hospitalized patients who leave against medical advice.  Here is an excerpt from his post about our work which includes a new Squidoo page created by Gabe Schaefer MS3 on what to do when patients leave AMA and the video vignette below.  Let us know what you think and please share this with anyone who you think may benefit!

Excerpt from this week at GlassHospital:

Like Mikey, the Life cereal kid who died from mixing Pop Rocks and Coke, or the spider eggs in Bubble Yum that help make it so soft and chewy, Medicine has its share of urban legends.  Did you know, for example, that if you’re hospitalized and decide that you want to leave “Against Medical Advice” [AMA], that your insurer won’t pay for the hospitalization?

Bunk.

Apparently, this canard is pervasively believed amongst doctors and passed from generation to generation of trainees just like the nonsense about cute ol’ Mikey.  A few years ago, a medical student came to me with a case of moral distress. She had seen the doctor-in-training with whom she was working become upset at a patient for declining an invasive heart procedure.

Rather than reason with the patient and convince her that the test was indeed indicated and would be of greater benefit than possible harm, the resident doctor in question quickly informed the patient that if she refused the procedure and signed out AMA, she’d be financially responsible for the entire cost of the hospitalization, as her insurer would decline to pay.

This left our student wondering if this was true, and if there were ethical safeguards against this.   Her moral distress led to a research project that debunks this notion [we hope] once and for all.

I can’t give you the specifics (an article on our findings is under review at a medical journal) just yet, but GlassHospital and FutureDocs are happy to share with you the educational fruits of our findings to date. You can click over here to learn more in true interactive fashion, or if you prefer, watch only the cameo-encrusted video tour-de-force right below. [Who is that guy playing angry Mr. Smith? He looks familiar. And who, for heaven's sake, does his wardrobe?]

Let us know your thoughts! On the video, the website, the urban legend. What other medical urban legends would you like to see debunked?





Can We Trust Medical Trainees with Social Media and Other Digital Dilemmas

18 04 2011

Last weekend, I was on a panel for internal medicine residents at the American College of Physicians Council of Associates forum in San Diego.  I was invited by Erin Dunnigan and Baligh Yehia, the Co-Chairs of the Council, a position that I have also held earlier in my career.  The topic – was about the debate on social media use among medical trainees and whether it was professional.  Fortunately, I was lucky enough to do it with my rock star colleague Darilyn Moyer, the program director at Temple, who also moderated last years panel on Mean Girls in Medicine with me.

The Temple chief resident, Brooke Worster, started us off by asking the much debated anathema in medical education – what is professionalism – and if it is in the digital domain, it’s even harder to describe.  Then she proceeded to show some videos of medical students that you could say exercise some creativity – from the harmlessly funny to incredibly poor taste and ranging from schools such as UT Southwestern to my own alma mater Washington University in St. Louis.

The questions from the residents were spot on and here were some of the Q&A that followed:

Medical trainees are people too – shouldn’t they able to express themselves in ways  using colorful medical humor either in a show or their profile?

The objection is not for class shows and parodies – those have existed since the very first class medical show that took place at the University of Michigan and called the Galen’s Smoker (this year’s name- “Spleen Girls”).  The issue is more complicated with public consumption of materials never meant to be seen by a public audience.  Then, when a video is seen by a patient, an employer, or another interested stakeholder, alumni, philanthropists, those that donate their body to science (to name a few), the meaning of the video is not clear and those individuals often lose faith in the medical system.  There have been cases where patients have refused care by a residency trainee after seeing their Facebook profile with images that don’t seem suitable for their doctor.  So, while medical trainees deserve the right to blow off some steam and exercise creativity, it should not compromise their ability to see patients or work in the future.

Shouldn’t we just trust students and residents to police themselves on social media?

The answer here is that while most students are capable of policing themselves, a breach of professionalism on the internet is like a NEVER event – especially if it relates to patient information or trainee information that could result in harm.  So, opting for a putting out fires approach will not be effective and it’s important for medical educators to teach students and residents about responsible use of social media.  The good news is that the more one uses social media, the more likely they are to be able to draw that line in the sand.  Our research shows that superusers, or more frequent users, are more likely to oppose regulation but are also more likely to believe that they are responsible for portraying a professional image.  So, by teaching people to use it appropriately, we may actually prevent violations and breaches.

Should schools screen social media as part of its application process?

Interestingly, some students and faculty in the audience advocated for ‘second chances’ and redemption if a student had a inappropriate picture posted since Facebook privacy settings are initially confusing and a student could be misguided initially. But, let’s face it… screening applications for admission to medical school or residency is hard and takes time.  People are looking for ANY red flag to set downgrade your application compared to others.  Don’t give them a reason.  Medicine is not unlike any other industry in which candidates are interviewed to see if they can get the job done and also represent that organization appropriately.  If a video is posted that showcases a student in a tasteless parody with your school logo or name in the background, a hospital or residency is not going to want to take that risk with you.

What can medical schools do to protect themselves?

Well, for starters, schools can have a social media policy that highlight that do’s and don’ts in this area.  Unfortunately, in a recent study by @kind4kids and @MotherinMedicine, most schools do not so we have room for improvement.   The second thing is that schools can also deliver education, not only on the negatives – or how NOT to use social media, but they can also encourage and role model proper use of social media through disseminating course materials, student press, recruitment and admissions, or communicating with their students.  A recent post on a new student blog actually has a Poll this week asking students if they would want to receive information via social media and the majority say yes.

What can students do to ensure that their digital image is safe?

This question actually came from a student that has the same problem as me – a person with another name who happens to be garnering attention for the wrong reasons – in my case, it’s someone with my same name who is an ophthalmologist and has been accused of blinding patients and has many negative patient testimonials.  So, what can I do – well I initially started on LinkedIn to try to distinguish myself from this person and I also took control of my own digital footprint using a Google Profile to highlight who I am and the links on the web that I want people to see.  (You’ll notice my Facebook profile is NOT on my Google Profile).

The same old adage about Vegas applies here- whatever happens on social media stays on social media.  Therefore, just like the national dialogue on health information technology, its important for medical educators and trainees to engage in a constructive dialogue and establish policies that both set standards and teach others how to meaningfully use social media.

–Vineet Arora, MD





Nature vs. Nurture in Medical Education: The Case of Student Bedside Manner

13 03 2011

Sir William Osler at the bedside

Believe it or not, it’s been a major news week about the soft stuff in medicine, bedside manner.   First, a Time magazine story about a new study showing that patients cared for by physicians with greater empathy had better diabetes control.  That study comes on the heels of an editorial in the New York Times written by a patient (who also happens to be a science journalist and an outstanding writer) with mitral valve prolapse who graciously volunteered herself to be examined by preclinical medical students learning to do the physical exam and lived to vividly document the experience for all of us.  As she eloquently describes, some students seemed like naturals, whereas others were awkward and clunky.   

These articles add more fuel to the fire for the most hotly contested question in medical education – Can you teach these behaviors?  One on side, you have the nature supporters, saying that the role of admissions committees is to screen these behaviors out.  The nurture supporters say that these behaviors can be taught and its medical schools responsibility to do so.  While it is true that some pathologic behaviors need to be screened in admissions, the question for most students is more refined—is it true that some students come in ‘empathetic’ and others are just hopeless oafs that can’t empathize with patients?  Well, it was refreshing to read Number Needed to Treat blog written by a medical student who says the NYT article was eating away at her soul…She nails it by saying the following:

“Almost every single med student I know is, in fact, an affable person. Yet it doesn’t always come through in the exam room.”

Why is this so hard?  Well, it is not easy to learn how to do a physical exam while also forming your bedside manner.  Our students have to pass a national standardized exam that requires doing the over 100 step “head to toe” physical exam.  As a ‘dinosaur’, I never had to take such a test. I’m not even sure what all the steps are but have asked my colleague, Dr. Farnan, who runs our Clinical Skills program for medical students who informed me of all the points and that they are to be memorized.  Let’s be honest- most of our faculty could not do this without referring to a cheat sheet.  If they had to memorize it for a test, they may even come across robotic and unempathetic at first. 

So, what does this mean for students’ bedside manners while they are learning?  Well, mental capacity is finite.  Workload has been well described as a construct that includes the mental and physical challenge of the work.  For complex tasks, it is important to consider how much ‘spare capacity’ one has after the ‘primary task’ is dealt with.  Elegant studies have shown that experienced physicians are BETTER at performing a secondary task than novice physicians when both are doing the same primary task.  Why?  The experienced physicians have more ‘spare capacity’ to deal with the second task.  

So what is the primary and secondary task in interviewing a patient?  Well, the primary task is learning the physical exam and how to take a history.  As we celebrate this week’s residency match, the job of medical school is to produce physicians that can perform these basic functions during residency training.  While our medical students acquire these skills, of course some will be naturals, and therefore have more spare capacity to key in on their bedside manner.  In contrast, others may struggle with basic skills and have difficulty with both.  The majority, however, will first initially put all their mental effort into learning how to do a history and physical, leaving little ‘spare capacity’ for bedside manner.  Is there hope?  Yes, as these students get better at taking a history and physical, they will be more at ease.  This will then free up the necessary spare capacity to be continuously cognizant of their bedside behaviors.  Consistent with this philosophy, one school has had success actively reinforcing bedside manner skills while prerounding during the third year clerkship.

This progression is important, and highlights the learned art of medicine.  This was articulated beautifully by our recent keynote speaker, Dr. Joel Schwab, for the Gold Humanism Society senior student honorees.   On the subject of being humanistic, he said that he THINKS about the landmark article on etiquette-based medicine every time he sees the patient and he follows the 6 steps –

  1. Knock on the Door (wait permission to enter)
  2. Introduce yourself (with name badge on display)
  3. Shake hands (wear glove if needed)
  4. Sit down (smile if appropriate)
  5. Briefly explain your role on the team
  6. Ask the patient how he or she is feeling 

While working at a free clinic last Saturday, I too thought about this article for every patient I saw.  The first year students I was working with came from a variety of medical schools in Chicago and were volunteering their Saturday to do this.  I had no doubt that they all cared about the patients.  But, I did notice that they were taking time to think very hard about the chief complaint, figure out the right questions to ask, and how to present it coherently.  So, the role of medical education is to make sure that doing a history and physical becomes second nature for our students, and that thinking about bedside manner becomes the primary task.

–Vineet Arora, MD





Love Letters for Medical Students

29 01 2011

While Valentine’s Day is coming soon, a different sort of ‘love letter’ may be sent or received by senior medical students.  As recruitment season draws to a close, residency programs and applicants may be busy exchanging notes of interest, affectionately dubbed “love letters” by scores of medical students and on StudentDoctor.net.

What do these love letters mean?  Some students have asked us whether it is a Match Violation to get or send a love letter.  Others have worried they did not send enough or what type of language they should use.  Well, here are some quick tips on how to approach this somewhat awkward situation.

  1. Is it a Match Violation? It is not a Match Violation for a program or a student to express interest in the other.  However, these statements of interest cannot be binding (i.e. we will only rank you highly if you rank us #1).  If there is any part of it that is binding, then it would escalate to the level of a Match Violation.  Read more about what constitutes a violation here.
  2. “Rank highly” vs. “Rank #1”? –  It is poor form to send more than 1 program a “I will rank you #1” note.  There are 2strategies that most students will use- The first is to select the #1 program to send a “rank #1” letter to and then to send “rank highly” to the next 2-3 programs on the list.  Since some believe that “rank highly” has become the code for “I love you but not enough,”  the alternative is to be coy and not let any program you will rank them #1, but use language like “I could see myself there” or “I would be honored to train there.”
  3. “Rank to match” statements from the program – It is possible that programs could call or email to alert you that they are ‘ranking you to match.’  While you may feel elated, this does NOT mean that you should pack up your belongings and move.  This also does NOT mean that you should cut programs from your list since are secured a spot.  What this DOES mean is that they are interested in you and have likely placed you in a position on their rank list where they THINK on an average year you could match there.  Because the Match is very tricky and the competitiveness for an individual program can change year to year, “ranked to match” in one year may mean “out of luck” in another year.  So our advice is to not put a lot of stock into these statements and still preserve the breadth and depth on your list that you will need to secure a position.  Remember the length of your Rank List is one of the best predictors of whether you will match or not.
  4. What about programs that I don’t send letters to? Will they think I hate them? –Absolutely not.  The letters can serve as a signal in the game that you are interested but just because you don’t send a letter does not mean that you can’t end up at that program.  Programs are maximizing their ability to get the best candidates regardless of this communication.   It would be extremely unusual for a program to strike someone from their list if they don’t receive a letter.  Likewise, if you are not very competitive for a program, your letter is not going to be the dealbreaker to move you in to the rankable range.  Remember, the letter is really a statement of interest that may help a little, but not a lot.
  5. Email vs. Paper – During the recruitment season, paper thank you cards can be a nice touch if sent in a timely fashion.  However, the post-recruitment love letter should probably be an e-mail given the occasional snafu in snail-mail especially in large hospitals.  The nice thing about the email is that it can be immediately forwarded to the members of the recruitment committee or others.  In terms of who to send the love letter to, it is usually sent to the program director unless someone else was clearly the lead recruitment person for the day (an associate program director or a faculty member).  As always, try to personalize the letter to highlight the things you enjoyed about the program that day.
  6. There is no ‘right’ answer – As with our other career advising posts regarding the Match, there is no right answer here.  Since everyone’s case is different, the best thing may be to consult with a faculty member from your field who has been advising you on the process.

Alas, in spite of all the love you may get or feel, the irony is that the key to a successful residency match is not to fall in love.   Remember, you are not in a relationship with any program yet.  Since anything is possible, you need to keep an open mind.  Try to group your list in tiers.  Consider that you would be happy at any of the programs in your ‘top tier’  to avoid being dead set on one place.  Visit last year’s archived post if you need more help creating a rank list or checking it twice.  Lastly, don’t forget to certify your list.

Happy Match List Making!

–Vineet Arora, MD and Shalini Reddy, MD





Professionalism is a dirty word… and why are medicine docs called fleas?

7 06 2010

At the recent AAMC meeting on how to integrate quality into teaching hospitals, the question that kept popping up from speaker after speaker was how to address the fact that doctors in teaching hospitals don’t get along.  Unfortunately, all the specialty bashing that takes place prevents the adoption of a team based culture necessary to advance quality and safety.  As one speaker highlighted, how can we really start to address this topic when specialty services are busy blocking the consult or disparaging the internal medicine doctor by calling them a ‘flea.’  I hadn’t heard the term ‘flea’ in a while but many onlookers were nodding in agreement, possibly thinking about the last time they heard someone disparaging the ER for an incomplete workup or a specialist blocking the consult as ‘inappropriate.’  The discussion about quality and safety morphed into every medical educator’s favorite topic, ‘professionalism.’ 

Ironically, while medical educators love discussing professionalism, this word has become despised by medical students.  It has been the subject of the last 2 years of senior class shows at Pritzker.  Why?  Because in response to numerous calls by the AAMC and other groups including the public, Pritzker, like many other schools, have launched a professionalism initiative designed to promote professionalism.  As you can guess, any efforts to ‘teach professionalism’ to students seem preachy and insincere.  So, what’s a medical educator to do?  After years of contemplating this problem with colleagues and experts, we concluded that we first need to identify and reward faculty role models and ensure that our faculty and residents emulate the behaviors that we wish to see in our students.  Apparently, we aren’t alone.  The American Board of Internal Medicine Foundation has awarded 6 grants to variety of organizations to promote professionalism among physicians in practice.  We are fortunate to have received funding through this mechanism to actually address the topic at hand – specialty bashing in teaching hospitals– particularly between hospitalists, primary care physicians, and emergency medicine doctors.  Interestingly, this problem is more prevalent in teaching hospitals.  When our residents rotate at a nearby community hospital, they often comment on how nice the doctors are to each other, even thanking them for consultations!  Of course, unlike the attendings in teaching hospitals on fixed salary, physicians in the community hospital actually make more money for each consultation.  So, aligning financial incentives can actually promote professionalism.

I was at this meeting with one of our 2nd year medical students Marcus Dahlstrom who earned rave reviews for his presentation on student efforts in teaching quality and safety at Pritzker (while I may be biased, you can see his presentation for yourself.)  On the way home, we noted that although professionalism is a dirty word among our students, but that medical educators continue to perseverate on it even at a meeting about quality and safety.  We need a better word and a better way to address these issues.  Because most students are professional, it’s the actions of a few that are remembered by faculty and attributed to all students and their generation. 

On a side note, Marcus also asked me why medicine doctors are called ‘fleas’ since he had not heard that term…yet.   I did not know the answer but here are some potential origins I found – the most useful of sources being StudentDoctor.net

  • Internists can be spotted with a stethoscope around their neck, or a “flea” collar
  • Internists, like fleas, are the last things to leave a dying body
  • They travel in packs on rounds
  • Doctors were very devoted to their plague patients, similar to fleas that were responsible for spreading the deadly disease. 

While I don’t know the exact reason, its interesting that while 3 of the reasons are clearly derogatory, one explanation of ‘fleas’ actually highlights ‘professionalism.’ Ironically, maybe all we have to do to get doctors to stop using this term is to say that it’s part of that dirty p word ‘professionalism.’

–Vineet Arora, MD





Teaching Futuredocs About Death and A Confession

3 06 2010

I have a confession to make.  I had never seen someone die until I was an intern.  As the daughter of first generation immigrants, I had little contact with my grandparents who lived in India when their time came.  During medical school, I had a lot of patients but never had a patient die while I was taking care of them.  I was reminded of this last week during three unrelated presentations that all converged around how to ensure that people’s wishes regarding how they want to die are honored.   That is when I had a flashback to my internship – to the first person that I had to pronounce dead.

It was July on a busy inpatient oncology service and month #1 of my intern year.  It was daytime and I got a call from a nurse about a hospice patient who had end stage multiple myeloma who had presumably died, but they needed me to go pronounce the patient dead.  So, I went to the bedside and the husband of the patient was sitting quietly at the bedside.  I introduced myself and thought – okay I’ve never done this before but I’m going to do a physical exam and note the absence of a heart beat, pulse, respirations, and neurologic function and then I would be done.  I started by listening for breath sounds – none and no air movement in the chest.  Then I put my stethoscope on the chest and heard nothing.  That was erie…it dawned upon me that I was in the room with a dead person.  I started to feel hot.  I raised the patient’s eyelids and shone a light into the eyes and again nothing.  At this point, I definitely did not feel like myself and my mind started to race as I was thinking how could I have gotten here without ever being in the room with a dead person?  Fortunately, sensing something was wrong, my attending and co-intern came to my rescue (our resident was off).  My attending escorted me out of the room with her arm around me and said you’re going to be okay and my co-intern brought me an orange juice so I could recover.  I felt so embarrassed. 

How did I get through without medical school without knowing how to pronounce a patient dead or have a family meeting?   Does this happen to medical students today?   Well, the three unrelated presentations I heard last week about how to improve how we train doctors about death and dying convinced me that at least change is on the way. 

  • Training first year medical students to follow a dying patient  First, today’s medical students have a lot more substantive experiences with death and dying then I did.  At a recent morning breakfast meeting of the Academy of Distingished Medical Educators at Pritzker, Dr. Stacie Levine, our fellowship director for geriatrics and our new palliative care program, describe a new longitudinal curriculum for palliative and end of life care for medical students.  In addition, she launched a very new and innovative program for our first year medical students to be trained as hospice volunteers.  Students who chose this option are making home visits and even receiving pages to participate in a “death watch” when the patient they are following dies.  They also reflect on the experience through journaling and discussion.
  •  Improving resident discussion of advance directives with clinic patients  While hospice can be one path to a ‘good’ death, any resident knows that a major barrier to hospice care is that families are not often prepared to make such decisions when their loved one is in duress.  In fact, most residents encounter death through family meetings for patients who were hospitalized with terminal illness or when continued care, usually in the ICU, appeared futile.  These were difficult discussions since often times the patient was unable to participate due to their grave illness and had may or may not have discussed their wishes with their immediate family or next of kin.  This was one reason that the residents, as part of their required ambulatory quality improvement curriculum, chose to improve the documentation of advance directives and identification of a surrogate decision makers for clinic patients that were above 65 years old.  Through earlier identification of surrogates and documentation of advance directive discussion, it is the hope of our residents that these things will be easier when patients are near death.  They have good reason to believe this.  A recent article in the New England Journal of Medicine demonstrated that patients who had prepared advanced directives received care that was strongly associated with their preferences.
  • A new way to discuss end of life preferences with families Lastly, I attended our Department of Medicine Grand Rounds last week which was given by Dr. Dan Sulmasy who happens to be a Medical Ethicist, an Internist, and a Franciscan Friar!  He eloquently described the problems that surrogates face when forced to make decisions for others.  Instead of the familiar concept of ‘substituted judgment’, where the surrogate has to make a decision on behalf of the patient, he argued for a new model which relied on ‘substituted values’ and ‘best judgment.’  Basically, he presented convincing data that shows that surrogates don’t always make the best decisions for patients but they may be able to tell you what the patient valued.  It’s also easier to ask a distraught family member to ‘tell me about your loved one and what they believed in.’  In other words, you will hear the patient story. Once you have a good understanding of the values, then you as the physician can offer the clinical information about the patient including the prognosis and then work with the family member to arrive at the ‘best judgment’ for the patient.  This method still had not been tested but has been highlighted as an alternative to the traditional model. It could also serve as a new way of teaching doctors how to conduct family meetings.  In fact, our fourth year medical students have been learning how to do family meetings through a team simulation through a new Transitions to Internship Course. 

With all of this activity around death and dying in one week culminating in Memorial Day, it was only natural to reflect on my first experience with patient death and how unprepared I felt.  With the focus on death and dying in medical education today, I hope that future doctors will be more prepared for these experiences than I was.

–Vineet Arora, MD








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