Residents: Healers in the making

1. Residents:Healers in the making Thalia Arawi, PhD Clinical Bioethicist Director, Salim El-Hoss Bioethics & Professionalism Program Vice-Chair, Medical Center Ethics Committee Faculty of Medicine ta16@aub.edu.lb

2. Welcome! • Welcome to Residency! • Being part of this profession entails ethical and professional obligations (Dr. Zeineldine addressed you on this) • In part, this requires learning to “think ethically” through self-reflection, alone and with others • At AUBMC we are committed to Patient Centered Care. • Any resident and attending who fails to do that fails in professionalism and betrays his/her profession.

3. Plan • Few words about what patients think of physicians. Food for thought • MCEC: Bioethics in direct relation to Patient Care • Final words

4. A study assessing the public perception regarding physicians in Lebanon revealed the following: The physician traits most desired by the public were found to be: moral traits (41%), interpersonal traits (36%), scientific traits (19%) and other (4%). The most unwanted traits/behaviours were a lack of interpersonal traits (57%), a lack of moral traits (40%) and a lack of scientific skills (3%).

5. Sample Traits • Inhumane • Negligent • Does not admit mistakes • Dishonest • Hurried • Does not discuss with patients • Unfriendly • Treats patients as a number or case • Disrespectful • Arrogant: • Does not respect appointments • High-handed • Treat patients as inferior • Pretentious • Annoyed with questions • Does not listen to patients • Humane • Honest • Ethical • Not materialistic • Compassionate • Humble • God fearing • Explains thoroughly • Good listener • Respects patients • Has good interpersonal skills • Gives time to patients • Caring • Patient • Smiles • Is not haughty Not Desired Desired

6. Regression in moral development and empathy in residents as they progress through medical school is RAMPANT. You can guard against it by emulating good role models and self-reflection. We all need to start thinking… • How not to fall prey to the dehumanization of medicine? • Invasion of Money into Medicine • Physicians became the service providers • Patients became “clients” • Doctors can now make a lot of money (regardless of how) • The profession began attracting the “wrong” kind of person • The Hidden Curriculum: everything matters (how you dress, talk, communicate, examine, treat, etc.)

7. "As I look into the future, I think we will undoubtedly be a much more divided profession than we are now. We will not have again an ethic which will bind all of us," There will be "those who choose to follow the moral imperative--the high ground--and those who become purely businessmen and entrepreneurs." It is YOUR CALL! E. D. Pellegrino, Previous Chairman of the President's Council on Bioethics

8. Being a “good physician” Healthcare Practitioner (ST) or Healer? YOUR CHOICE • Is much more than following rules and principles • It is about what kind of person you are and want to become • Rules and Principles taught • Becoming process (will, mind, heart) Doing the right thing when NO ONE IS LOOKING!

9. SHBPP-AUBFM HUMANISM AND PROFESIONALISM AWARD, 2012 Dr. Darwish

10. SHBPP-AUBFM HUMANISM AND PROFESIONALISM AWARD, 2013 Dr. Costa

11. SHBPP-AUBFM HUMANISM AND PROFESIONALISM AWARD, 2014 • Residents Graduation Ceremony June 10, 2014

12. You have all taken Bioethics • I will not repeat what you already know MCEC

14. AUBMC-MCEC http://www.aub.edu.lb/fm/shbpp/mcec/Pages/index.aspx

15. MCEC Handbook

16. MCEC Handbook

17. What is a Clinical Ethics Committee? Final treatment decisions are made between the attending physician and patient or surrogate-decision maker. Group of professionals who meet to consider and discuss the ethical aspects of clinical care within the hospital. It gives opinions or recommendations.

18. Education Functions of the MCEC facilitates educational opportunities for health care professionals, patients, and their families. provides consultative services regarding ethical issues pertaining to a specific patient. discussions and evaluations of policies and procedures having ethical implications. Case Consultation Case Consultation Policy MCEC

19. Members represent • Diverse medical depts. • Other departments (such as nursing, social services) • Religious views • Hospital administration • Lawyer • Bioethicist • Community Members bring experience and expertise from their areas.

20. Common Ethical Issues • Withholding or withdrawing treatment • Do Not Attempt Resuscitation orders (DNR/AND) • Identification of patient’s representative • Medical futility • Informed consent • Aborting a fetus with malformation • Determining decision-making capacity • Palliative care issues • Conflict resolution • Perinatal & neonatal issues • Other

21. 5’ The “Ashley Treatment”.. Ethics Committee recommended the Ashely Treatment http://ashleytreatment.spaces.live.com/

22. Born 1997 with static encephalopathy (permanent brain damage) of unknown etiology • Breathes on her own but unable to raise head up, sit up, hold and object, walk, talk, must be tube fed • 2003 Signs of puberty • 2004 received “Ashley Treatment” • High doses of estrogen to halt growth • Hysterectomy Breast bud removal

24. Was this right? • At least two points: • Ethics is part and parcel of patient care (medicine) • Discussion and decisions cannot be made at a distance • Who should decide? • Who should be involved when making the decisions? • The fact is that the decision created a great deal of controversy. • But it was done in good faith.

25. The average hospital ethics committee receives 3 requests for case consultation per year

26. AUBMC Medical Center Ethics Committee (MCEC) • From 2005 to March 2012, only 5 cases were referred to the medical center Ethics committee for recommendation.

27. Av. 2-3 hrs. http://www.aubmc.org.lb/Pages/AUBMC-leading-in-Bedside-Ethics-Consultations.aspx

28. 2013-2014 • TO DATE- 32 bedside ethics consultations • Called for by: • Attending physicians • Residents • Nurses • Patients Satisfied Pts and Phys.

29. Patch Adams Last Speech

30. Our Lives are Dedicated to Yours! Loaded term… we are responsible/accountable for it

31. A note.. The elderly • Often older people are treated with less enthusiasm, care and dedication • “They are old” • What you owe to the child, the adult, you owe to them, even more.

32. Good Luck in entering yet another learning phase.. As physicians • Remember: • Do not judge others from your own perspective. Keep an open mind, develop a bird’s eye view of things. You will be surprised what you will discover. • You are now residents. Med students are not your subordinates. They are what you have been just a few days ago and they are the future you. Be kind to them and help them learn as you learn. Be a role model. • Medicine is about team work. Nurses, Physiotherapists, etc. are educated healthcare professionals and members of the healthcare team. Without them, there is no patient centered care. • The patient is your “partner”, your “teacher”, not your “tool”.

33. The patient “has” a disease, he/she “is” not a disease. • The patient has a name like yours, which is not a room number nor ends with something like “-itis”. • Residents and physicians often suffer from a chronic iatrogenic disease called Egotitis. The only proven remedy to this illness is humility and remembering your own finitude and mortality. • The reputation of a lifetime may be determined by the conduct of a single moment. • RESPICE FINEM, for you too are mortal.

34. Questions?