Everything I Really Needed to Know to Be a Clinical Ethicist, I Learned From Elisabeth Kübler-Ross.

I analyze the insights present in Elisabeth Kübler-Ross's seminal work, On Death and Dying that have laid the foundation for contemporary clinical bioethics as it is practiced by clinical ethics consultants. I highlight the landmark insight of Elisabeth Kübler-Ross that listening to dying patients reveals their needs and enables them to enjoy a better death. But more important for contemporary clinical ethics is that the text highlights three tensions that the clinical ethicist must navigate but can never truly resolve. Clinical ethicists must balance: (1) the need to hear the patient's voice with the temptation to overly medicalize the case, (2) helping the patient achieve a better death with enabling the patient to die in the way he or she chooses, and (3) keeping professional distance with engaging the patient in a way that respects the intimacy of the patient's disclosures.

Supporting DACA recipients and international students pursuing careers in medicine: A pilot program for advisors.

The United States (U.S.) health professions are becoming more invested in diversity. Information on students who are undocumented or recipients of Deferred Action for Childhood Arrivals (DACA), and international students on student visas entering U.S. medical education is sparse. Few programs offer targeted training for educators on advising students who are undocumented, DACA recipients, or on a visa. We piloted a virtual program for pre-health advisors and educators on supporting students who are undocumented or recipients of DACA and international students transitioning to medical school. Program evaluation consisted of an anonymous retrospective pre-post survey. Of 117 registrants, 40% completed the survey. Prior to the program, most participants indicated that they were unsure or thought students were ineligible for financial aid during medical school if they were DACA recipients (40% unsure, 26.6% ineligible) or on a student visa (30% unsure, 30% ineligible). After the program, most respondents reported students were eligible for merit scholarship or private loans with DACA (66.6% eligible) or an international student visa (60% eligible). Perceptions of students with DACA being able to lawfully practice medicine in the U.S. changed from pre-program (43.3% unsure or not eligible) to post-program (90% eligible). Participants indicated they were more confident advising DACA recipients and international students post program. This virtual program was an effective step in providing support for advisors who are assisting non-citizen or permanent resident students start their careers in healthcare. Our findings show the need for more information on advising students who are DACA recipients, undocumented, or on student visas prior to matriculating to medical school and throughout training.

Surrogate decision-making and the need for advance care planning: issues raised by the Al Barnes case.

Decisions regarding health care are increasingly difficult to make, especially as patients live longer and with more medical comorbidities. The case of Al Barnes, a man with advanced dementia who recently died in a Minnesota hospital despite months of aggressive care, illustrates the frequently encountered challenges that go along with making decisions about medical care for patients who lack the ability to do so themselves. These challenges can lead surrogates to opt for treatments that are efficacious but may be burdensome and inconsistent with the values, goals, or preferences the patient previously expressed either orally or in a written advance directive. In this article, we describe approaches that may help those who must make decisions for patients who cannot do so themselves and the merits and limitations of advance care planning.

Addressing Systemic Health Inequities Involving Undocumented Youth in the United States.

The Deferred Action for Childhood Arrivals (DACA) program has dramatically improved the lives of undocumented youth in the United States. In particular, DACA has improved these young adults' health by improving the social determinants of health. Furthermore, as health professionals, DACA recipients increase the diversity of medicine and the health professions and are thereby suited and well positioned to promote health equity. The medical profession should continue its support for ad hoc legislative remedies, such as the DREAM Act, which target relief for particular populations of undocumented youth. In addition, the medical profession should highlight the need for a legislative solution that goes beyond a one-time fix and corrects the systemic marginalization of undocumented youth.

How Should History of Physician Involvement in the Holocaust Inform How Physicians Approach Employers?

In response to a case involving an advertisement for a physician to work in a private detention center housing asylum seekers and immigrants, this commentary considers ethical obligations of physicians responsible for detainees' health care. The commentary also suggests key points a physician should make during a job interview at a detention center and concerns a physician might articulate about caregiving practices for detainees.

The Termination of Deferred Action for Childhood Arrival (DACA) Protections and Medical Education in the U.S.

The termination of the Deferred Action for Childhood Arrivals (DACA) immigration policy poses unique challenges for medical education and healthcare. A survey on DACA was administered online using Qualtrics Software System to 121 unique U.S.-MD granting medical school admissions leadership using e-mails between January 2018 and April 2018. A total of 39 individuals out of 121 (32%) responded to the survey; 23 (59%) of respondents identified as medical school admissions deans, 11 (28%) identified as directors and 5 (13%) as staff/officers. During the past 4 years, 19 (49%) reported having accepted DACA students. The majority either incorrectly answered or were otherwise unsure about the effect of DACA on medical education. The correlation between perception of understanding DACA and mean knowledge composite score was 0.38, P < 0.05. This study found that U.S.-MD granting medical school admissions leaders self-reported knowledge was moderately correlated with actual knowledge about DACA.

Good Sanctuary Doctoring for Undocumented Patients.

Clinicians whose practice includes a significant immigrant population report a climate of fear adversely affecting their current patients. Increased immigration enforcement targeting undocumented immigrants increases these patients' stress and negatively affects their willingness to seek medical care. To address these concerns, this article draws upon the literature and the authors' experience to develop guidance on sanctuary doctoring. These materials provide opportunities for patients to open a dialogue about their immigration concerns and can assist clinicians in connecting patients to networks and resources that can address their needs. The materials are designed to be used in single, brief clinical encounters.

"We Have a Lot of Power ": A Medical School's Journey Through Its New Deferred Action for Childhood Arrivals (DACA) Initiative.

Purpose To describe and analyze qualitatively the impact of implementing the "Stritch Deferred Action for Childhood Arrivals (DACA) Initiative" (SDI) at the Stritch School of Medicine (SSOM), Loyola University, Chicago in 2012. The SDI is a three-step process that included: 1) opening the Stritch admissions policy to welcome DACA students to apply, 2) evaluating DACA applicants equitably with all other applicants, and 3) seeking funding to enable these students to matriculate.  Method Focus groups and in-depth interviews were conducted to explore DACA and non-DACA students' experience of the SDI on their medical school journey and the institutional culture. During the study (in 2017-18), the medical school year (M)1-M3 cohorts included DACA students, while the M4 class did not. A grounded theory method was used to summarize and analyze qualitative data. Results Four major themes and 11 subthemes emerged from the data analysis. "Beliefs and Attitudes" included the subthemes of motivation to become physicians, resilience, and the mission and values of individuals and the institution. Students noted "obstacles" in reaching medical school, along with those they encountered within it. They also noted multiple "opportunities" presented through the SDI and the importance of mentors and allies. Lastly, the "impact" of the SDI on individuals, the institution, and the wider community was discussed by participants. Conclusion Enacting the SDI enabled cohorts of DACA recipients to matriculate at SSOM. Both DACA and non-DACA students in this study identified the importance of including these students as future physicians and articulated the impact of this change on them, their classmates, the institution, and the community as solidarity was formed and students' awareness of their power as future physicians to advocate for underserved populations developed.

Operation Homefront: Meeting Clerkship Competencies with Home Visits to Families of Children With Special Needs.

OBJECTIVE: We assessed how third-year medical students' written reflections on home visit experiences with families of children with special needs demonstrate evidence of exposure to 9 selected competencies for pediatric clerkships designated by the Council on Medical Student Education in Pediatrics. METHODS: We reviewed written reflections from 152 third-year medical students. For each competency (2 related to communication were combined), we tabulated the number of reflections in which a given competency was demonstrated. Within each competency, themes are described and presented with exemplary quotes to provide a more robust picture of students' exposure and experience. RESULTS: Of 152 reflections, 100% demonstrated at least 1 of the 8 expected competencies. Each reflection exhibited an average of 3 (3.1) competencies (range: 1-7). The competencies most frequently mentioned were demonstration of respect for patient, parent, and family attitudes, behaviors, and lifestyles (90%) and demonstration of positive attitude toward education (76%). Less frequently mentioned competencies included demonstration of behaviors and attitudes that promote patients' and families' best interests (41%), demonstration of effective verbal and nonverbal communication skills (a combination of 2 communication-related competencies) (33%), and description of barriers that prevent children from accessing health care (37%). The following competencies were least often mentioned: description of a pediatrician's role and responsibility in advocating for patients' needs (10%), description of the important role of patient education (8%), or description of the types of problems that benefit from a community approach (17%). CONCLUSIONS: Our analysis demonstrates that community-based home visits can provide medical students with opportunities to meet required pediatric clerkship competencies.

What Is the Minimal Competency for a Clinical Ethics Consult Simulation? Setting a Standard for Use of the Assessing Clinical Ethics Skills (ACES) Tool.

Background: The field of clinical ethics is examining ways of determining competency. The Assessing Clinical Ethics Skills (ACES) tool offers a new approach that identifies a range of skills necessary in the conduct of clinical ethics consultation and provides a consistent framework for evaluating these skills. Through a training website, users learn to apply the ACES tool to clinical ethics consultants (CECs) in simulated ethics consultation videos. The aim is to recognize competent and incompetent clinical ethics consultation skills by watching and evaluating a videotaped CEC performance. We report how we set a criterion cut score (i.e., minimally acceptable score) for judging the ability of users of the ACES tool to evaluate simulated CEC performances. Methods: A modified Angoff standard-setting procedure was used to establish the cut score for an end-of-life case included on the ACES training website. The standard-setting committee viewed the Futility Case and estimated the probability that a minimally competent CEC would correctly answer each item on the ACES tool. The committee further adjusted these estimates by reviewing data from 31 pilot users of the Futility Case before determining the cut score. Results: Averaging over all 31 items, the proposed proportion correct score for minimal competency was 80%, corresponding to a cut score that is between 24 and 25 points out of 31 possible points. The standard-setting committee subsequently set the minimal competency cut score to 24 points. Conclusions: The cut score for the ACES tool identifies the number of correct responses a user of the ACES tool training website must attain to "pass" and reach minimal competency in recognizing competent and incompetent skills of the CECs in the simulated ethics consultation videos. The application of the cut score to live training of CECs and other areas of practice requires further investigation.

Talking about spirituality in the clinical setting: can being professional require being personal?

Spirituality or religion often presents as a foreign element to the clinical environment, and its language and reasoning can be a source of conflict there. As a result, the use of spirituality or religion by patients and families seems to be a solicitation that is destined to be unanswered and seems to open a distance between those who speak this language and those who do not. I argue that there are two promising approaches for engaging such language and helping patients and their families to productively engage in the decision-making process. First, patient-centered interviewing techniques can be employed to explore the patient's religious or spiritual beliefs and successfully translate them into choices. Second, and more radically, I suggest that in some more recalcitrant conflicts regarding treatment plans, resolution may require that clinicians become more involved, personally engaging in discussion and disclosure of religious and spiritual worldviews. I believe that both these approaches are supported by rich models of informed consent such as the transparency model and identify considerations and circumstances that can justify such personal disclosures. I conclude by offering some considerations for curbing potential unprofessional excesses or abuses in discussing spirituality and religion with patients.

How Medicine May Save the Life of US Immigration Policy: From Clinical and Educational Encounters to Ethical Public Policy.

Medicine has a conceptual contribution to make to the immigration debate. Our nation has been unable to move forward with meaningful immigration reform because many citizens seem to assume that immigrants are in the United States to access benefits to which they are not entitled. In contrast, when medicine encounters undocumented immigrants in the health care or medical education setting, it is obvious that their contributions to our health care system are denied by exclusionary laws. When the system is amended to be inclusive, immigrants become contributors to the systems that they access. I illustrate this thesis concerning the benefits of inclusion through an examination of the issues of forced medical repatriation, access to health insurance, and the access of undocumented students to medical education.

Physician, know thyself: the role of reflection in bioethics and professionalism education.

Reflection in medical education is becoming more widespread. Drawing on our Jesuit Catholic heritage, the Loyola University Chicago Stritch School of Medicine incorporates reflection in its formal curriculum and co-curricular programs. The aim of this type of reflection is to help students in their formation as they learn to step back and analyze their experiences in medical education and their impact on the student. Although reflection is incorporated through all four years of our undergraduate medical curriculum, this essay will focus on three areas where bioethics faculty and medical educators have purposefully integrated reflection in the medical school, specifically within our bioethics education and professional development efforts: 1) in our three-year longitudinal clinical skills course Patient Centered Medicine (PCM), 2) in our co-curricular Bioethics and Professionalism Honors Program, and 3) in our newly created Physician's Vocation Program (PVP).

The professionalism movement: can we pause?

The topic of developing professionalism dominated the content of many academic medicine publications and conference agendas during the past decade. Calls to address the development of professionalism among medical students and residents have come from professional societies, accrediting agencies, and a host of educators in the biomedical sciences. The language of the professionalism movement is now a given among those in academic medicine. We raise serious concerns about the professionalism discourse and how the specialized language of academic medicine disciplines has defined, organized, contained, and made seemingly immutable a group of attitudes, values, and behaviors subsumed under the label of "professionalism." In particular, we argue that the professionalism discourse needs to pay more attention to the academic environment in which students are educated, that it should articulate specific positive behaviors, that the theory of professionalism must be constructed from a dialogue with those we are educating, and that this theoretical and practical discourse must aim at a deeper understanding of social justice and the role of medicine within a just society.

Casuistry and its communitarian critics.

Communitarian critics have derided case-based reasoning for ignoring the need to arrive at a shared hierarchy of goods prior to case resolution. They claim that such a failure means that casuistry depends on either a naive metaphysical realism or an ethical conventionalism. Casuistry does embrace a certain unobjectionable moral realism and can require appeals to narrative histories, but despite this dependence on the surrounding culture, casuists possess a way to remain critical of society through the concept of practical wisdom and the use of a moral taxonomy. Therefore, casuistry's viability depends upon the existence and employment of this Aristotelian virtue. Furthermore, the casuistry that emerges is a sophisticated type of communitarianism rather than a free-standing method.