Medical Wisdom.

Wise medical actions hinge on deliberative judgment. In the medical context, deliberation requires a grasp of a problem's relevant generalizations, its particulars, and their interactions. The process of generalization, rooted in the advancement and application of scientific knowledge and statistical methods, is well understood. But particularization, the process of teasing out relevant unique features of a case, is obscure, neglected, or even trivialized. Physicians must take the time necessary to identify, carefully disentangle, and weigh the various biological, interpersonal, contextual, technical, and ethical facets of a case. Not only are such details fundamental to making worthwhile and acceptably achievable medical decisions, but a practiced dealing with these details is a key feature of wisdom in medicine. This essay proposes a set of strategies to guide physicians in achieving a thorough understanding of individual cases and their constituent particulars, a proposal informed by extensive experiences in the clinic and classroom and by a review of the literature, and enriched by consultations with colleagues from multiple disciplines in medicine and the humanities.

Intractable end-of-life suffering and the ethics of palliative sedation.

Palliative sedation (sedation to unconsciousness) as an option of last resort for intractable end-of-life distress has been the subject of ongoing discussion and debate as well as policy formulation. A particularly contentious issue has been whether some dying patients experience a form of intractable suffering not marked by physical symptoms that can reasonably be characterized as "existential" in nature and therefore not an acceptable indication for palliative sedation. Such is the position recently taken by the American Medical Association. In this essay we argue that such a stance reflects a fundamental misunderstanding of the nature of human suffering, particularly at the end of life, and may deprive some dying patients of an effective means of relieving their intractable terminal distress.

Abraham Flexner's "mooted question" and the story of integration.

Contemporary medicine is characterized by dualities. They include psyche and soma, subject and object, and, most important, science and humanism. The authors, in exploring Flexner's landmark publication, suggest that the history of curricular evolution has been marked by a quest for the integration of two knowledge bases: science and clinical medicine. They describe this goal as a preoccupation of medical educators, arguing that it was triggered, in part, by Flexner's recommendation for a two-phase curriculum. Their claim is illustrated with an analysis of motives for curricular renewal at one medical school and a review of published reports from educational opinion leaders. They discuss Flexner's conception of integration-namely, that unity could be achieved through methodology and, in particular, through inductive reasoning. They situate this perspective in the context of other purported integrative principles such as bioethics, narrative medicine, and the biopsychosocial model. They conclude by recommending an alternative framework for integration. The authors propose that a synthesis of two separate knowledge domains can be achieved through a common purpose and that, in a clinical context, that purpose is the well-being of the patient. Well-being is defined as the patient's ability to pursue achievable goals and purposes. It can be brought about by changing medicine's emphasis from the eradication of disease to the restoration of functions impaired by sickness. This idea is congruent with aspects of Flexner's understanding of medical practice, as shown in his statement that the restoration of normal functioning should be the doctor's "goal in action."

Teaching clinical thinking to first-year medical students.

BACKGROUND: The ability to think clearly and critically is necessary to normal human conduct. Particular forms of reasoning characteristic of practitioners of medicine have been studied, but a principled pedagogical framework that also reflects clinical practice has not been delineated. AIMS: The goals are: identify the principles that underlie the clinical thinking of physicians, develop a pedagogical framework, and design and implement curricular modules for medical students in the first year of their studies. METHODS: The authors reviewed prior work on clinical thinking of physicians and medical students as well as reflective pieces by seasoned clinicians. They also examined modalities of logic and inference used by physicians and others. The designed modules were implemented at the Faculty of Medicine at McGill University and linked to training in attentive listening and clinical observation. RESULTS: Five core features of a pedagogic framework on clinical thinking were developed and used to design and implement a series of teaching modules for first-year medical students. CONCLUSIONS: The core features, and the modules based upon them, can serve for further empirical work on clinical reasoning and lead to modules for advanced students as they progress in their acquisition of expertize.

Preparing medical students to become attentive listeners.

BACKGROUND: The ability to listen is critically important to many human endeavors and is the object of scholarly inquiry by a large variety of disciplines. While the characteristics of active listening skills in clinical practice have been elucidated previously, a cohesive set of principles to frame the teaching of these skills at the undergraduate medical level has not been described. AIMS: The purpose of this study was to identify the principles that underlie the teaching of listening to medical students. We term this capacity, attentive listening. METHODS: The authors relied extensively on prior work that clarified how language works in encounters between patients and physicians. They also conducted a review of the applicable medical literature and consulted with experts in applied linguistics and narrative theory. RESULTS: They developed a set of eight core principles of attentive listening. These were then used to design specific teaching modules in the context of curriculum renewal at the Faculty of Medicine, McGill University. CONCLUSIONS: Principles that are pragmatic in nature and applicable to medical education have been developed and successfully deployed in an undergraduate medical curriculum.

Preparing medical students to become skilled at clinical observation.

BACKGROUND: Observation is a fundamental skill for physicians and it is has been the subject of a resurgent interest. Although strategies for teaching observation have been described previously, many of them linked conceptually to emerging insights in visual literacy and aesthetic development, principles of clinical observation have not been elucidated. AIMS: The purpose of this study was to develop a set of principles that would be useful in guiding educators teach medical students how to observe. METHODS: The authors conducted a comprehensive review of the literature on the history and theory of clinical observation. They then consulted a group of individuals from a highly diverse background who, based on the nature of their work, were considered to have expertise in observation. RESULTS: Informed by the literature and the group of experts, the authors developed a set of four guiding principles relating to pedagogy and eight core principles of clinical observation. In the context of curriculum renewal at the Faculty of Medicine, McGill University, these principles were then used to create specific teaching modules. CONCLUSIONS: Principles that are pragmatic in nature, anchored in a theoretical framework of visual competence and applicable to medical education have been developed and successfully deployed.

A healing curriculum.

CONTEXT: The banner of patient-centredness flies over many academic institutions; however, the practice and teaching of medicine remain oriented to disease. This incongruence is the result of an original Flexnerian dichotomy between the basic and clinical sciences and is maintained by a more recent distinction between disease and illness. One mind-set emphasises basic science and pathology pedagogically, whilst clinical medicine becomes a search for disease. The second introduces the patient as the focal point, underlining the personal and social contexts of illness. RESPONSE AT A CONCEPTUAL LEVEL: We must orient ourselves to a single central theme, namely, the well-being of the individual patient. Doing so does not deny the importance of the scientific understanding of biological function. Indeed, recent advances in genetics may permit a richer view of the individual as a unique product of genetic, developmental and experiential forces. The foregoing provide a coherent framework for a scientifically guided and humanistic medicine, which replaces the false dichotomies that have plagued medical school curricula with a congruent and stereoscopic view of medical education. RESPONSE AT A CURRICULAR LEVEL: We describe an undergraduate programme, entitled 'Physicianship', based on the fundamental premise that healing is the doctor's primary obligation. Explicit training in a specific clinical method, whose cardinal features include observation, attentive listening and clinical reasoning, emphasises the knowledge and skills necessary to effect this theoretical framework. The understanding of illnesses emphasises loss of homeostasis, whereas the physical examination highlights impairments of function. The educational experience is enriched with numerous opportunities for self-reflection.

Ethics of practicing medical procedures on newly dead and nearly dead patients.

OBJECTIVE: To examine the ethical issues raised by physicians performing, for skill development, medically nonindicated invasive medical procedures on newly dead and dying patients. DESIGN: Literature review; issue analysis employing current normative ethical obligations, and evaluation against moral rules and utilitarian assessments manifest in other common perimortem practices. RESULTS: Practicing medical procedures for training purposes is not uncommon among physicians in training. However, empiric information is limited or absent evaluating the effects of this practice on physician competence and ethics, assessing public attitudes toward practicing medical procedures and requirements for consent, and discerning the effects of a consent requirement on physicians' clinical competence. Despite these informational gaps, there is an obligation to secure consent for training activities on newly and nearly dead patients based on contemporary norms for informed consent and family respect. Paradigms of consent-dependent societal benefits elsewhere in health care support our determination that the benefits from physicians practicing procedures does not justify setting aside the informed consent requirement. CONCLUSION: Current ethical norms do not support the practice of using newly and nearly dead patients for training in invasive medical procedures absent prior consent by the patient or contemporaneous surrogate consent. Performing an appropriately consented training procedure is ethically acceptable when done under competent supervision and with appropriate professional decorum. The ethics of training on the newly and nearly dead remains an insufficiently examined area of medical training.

How the Report made a difference: reflections on a 15th anniversary.

To mark the 15th anniversary of the Hasting Center Report, six authors who have written for the Report since its beginning comment briefly on an article or a theme from the Report that has had an impact on their thinking or on the way that bioethics has developed as a discipline. The titles of the commentaries are as follows: "In praise of William May's 'attitudes'" (A.M. Capron); "On opening human experimentation to moral debate" (S. Bok); "Learning from Ramsey" (R.A. McCormick); "Toward a science of particulars" (E.J. Cassell); "Challenging the power of codes" (R.M. Veatch); and "Relating moral principles and moral behavior" (D. Callahan).