Advice for my chief resident

I have been privileged to have served as a division of rheumatology chief and/or program director for 18?years and as a department of medicine chair and medicine residency program director for another 22?years. During the latter, I collected and codified advice for my chief residents. Selected highlights are presented as follows.     

“Please amputate my child's arms”

Jeremy sustained bilateral complete brachial plexus injuries in an auto collision on an icy road a month before his third birthday. The accident rendered both upper extremities completely flail and insensate: he has no motor or sensory function of his shoulders, elbows, wrists, or digits. Jeremy does, however, have normal function of the lower extremities. Physical therapists have worked with the child for over a year with no noted improvement in arm function. Jeremy falls frequently, causing injury to his face and head, and occasionally, his arms get twisted or caught in his crib and his fingers turn blue. Jeremy's mother, who carries the main responsibility for his daily care, believes that his insensate arms are too heavy and “get in his way,” causing the falls. She and Jeremy's father present to the orthopedic clinic at the children's hospital with the request of having both arms amputated. The primary orthopedic surgeon and the orthopedic team disagree with the parents that bilateral upper‐extremity amputation offers any medical benefit, but Jeremy's mother tells the surgeon that, if he will not perform the surgery, her family will find a doctor who will. The surgeon, who feels ethically distressed by the parental insistence on this amputation in such a young child, requests an ethics consultation.     

'Losing my touch': decline in self-reported confidence in performing practical procedures in consultant oncologists

This study aimed to compare the confidence of oncology consultants and specialist registrars (SpRs) in the performance of practical procedures, to contrast this with confidence in other areas of practice and to determine at what grade they felt most confident. Questionnaires were sent to all 57 oncology consultants and SpRs in the South-West region. Respondents scored confidence on a five-point Likert scale. The response rate was 70%. SpRs were significantly more confident in cardiopulmonary resuscitation (p = 0.003) and central line insertion (p = 0.006). Consultants were significantly more confident in developing management plans (p = 0.001) and performing committee work (p = 0.002). Only 6% of consultants felt most confident performing practical procedures as a consultant, and were less confident about these than other tasks (p = 0.001). Some 86% of SpRs considered they were more confident performing practical procedures as senior house officers (SHOs). In conclusion, self-reported confidence in performing practical procedures declines during career progression in oncology. This raises questions about the teaching and supervision of these procedures. If there is a greater emphasis on a consultant-provided service, their educational needs will need to be recognized and retraining or outsourcing of these procedures to other specialties may be necessary.     

Professional socialization revised: medical students' own conceptions related to adoption of the future physician's role--a qualitative study

This qualitative study investigated medical students' experiences of and conceptions concerning their professional development during their first clinical year. Twenty-two medical students participated in a portfolio course. Their personal writings were analysed by qualitative content analysis. Self-image as a future doctor rapidly evolved during patient contacts in the first clinical year. At the beginning, students felt lacking in credibility in front of their patients but towards the end they enjoyed their role as student-physicians. The medical students felt intense stress but the majority of this may stem from strong emotional experiences rather than the medical knowledge to be absorbed. Students were afraid of being humiliated by hospital staff and they felt themselves to be outsiders. No cynicism or suppression of feelings was observed in writings. The first clinical year is a period of intense emotional experiences and rapid development. Portfolios as learning tools may help in recognizing key experiences and in supporting professional development.     

A Demanding Ethics of Care

The writer responds to the book review essay “Caring for People with Disabilities: An Ethics of Respect,” by Kevin Mintz and David Wasserman, in the January-February 2020 issue of the Hastings Center Report, which discusses her book Learning from My Daughter: The Value and Care of Disabled Minds.     

A Futile Use of Futility

As the rates of intravenous opioid use have increased, so have its associated medical complications, such as endocarditis, and known interventions, such as heart-valve replacements. For many patients, including Jacob, whose case was brought to my psychiatric consult service and to my colleagues in the clinical ethics service, relapse increases the risk of repeat endocarditis and the need for repeat surgical interventions. Previous works have posed the bioethical quandary regarding the responsibilities of a surgeon in these repeat procedures and whether a surgeon may ethically refuse to perform a repeat intervention in a patient who has relapsed. Notions of futility are commonly used to navigate this complex terrain, and they were the focus of the ethics consideration given to Jacob's case, in which surgeons were reluctant to perform valve replacements. In this narrative essay, I interrogate the concept of futility by appealing to its history and variable meanings, and I argue against its relevance in cases like Jacob's. I propose that a more suitable bioethical approach in such cases would consider resource allocation, the sociocultural stigma of addiction, and the interpersonal and narrative factors that make each case unique.