tag:blogger.com,1999:blog-74766218883836048342024-03-13T16:14:34.454-04:00Health Care Organizational EthicsFor discussion and debate about the ethics of health care organizations and the wider health system.Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.comBlogger677125tag:blogger.com,1999:blog-7476621888383604834.post-58409849990646019892019-06-30T10:30:00.000-04:002019-06-30T19:16:49.662-04:00Teaching English in an anti-democratic culture<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-size: large;">Two days ago I led a workshop for teachers on "Making Ethics part of High School and Middle School English Class" at the <a href="http://www.middlebury.edu/blse">Bread Loaf School of English</a> in Vermont, as I've done every summer since 2012. (A post about last year's workshop, with links to earlier posts, is <a href="https://healthcareorganizationalethics.blogspot.com/2018/07/ethics-education-and-democratic-values.html">here</a>.)<br /></span><br />
<span style="font-size: large;">We began from the perception held by the teacher-participants that many of our leaders do not demonstrate democratic values. Not surprisingly, the anti-democratic characteristics that are so prominent in our political culture are showing up in the classroom as self-centeredness, lack of respect for others and intolerance of differences. The teachers believe that our political culture intensifies the self-centeredness that is part of human nature and normal development.</span><br />
<span style="font-size: large;"><br />The teachers discussed a wide array of classroom approaches they use to encourage democratic values in their students. These included:</span><br />
<ul style="text-align: left;">
<li><span style="font-size: large;">Materials from the <a href="https://www.tolerance.org/">Teaching Tolerance</a> program</span></li>
<li><span style="font-size: large;">The <a href="https://www.exeter.edu/exeter-difference/how-youll-learn">Harkness</a> method, pioneered at Phillips Exeter Academy</span></li>
<li><span style="font-size: large;">A systematic approach to <a href="https://sociallyskilledkids.com/perspective-taking/">Perspective Taking</a> </span></li>
<li><span style="font-size: large;"><a href="http://www.pz.harvard.edu/">Project Zero</a> at the Harvard University School of Education </span></li>
<li><span style="font-size: large;">Schools that introduce <a href="https://www.mindfulschools.org/">Mindfulness </a>across the curriculum</span></li>
</ul>
<span style="font-size: large;">As someone who has never taught at the pre-college level, all of these techniques made sense to me, much as many of the different "schools" of psychotherapy make sense. I believe they share the aim that a participant called "metacognition" - the capacity to step back from our own initial thoughts and emotions to take a wider view of the situation we are engaged with.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Another participant urged teachers to "return to our lofty purpose" of drawing students into the magical world of words - literature and writing - as both a primary aim and as a path towards strengthening democratic values.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">The teacher-participants unanimously agreed that literature and writing promote the democratic orientation that American schools seek to strengthen. Well chosen texts act both as "mirrors" (helping students sharpen their own sense of identity) and "windows"(fostering understanding of others). And learning to write well teaches us to step back from our original thoughts and words to see whether we can back up what we're saying and whether we're saying it in a way our readers will understand.</span><br />
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<span style="font-size: large;"><span style="font-family: "times new roman" , serif; font-size: 18.0pt;"><br />Over the many years I've spent at the Bread Loaf School of English I've learned from the teachers who are students in the program that the primary objectives they have for their students are to (1) increase skill and engagement with literature and writing and (2) promote development of democratic attitudes, altruism and concern for social justice. </span></span></div>
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<span style="font-size: large;"><span style="font-family: "times new roman" , serif; font-size: 18.0pt;"><br />At its heart, teaching, like medicine, is a calling. Supporting education for all should be one of our first goals as citizens. It's a privilege to be able to work with dedicated teachers like the group I worked with on Friday.</span></span></div>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 4"/>
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Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-5644345053908268982018-08-07T09:30:00.000-04:002018-08-08T20:51:53.435-04:00The Moral Responsibilities of Pastors and Psychiatrists<div dir="ltr" style="text-align: left;" trbidi="on">
A recent New York Times <a href="https://www.nytimes.com/2018/08/05/us/bill-hybels-willow-creek-pat-baranowski.html">article</a> reports accusations of "inappropriate" sexual behavior on the part of Reverend Bill Hybels. The article describes Hybels as a "superstar pastor" who initiated the megachurch era by founding the <a href="https://www.willowcreek.org/">Willow Creek Community Church</a>.<br />
<br />
In 1985, feeling lost after her divorce, Pat Baranowski felt that God had spoken to her when Reverend Hybels reached out to her, drew her into the church, gave her a job, and ultimately invited her to live with him and his wife and children. She alleges that Reverend Hybels drew her into a relationship that included oral sex. She ultimately ended the relationship, but was plagued with guilt, shame and a feeling that God's servant had betrayed her.<br />
<br />
Ms. Baranowski kept her story to herself until other women brought forward allegations of their own. Reverend Hybels vigorously <a href="http://www.chicagotribune.com/news/local/breaking/ct-met-willow-creek-pastor-20171220-story.html">denies </a>all of the allegations, calling them a mix of "misinterpretations" and "outright lies." The church elders investigated the allegations against Reverend Hybels and concluded that they were not believable. But a day after the New York Times article, Reverend Hybels <a href="https://www.nytimes.com/2018/08/06/us/willow-creek-bill-hybels-investigation.html">resigned </a>from his leadership role in the church.<br />
<br />
The Hybels/Baranowski story illustrates in dramatic fashion the tinder-box nature of pastoral and psychiatric relationships. A vulnerable person feels uniquely understood by a trusted caretaker who is invested with the charisma that comes from being seen as a pastor serving God or a physician serving the healing profession. The pastor or physician receives love, gratitude and idealization. Used skillfully and responsibly, this "transference" can promote healthy development. But as Ms. Baranowski and other members of the Willow Creek congregation allege, the relationship of trust can be exploited, with potentially devastating consequences for the congregant or patient.<br />
<br />
As is so often the case, this is a "he said/she said" situation. Reverend Hybels presents himself as a victim, not an exploiter/sinner. There is a continuum of possibilities. At one extreme, he could be the victim of a combination of misunderstandings, fantasies, and malicious accusations. At the other he could be an exploiter who is fully aware of his duplicity and issues denials he knows to be false. In between is a range of misunderstandings and human frailties on the part of all parties to the relationships.<br />
<br />
Pastors and psychiatrists have distinctive ethical obligations associated with their roles in society. These obligations go beyond ordinary morality. Whatever religion they follow, pastors present themselves as servants of gods, devoted to the salvation of their congregants. Psychiatrists and other physicians present themselves as servants of medicine, devoted to serving their patients' health and well-being. In return for these commitments, society grants pastors and physicians distinctive forms of respect and privilege.<br />
<br />
Whatever the truth is about the Willow Creek Church situation, it's a tragedy. #metoo will see one more example of male exploitation. Some of the faithful Willow Creek congregants will see misunderstanding, maliciousness, or even the devil instigating false accusations. An anthropologist from Mars will not claim certainty about the truth of the situation, but will see it as an inevitable hazard created by our human needs, vulnerabilities and limitations.<br />
<br />
(For posts that discuss the power of transference in the pastoral and psychiatric relationships, see <a href="http://healthcareorganizationalethics.blogspot.com/2015/11/if-youre-moviegoer-dont-miss-spotlight.html">here</a> and <a href="http://healthcareorganizationalethics.blogspot.com/2016/03/computer-patient-sex.html">here</a>.)</div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-67485823284096341772018-08-03T08:00:00.000-04:002018-08-15T10:16:12.237-04:00The Enduring Wisdom of Franz Ingelfinger<div dir="ltr" style="text-align: left;" trbidi="on">
On May 5, 1977, Dr. Franz Ingelfinger, editor of the <i>New England Journal of Medicine</i>, delivered the <a href="http://bioethics.hms.harvard.edu/gay-lecture">George W. Gay lecture</a> on medical ethics at Harvard Medical School. I was in full time practice at the time and, alas, was not at the lecture.<i> </i><br />
<br />
Dr. Ingelfinger, one of the world's experts on esophageal cancer, had developed the disease he had taught so many others about. Here's what he tells us with regard to the difficult question of
whether to undergo chemotherapy and radiation after surgery:<br />
<br />
<blockquote class="tr_bq">
<i>I received from physician friends throughout the country a barrage of
well-intentioned but contradictory advice. As a result, not only I, but
my wife, my son and daughter-in-law (both doctors), and other family
members became increasingly confused and emotionally distraught.
Finally...one wise physician friend said, "What you need is a doctor."
He was telling me to forget the information I already had and the
information I was receiving from many quarters, and to seek instead a
person who would...tell me what to do, who would in a
paternalistic manner assume responsibility for my care. When that
excellent advice was followed, my family and I sensed immediate and
immense relief."</i></blockquote>
Yesterday I spoke with a dear friend whose spouse is suffering from a profoundly serious medical condition that calls for complex clinical, psychosocial and financial decisions. My friend reported "if I had a dollar for every time I was asked - 'what should we do about XYZ' - there would be no financial problems to deal with!" My friend described feeling "you are the doctor - what do you think we should do?"<br />
<br />
My friend was encountering a common medical ethics dilemma. We physicians are taught to provide "patient-centered" care, to "respect patient and family autonomy" and to avoid "paternalism." But as Dr. Ingelfinger described so poignantly, in the context of serious illness, patients and families also need support and guidance. Physicians need to develop communication skills that allow us to thread between respecting autonomy and providing structure and guidance.<br />
<br />
There's no single right answer as to how to do this. I often found it helpful to (a) elicit the patient's goals and values, (b) give my view of what course of action these goals and values called for, but then (c) check on whether, from the patient's perspective, I'd gotten it right.<br />
<br />
Over the years with medical students and residents I've often quoted Muhammad Ali's philosophy of boxing: "float like a butterfly/sting like a bee." Ali's eight-word formula conveys the need to embrace and integrate ostensibly incompatible components. Doing this takes experience. It also takes time.<br />
<br />
I don't know if my friend's physicians felt rushed. My brilliant colleague Dr. Amy Ship recently <a href="https://link.springer.com/article/10.1007/s11606-018-4494-7">wrote</a> about how limited time constrains us in our efforts to be the best we can with patients and families. But whether or not time was a factor for my friend's physicians, Dr. Ingelfinger's guidance from his own experience as a patient holds true forty-one years after his lecture.<br />
<br />
(Dr. Ingelfinger's lecture, published in 1980 after his death, is available <a href="http://lapinelarts.com/Arrogance001.pdf">here</a>. "Physicians as counsellors," a previous post on a related topic, is <a href="http://healthcareorganizationalethics.blogspot.com/2016/02/physicians-as-counsellors.html">here</a>. ) </div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-85287082070587678402018-07-23T09:00:00.000-04:002018-07-23T10:52:13.037-04:00Forest Bathing<div dir="ltr" style="text-align: left;" trbidi="on">
For years I've enjoyed taking long walks in the woods. But it's only from reading a recent New York Times <a href="https://www.nytimes.com/2018/07/12/well/take-a-walk-in-the-woods-doctors-orders.html">article </a>that I learned I've been following the Japanese practice of <i>shinrin yoku</i> - "forest bathing."<br />
<br />
There's nothing new about walking in the woods. Our ancestors spent their lives in forests. I assume many forest-dwelling genes are buried in our DNA. But as our species has become progressively more urbanized we spend most of our time indoors. A 2001 EPA survey <a href="https://www.washingtonpost.com/news/to-your-health/wp/2016/05/17/forest-bathing-is-latest-fitness-trend-to-hit-u-s-where-yoga-was-30-years-ago/?utm_term=.86a285517b3e">reported </a>that we Americans spend 87% of our waking time indoors, and another 6% in an enclosed vehicle!<br />
<br />
In 1982 the Japanese Ministry of Agriculture, Forestry and Fisheries coined the term translated as "forest bathing" to describe the effort to imbibe what it saw as the healing power of nature by going into green areas with a mindful attitude. Since then, in the U.S., an "<a href="http://www.natureandforesttherapy.org/">Association of Nature Forest Therapy</a>" has trained and certified multiple cohorts of forest guides. A Google search shows that forest bathing is catching on as a commercial "back to nature" trend.<br />
<br />
As an adolescent, <i>Walden</i> and Henry Beston's <i>The Outermost House</i> were among my favorite books. It seemed obvious that there was something very "natural" about being in "nature."<br />
<br />
Three days ago the Journal of the American Medical Association <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2688343">published </a>an important study demonstrating that creating green spaces of grass and trees on what had been garbage-strewn abandoned lots has a positive mental health effect on the neighborhood. This was a methodologically rigorous, randomized study that is likely to convince skeptics that there's more than sentimental anecdote behind the endorsement of time in the woods as a promoter of health and well-being.<br />
<br />
In an aggressively capitalist society, it only takes a few nanoseconds for good ideas to become "monetized" and the focus for snake oil style hype. On the web I found vendors hinting that walking in the forest will combat cancer. But despite the hype surrounding the forest bathing concept, if I were still in clinical practice I would add spending time in "nature" as a recommendation to many of my patients.</div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-39020487329841655952018-07-21T11:00:00.000-04:002018-07-21T11:36:06.639-04:00Medications and Religious Rituals<div dir="ltr" style="text-align: left;" trbidi="on">
This morning as I put the pills I take into the pill container I fill each week, I thought about religious ritual.<br />
<br />
On average, Americans over 65 take between 4-5 different medications each day. (See <a href="https://assets.aarp.org/rgcenter/health/rx_midlife_plus.pdf">here </a>and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4573668/">here </a>for more information on pill-taking.) I noticed my feeling of pleasure as I put each of the 4 pills I take into the slots of the days of the week. I was carrying out an instrumental task, but the emotion I felt came from an entirely different realm.<br />
<br />
I understood the rationale for each of the medications and found myself thinking of them as friendly presences, whose aim was to minister to my well-being. These thoughts led me to recall all the families I'd visited at home in my years of practice who showed me the Saints (Catholic) or Gods (Hindu) they prayed to and who they saw as crucial contributors to their health.<br />
<br />
Although in theological terms I define myself as a "secular humanist," I respond to the pill-container filling with the same underlying emotions that my religiously observant patients felt about their Saints and Gods. It's important that I understand the medical rationale for the medications and their potential side effects, but I'm sure that a component of their efficacy comes from my attributing to them a benevolent intention to heal.<br />
<br />
In the early 1970s I chose to work on the Jewish High Holidays, based on my lack of theological acceptance of the dogmas the holidays were based on. On Rosh Hashanah I was making a home visit to a Catholic family whose treatment I was involved with. They proudly showed me the little alter they used for prayer. It occurred to me that they might not have any more <u>theological</u> conviction about the Saints they prayed to than I did for Jewish theology. But unlike me, they were respecting the traditions and values they'd been brought up with.<br />
<br />
From that day on, whether or not I was attending religious services, I didn't work on the High Holidays. I'm grateful to the family that taught me to distinguish between ritual, symbolic action, and literal theological beliefs.<br />
<br />
In similar fashion, I'm grateful for the caretaking attitudes I associate with the medications I put into the pill container this morning.<br />
<br />
(For a previous post on why religious language can be so valuable in clinical practice, see <a href="http://healthcareorganizationalethics.blogspot.com/2016/04/bringing-best-of-religion-into-medicine.html">here</a>, and for a discussion of physicians as "Counsellors," see <a href="http://healthcareorganizationalethics.blogspot.com/2016/02/physicians-as-counsellors.html">here</a>.)<br />
<br /></div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-88269702739914848192018-07-12T18:00:00.000-04:002018-12-08T15:55:27.721-05:00Ethics education and democratic values in high school and middle school<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-size: large;">Every summer since 2012 I've taught at least one workshop on "making ethics part of high school and middle school English class" at the <a href="http://www.middlebury.edu/blse">Bread Loaf School of English</a>, a Middlebury College program in which the students, mostly teachers, can get a Masters degree in English in the course of 4-5 summers. I've written a series of posts on what I've learned in the workshops (see <a href="http://healthcareorganizationalethics.blogspot.com/2012/07/teaching-ethics-in-high-school-and.html">here</a>, <a href="http://healthcareorganizationalethics.blogspot.com/2016/08/close-reading-improved-writing-and.html">here</a>, <a href="http://healthcareorganizationalethics.blogspot.com/2017/07/teaching-ethics-in-high-school-and.html">here</a>, <a href="http://healthcareorganizationalethics.blogspot.com/2017/07/self-disclosure-in-clinic-and-classroom.html">here</a> and <a href="http://healthcareorganizationalethics.blogspot.com/2017/07/encouraging-democratic-values-in.html">here</a> if you're interested.)</span><br />
<span style="font-size: large;"><br /></span>
<br />
<div class="MsoNormal">
<span style="font-size: large;">I build the workshops around the issues the teacher-students bring to it. This year several teachers brought up the question of how best to deal with students who assert views the teachers regard as morally repugnant. They don't want to let the repugnant views go unchallenged but at the same time they don't want to put down the student. </span><span style="font-size: large;">To squelch the student goes against the goal of fostering
a classroom atmosphere of respectful deliberation, but to let the repugnant view stand can be seen as
enabling.</span></div>
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">The National Conference of Teachers of English (NCTE) <a href="http://www.ncte.org/positions/statements/academic-freedom">statement on Academic Freedom</a> urges teachers to cultivate democratic values in the classroom as a central objective:</span>
<br />
<blockquote>
<span style="font-size: large;"><i>NCTE maintains that students have the right to materials and
educational experiences that promote open inquiry, critical thinking,
diversity in thought and expression, and respect for others. </i></span></blockquote>
<span style="font-size: large;">
At the same time, the NCTE directs teachers not to proselytize or preach to their students: </span><span style="font-size: large;"><i><br /></i></span><br />
<blockquote>
<span style="font-size: large;"><i>Educators and educational institutions must not require or coerce
students to modify their beliefs or values. Efforts to convince students
to modify their beliefs or values must be academically justifiable.</i></span></blockquote>
<span style="font-size: large;">The teachers are in a difficult bind. They want to encourage "diversity of thought," but human nature (and adolescence) being what it is, diversity can include prejudice, bias, and hate - the opposite of the "respect for others" NCTE calls for!</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">The teachers asked each other - "how can we best deal with this dilemma?" Three examples illustrate the kinds of strategies they suggested:</span><br />
<ul style="text-align: left;">
<li><span style="font-size: large;"> After a hurricane, a student said "why should we spend money helping people from XYZ?" This touched a very personal nerve - XYZ was where the teacher came from. The teacher kept anger in check and asked the class "does anyone have ideas about why we might want to spend money helping XYZ?" The question led to a thoughtful discussion. </span></li>
<li><span style="font-size: large;">A student called a classmate "you bitch." The teacher used a jiu jitsu-like approach: "thank you for bringing that up - it lets us discuss the implications of the language we use..."</span></li>
<li><span style="font-size: large;">Another teacher described how she used "kindness" in dealing with cruel comments: "that might be hurtful...let's put it aside."</span></li>
</ul>
<span style="font-size: large;">In medical practice and medical education we pay tremendous attention to the doctor/patient relationship. For teachers, "classroom management" has the same prominence. But the challenges I've faced over the years in relating to patients strike me as much easier than the challenges the teachers I've come to know at Bread Loaf have to deal with. </span><br />
<br />
<span style="font-size: large;">As physicians, we're largely in 1:1 interactions, except for pediatricians, who deal with parents as well as the child, and geriatricians, who often deal with their patient's caretakers as well as the patient. Our field of action is less complex than a classroom that could have as many as 30 youngsters. And teachers typically must consider the expectations of principals and other administrators, parents and the school board in addition to dealing with a classroom full of bumptious students.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">At the end of the workshop, I asked if the participants could help me pull together the wide-ranging discussion. The final comment, coming from an ex-teacher, was especially useful. He pointed out how much students learn from the way we comport ourselves and relate to them. Whatever the problematic situation we're dealing with, fairness, thoughtfulness and compassion will always convey "good lessons."</span><br />
<span style="font-size: large;"><br /></span>
<br />
<div style="text-align: left;">
<span style="font-size: large;">Recalling his comments put me in mind of Francis Peabody's 1927 address to Harvard Medical Students on "<a href="https://depts.washington.edu/medhmc/wordpress/wp-content/uploads/Peabody.html">The Care of the Patient</a>" that was given to us in a thin red booklet on our first day of medical school in 1960. Peabody's unforgettable final line rings true 91 years later. I expect the same will be said in 2118 and 2218: "One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient."</span></div>
</div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-1500392241271403902018-07-03T09:00:00.000-04:002018-07-04T15:24:35.504-04:00Transmission of Values within a Profession<div dir="ltr" style="text-align: left;" trbidi="on">
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Last night I had the pleasure and
privilege of having an extended conversation about medical ethics with <a href="http://www.middlebury.edu/about/president/bio">Laurie Patton</a>,
president of Middlebury College. I was surprised when Laurie expressed great
interest in my experience teaching medical ethics. Was she just being polite?
It turned out to be much more than that.</div>
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<br /></div>
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Laurie explained that two months ago she’d invoked the
Hippocratic oath and the influence of her surgeon father in an <a href="http://middleburymagazine.com/old-chapel/our-moral-directive/">essay</a>
titled “Our Moral Directive,” in which she argued that “a Middlebury education
should be accessible to all, regardless of financial means.” Here’s the opening
paragraph:</div>
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<br />
<blockquote>
<i style="mso-bidi-font-style: normal;">My father is a retired
cardiovascular thoracic surgeon. My childhood memories are punctuated with
instances of him being called away from home for emergency surgeries. On those
days, and many others over his long career, he never questioned whether the
patients whose lives he was trying to save were able to pay for his
services. He had taken the [Hippocratic] oath to heal to the best of his
ability all those who presented themselves—and he spent his career doing so…In
higher education, we don’t—yet—have our own official version of the Hippocratic
oath. But at Middlebury, we do have a mission that serves as our moral
directive…</i> </blockquote>
<br />
<div class="MsoNormal">
</div>
<br />
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Our conversation and her essay conveyed a crucial insight
into what it means to be part of a profession. As professionals we profess
values imbibed from our teachers. Laurie invokes two - her father and
Hippocrates. She treasures stories her father told about nurses in the operating room who
saved him from making mistakes. From those stories she took lessons about
respect for competent women, humility about one’s own expertise, and teamwork to
serve patients.</div>
<div class="MsoNormal">
<br /></div>
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Out of curiosity I Googled “Dr
Patton cardiovascular surgeon.” What I found reinforced the lesson about
transmission of values within a profession. In college Dr. Patton broke his
collar bone playing hockey. Two of his moral <a href="http://magazine.hms.harvard.edu/surgery/taking-history">influences</a>
were the surgeons who took care of him – their empathy, competence, positive
attitude and the pleasure they took in their work. And in an <a href="https://www.massgeneral.org/surgery/assets/pdfs/surgicalsociety/FALL_2007.pdf">essay
</a>of his own, Dr. Patton tells the story of Dr. Daniel Fiske Jones, a noted
surgeon who graduated from Harvard Medical School 62 years before Dr. Patton
did. The subtext of the story is that Dr. Patton is guided by the same values that guided Dr. Jones.<br />
<br />
In my first year of medical school I experienced the process of value
transmission directly. I was in a tutorial group that met with <a href="http://www.nasonline.org/publications/biographical-memoirs/memoir-pdfs/castle-wb.pdf">Dr.
William Castle</a>, a distinguished hematologist. Dr. Castle, who was 63 at the
time, described the following dialogue from when he interned at the
Massachusetts General Hospital in the early 1920s:</div>
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<i>Teacher:
Dr. Castle, if you had a patient with pneumonia, and you did ABCD, but the
patient died, how would you feel?</i></div>
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<i> </i> </div>
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<i>Dr. Castle: I would feel terrible!</i></div>
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<i> </i> </div>
<div class="MsoNormal">
<i>Teacher: Dr. Castle - if you persist in feeling that way,
you will have to leave medicine. You would have done everything that we are
able to do at this time. You will have to learn to govern your emotions! </i>(reconstructed
from my memory)</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Dr. Castle was a gentle, compassionate man who I admired. Over the years his story has led me to reflect on the challenge of how to be close enough to our patients to feel <a href="http://healthcareorganizationalethics.blogspot.com/2013/11/the-right-kind-of-love-between-doctors.html">love </a>for them, and at the same time to have enough internal "insulation" to maintain our own stability when our patients do not do well.<br />
<br />
Laurie Patton is applying the values professed by her surgeon father. I reflect with my own students about the values Dr. Castle's teachers tried to pass on to him almost 100 years ago. </div>
<div class="MsoNormal">
<br /></div>
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That's a large element of what professions are all about!</div>
</div>
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<br /></div>
<blockquote class="tr_bq">
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</div>
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<span style="font-family: "times new roman" , serif; font-size: 12.0pt; line-height: 107%;"><br /></span></div>
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<span style="font-family: "times new roman" , serif; font-size: 12.0pt; line-height: 107%;"><br /></span></div>
</div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-30019103228435101512018-06-29T09:00:00.000-04:002018-06-29T15:35:33.416-04:00How not to handle conscientious objection<div dir="ltr" style="text-align: left;" trbidi="on">
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<![endif]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">On the evening of June 21, Nicole Mone Arteaga went to
Walgreen's Pharmacy in Peoria, Arizona (a suburb of Phoenix) to fill a
prescription for misoprostol. The 9 week fetus in her longed-for pregnancy had
no heartbeat, and the pregnancy would end in a miscarriage. She chose a medical
rather than surgical removal of the non-viable fetal tissue.</span><br /><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"></span><br />
<div class="MsoNormal" style="line-height: normal; margin-bottom: 5.0pt;">
<span style="font-family: "Times New Roman",serif; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">
<br />
When she arrived at the pharmacy, staff pharmacist Brian Hreniuc asked if she
was pregnant. On hearing the answer he told her his "ethical beliefs"
forbade him from filling the prescription. According to Ms. Arteaga's <a href="https://www.facebook.com/nicole.arteaga1?lst=100000367783273%3A1599340517%3A1530236041"><span style="color: blue;">Facebook post</span></a> her 7 year old and five customers
could hear the exchange. The result: "I left Walgreens in tears, ashamed
and feeling humiliated by a man who knows nothing of my struggles but feels it
is his right to deny medication prescribed to me by my doctor."<br />
<br />
Next day Ms. Arteaga was able to fill the prescription at another branch of
Walgreen's. <br />
<br />
Arizona law allows pharmacists to exercise conscience as Mr. Hreniuc did. And
while reflective individuals differ on whether professional responsibility to
serve one's patients or individual conscience should rule in situations like
this, my Catholic friends have helped me understand how for Mr. Hreniuc,
filling the prescription could make him feel complicit in what he might see as a
mortal sin. But as experienced by Ms. Arteaga, he did not communicate in the
right way.<br />
<br />
Here's what needed to be done. (1) "I'm so sorry for what you are going
through." (2) "I have to refer you to another
pharmacy/pharmacist." (3) "I want to wish you the best for the
future." The conversation should have been private, not audible to others.
The tone should be warm, caring and apologetic, not self-righteous. Ideally,
Walgreen’s would have systems in place so that patients would not encounter
pharmacists who were not willing to fill their prescriptions. And for those
like Mr. Hreniuc, there should be rigorous training in how to communicate in a
manner that respects the needs of patients as well as the conscience claims of
the staff.<br />
<br />
It's not impossible that Mr. Hreniuc conducted himself this way. The pain of
the situation could have prevented Ms. Arteaga from experiencing an effort at
compassion. I know from experience that this can happen. Many years ago I came
upon a distraught couple at the health center where I worked. They had just
received bad news. The husband had cancer. I had recently taken a course on
dealing with bad news. I sat down with the couple and spoke with them. I'm
reasonably confident that a videotape would have shown that I applied what I
had learned.<br />
<br />
A week or two later a letter of complaint came to the administrator of the
health center (me) from the couple. The letter described the cold, cruel person
they had encountered (me). For me it was a chastening lesson in the potential
difference between what is intended and said by the clinician and heard by the
patient.<br />
<br />
Arizona state Sen. John Kavanagh, co-sponsor of the 2009 law that allows
pharmacists to refuse to fill abortion or emergency-contraceptive prescriptions
based on moral or religious beliefs, showed a shameful defensiveness and lack
of empathy in his <a href="http://www.chicagotribune.com/business/ct-biz-walgreens-pharmacist-training-20180626-story.html"><span style="color: blue;">comments </span></a>on Ms. Arteaga's experience:</span></div>
<br />
<blockquote>
<blockquote class="tr_bq">
<span style="font-family: "Times New Roman",serif; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">He said he was surprised that Arteaga wasn't more
sympathetic with the pharmacist, given that she eventually was able to get the
medicine from another Walgreen's location. "What's the problem?" he
said. "She got what she wanted. The pharmacist complied with the law. I
don't see why she doesn't respect the pharmacist's right to not do this,"
he said.</span></blockquote>
</blockquote>
In her Facebook post Ms. Arteaga shows an admirable understanding of the situation: "<span class="text_exposed_show">I get it, we all have our beliefs." She appears to accept the issue of conscience but rightfully does not accept the way the conscience exception was carried out. In her response - a public post and a complaint to Walgreen's management - she is being an ideal advocate. Her complaint gives Walgreen's, and professionals who might invoke conscience in not offering a medically indicated legal service, guidance in how to conduct themselves in a more ethically admirable manner. </span> <br />
<br />
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<br />
<br />
</div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-24866065655234998762018-06-24T09:00:00.000-04:002018-07-04T21:21:59.712-04:00The Moral Vision of Primary Care<div dir="ltr" style="text-align: left;" trbidi="on">
The underlying vision of primary care is to do what is needed to promote and restore health. Sometimes this requires referring patients to specialists, but more often it is done directly.<br />
<br />
An <a href="https://www.nytimes.com/2018/06/23/health/opioid-addiction-suboxone-treatment.html?emc=edit_th_180624&nl=todaysheadlines&nlid=424309060624">article</a> in today's New York Times about Dr. Nicole Gastala describes how the young physician, just out of residency and paying off her loans through practice in a <a href="https://www.youtube.com/watch?v=xZFPe2RsaqY">community clinic</a> in Marshalltown, Iowa, encountered the opiate epidemic and decided to do something about it. She did the required training to be licensed to prescribe buprenorphine so that she could provide medication assisted treatment to patients with opiate addiction. She got a federal grant that facilitated starting a program and hiring a nurse to join her in staffing it. She continues her own education via telemedicine with a <a href="https://www.weitzmaninstitute.org/clinics/substanceabuse/">clinic in Connecticut</a> that provides consultation and education to primary care buprenorphine providers. She has strengthened her own capacity for acceptance of patients who relapse. And, as she and her husband prepare to move back to Chicago, she is taking steps to perpetuate the buprenorphine program.<br />
<br />
For the past twenty years I've had the privilege of co-facilitating a "patient-doctor" seminar for superb primary care residents throughout the three years of their residency. They've reported how frequent it is to hear versions of "you're so smart and capable - why aren't you going into a medical specialty?" As I thought about their choice of primary care, the Buddhist concept of Bodhisattvas of Compassion came to mind. I've written before about the statue of <a href="http://healthcareorganizationalethics.blogspot.com/2017/05/medicine-and-mysticism.html">Guanyin </a>at the Boston Museum of Fine Arts. In Buddhist tradition, Bodhisattvas are enlightened beings who <u>choose</u> to remain among mortals to alleviate suffering.<br />
<br />
This vision is available to any and all health professionals, and of course to others in professions like education. But in medicine I see primary care as the purest form of the "Bodhisattva-like commitment," since it puts the fewest filters between the individual physician and the full range of human suffering. The article in today's New York Times does not contain high falutin language, but the simple story of a young physician's post-residency practice gives a down to earth picture of the moral vision underlying primary care.<br />
<br />
<b>Addendum:</b> The July 5th issue of the <i>New England Journal of Medicine</i> has an excellent <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1802741?query=TOC">article </a>on "Primary Care and the Opioid-Overdose Crisis: Buprenorphine Myths and Realities." If you've read this far I urge you to follow the link to the NEJM article.<br />
</div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-65361768362094659982018-06-22T12:15:00.000-04:002018-06-22T12:56:37.218-04:00Civil Society and Doctor-Patient Sex<div dir="ltr" style="text-align: left;" trbidi="on">
On June 4 the <i>Boston Globe</i> <a href="https://www.bostonglobe.com/metro/2018/06/03/she-accused-her-psychologist-sexual-misconduct-the-board-found-her-credible-but-still-has-license-practice/ZTmaFHXmdzL21X1wbfI1dO/story.html">reported </a>that for two years the Massachusetts Board of Registration of Psychologists had taken no action on Ms. Lisa Grover's complaint of abuse by her therapist, Dr. Mel Rabin. In a subsequent <a href="https://www.bostonglobe.com/metro/2018/06/08/psychologist-accused-sex-with-patient-surrenders-license/5l5z1fRrnWoU9Fzj7H5SDL/story.html?event=event12">article </a>the <i>Boston Globe</i> told readers that the next day Dr. Rabin surrendered his license, "<span style="font-family: "Times New Roman",serif; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">acknowledging that he put the
patient 'at risk of harm' and failed to maintain professional boundaries."</span> In response to Dr. Rabin's letter the Board revoked his license, information that can be found on its <a href="https://elicensing.state.ma.us/CitizenAccess/_SearchaLicense.htm">website</a>.<br />
<br />
In cases with allegations as serious and believable as those brought forward by Ms. Grover, a professional board must act, as by suspending the practitioner's license while the case is investigated, by requiring monitoring of the practice, or some other way of protecting the public. Failing to act invites public distrust of the regulatory process and of the profession itself, and exposes the public to avoidable risks. In Dr. Rabin's case the media report accomplished what the Board of Registration should have done two years earlier.<br />
.<br />
After I published my initial post on the <a href="http://healthcareorganizationalethics.blogspot.com/2018/06/doctor-patient-sex-and-professional.html">situation </a>I spoke with Ms. Grover. Our conversation highlighted two additional issues - the mysterious sources of <u>resilience</u> and the power of <u>peer support</u>.<br />
<br />
When Ms. Grover came to see her relationship with Dr. Rabin as exploitative, she determined to land on her feet and to do all she could to protect others from comparable abuse. She's not clear where her strength came from. Her family was supportive, but there was also an internal resolve to speak out. It's not uncommon for legal settlements to include a gag order, under which the complainant agrees not to speak in public about the situation in return for the financial agreement. Ms. Grover refused to accept any such requirement.<br />
<br />
She made her way to the <a href="http://www.therapyabuse.org/index.htm">TELL</a> (Therapy Exploitation Link Line) website where she "met" others struggling with their own experiences of abuse. Meeting peers strengthened her resolve and sharpened her sense of how to take effective action on behalf of others and for her own healing. She is working with other volunteers to respond to the 40,000 hits TELL receives each year.<br />
<br />
In Ms. Grover's situation, government regulation (the psychology licensing board) failed, but civil society - in the form of the press (the two <i>Boston Globe</i> articles) and peer support (TELL) - came though. Dr. Rabin did not govern himself by the ethics of his profession, and the licensing board was dilatory in its response, but resilience, the press and peer support helped Ms. Grover move from victimization to effective advocacy.</div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-75777403109110737362018-06-04T17:30:00.000-04:002018-06-22T11:36:55.548-04:00Doctor-patient sex and professional self-regulation<div dir="ltr" style="text-align: left;" trbidi="on">
The topic that has attracted the largest readership on this blog is <a href="http://healthcareorganizationalethics.blogspot.com/search/label/doctor-patient%20sex">doctor-patient sex</a>. In the past 10 years the 30 posts I've written on the topic have received 75,000 hits. An <a href="https://www.bostonglobe.com/metro/2018/06/03/she-accused-her-psychologist-sexual-misconduct-the-board-found-her-credible-but-still-has-license-practice/ZTmaFHXmdzL21X1wbfI1dO/story.html">article </a>in today's <i>Boston Globe</i> focuses on an aspect I've discussed only briefly thus far - professional self regulation.<br />
<br />
The story concerns a complaint from Ms. Lisa Grover that Dr. Melvin Rabin, the psychologist she sought out when her marriage broke up, drew her into a sexual relationship. Grover's allegations dramatize the way "boundary crossings" like calling the patient at home "just to talk," calling the patient a "special person," and hugging at the end of the appointment, can lead, over time, to "boundary violations" like sex. Apparently Grover brought a malpractice action against Rabin which, the article reports, was "settled for an undisclosed sum."<br />
<br />
In February 2016 Grover complained to the Massachusetts Board of Registration of Psychologists, but the case is still "open" and Dr. Rabin's license is still unrestricted.<br />
<br />
A core component of the implicit contract between the health professions and society is that in exchange for the autonomy and trust society gives to the professions, the professions will regulate themselves with regard to quality and integrity. Two years is much too long for a professional board to leave a serious complaint like Ms. Grover's unsettled.<br />
<br />
In dealing with complaints of the kind Ms. Grover brought, a board must consider three values:<br />
<br />
First and foremost, safety for patients. If the board believes Ms. Grover's accusations, it should have suspended Dr. Rabin's license. A therapist who acted as Ms. Grover describes should not have an unrestricted license, which allows unrestricted, unmonitored access to patients. What Ms. Grover describes, if true, is very serious misconduct.<br />
<br />
But second, a board must also recognize that complaints are not necessarily true. The board must consider fairness to the accused.<br />
<br />
I know this first hand.When I joined the Harvard Community Health Plan practice in 1975, one of my first patients was a sensitive and vulnerable young woman with a mild autism spectrum disorder. The treatment was proceeding well until I cancelled an appointment because I was going away. My patient contacted the psychiatry board to complain that I had molested her. Psychologically my cancellation felt to her like a "molestation." By the time I heard from the board my patient and I had resumed meeting and the treatment was again on track. She explained that she had been upset by the cancellation and apologized for what she said to the board. I didn't appreciate at the time just how serious a threat a false accusation could be.<br />
<br />
To the credit of the <i>Boston Globe</i>, the headline to the article refers to an "alleged betrayal." But if the Board does not believe Ms. Grover, it should have closed the case by now. Two years is too long for the case to be in limbo. A false accusation is a serious injury to the clinician.<br />
<br />
Finally, a professional board should conduct itself in a way that fosters trust in the profession. The story reported in the <i>Boston Globe</i> does the opposite.<br />
<br />
(In addition to the <i>Boston Globe</i> <a href="https://www.bostonglobe.com/metro/2018/06/03/she-accused-her-psychologist-sexual-misconduct-the-board-found-her-credible-but-still-has-license-practice/ZTmaFHXmdzL21X1wbfI1dO/story.html">article </a>describing Ms. Grover's allegation, readers may be interested in an <a href="http://bostonvoyager.com/interview/meet-dr-mel-rabin-dr-mel-rabin-corporate-work-rabin-associates-74-w-central-st-natick-ma-46-brentwood-circle-needham-ma/">interview </a>with Dr. Rabin in which he describes himself and his approach to therapy.)</div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-70278884282053710062018-05-30T08:30:00.000-04:002018-05-30T20:32:31.876-04:00Loneliness and Health<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
It's easy to make jokes about the British "Minister of Loneliness," as <a href="https://www.youtube.com/watch?v=gEX56vZPZFE">Steven Colbert </a>did when Theresa May <a href="https://www.gov.uk/government/news/pm-commits-to-government-wide-drive-to-tackle-loneliness">announced</a> creation of the new position this winter. But for several decades we've known that loneliness isn't a joke - it's a significant risk factor for poor health and premature death.<br />
<br />
Here's how Vivek Murthy, the former Surgeon General, <a href="https://hbr.org/cover-story/2017/09/work-and-the-loneliness-epidemic">explains </a>the health impact of loneliness:<i><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"><br /><br />...Over
thousands of years, the value of social connection has become baked into our
nervous system such that the absence of such a protective force creates a
stress state in the body. Loneliness causes stress, and long-term or chronic
stress leads to more frequent elevations of a key stress hormone, cortisol. It
is also linked to higher levels of inflammation in the body. This in turn
damages blood vessels and other tissues, increasing the risk of heart disease,
diabetes, joint disease, depression, obesity, and premature death. <br /></span></i><br />
Understanding the toxicity of loneliness has implications for public policy and health care practice. The UK ministry exemplifies a public policy action. But my interest for this post is health care.<br />
<br />
Physicians are overburdened with requirements, but asking about our patients' social connectedness is central to understanding them. Loneliness is often the <u>result</u> of illness. People who are ill may withdraw from the social world, and sometimes others may withdraw from them. And loneliness can <u>cause</u> vulnerability to illness and diminish the resilience we need to recover.<br />
<br />
In my psychiatric practice I sometimes took out my prescription pad and wrote instructions like "talk with a friend at least once every day" to dramatize my belief that in many circumstances, persons could be more effective than pills. And I kept a file with resources patients mentioned: AA and NA groups, Alliance for the Mentally Ill support programs, and more. Over time this helped me suggest venues that aligned with my patients' temperaments for those who might benefit from the right kind of peer support.<br />
<br />
When I was asked to start an HMO outpatient program for patients with chronic mental illness I surveyed the literature for guidance. While the term "loneliness" wasn't used, the most promising <a href="https://www.sciencedirect.com/science/article/pii/0010440X78900366?via%3Dihub">models </a>were group-based programs with an informal, friendly and welcoming atmosphere. For several years I had the privilege of being the psychiatrist who met with the group. Patients could come as often or as rarely as they wished. When a patient had a question about medication of some other aspect of treatment, I could usually direct the question to another patient with first hand experience of the treatment in question. Patients often became friends.<br />
<br />
The widening recognition of loneliness as a toxic state and meaningful social connection as a health promoting factor is a positive step for health care. But, unfortunately, valuable insights can be drowned in bureaucratic regulations. Reducing inquiry about loneliness to a required checklist of questions risks coming across to patients as sterile and perfunctory, and to physicians as one more requirement in the ever-lengthening list of externally driven expectations.<br />
<br />
But when interest in the social texture of our patients' lives is part of the clinician and patient coming to know each other as human beings and collaborating in service of health, both parties will gain.<br />
<br />
<br />
<br /></div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-29760594498657853452018-01-08T09:00:00.000-05:002018-01-11T11:44:20.097-05:00Hiatus<div dir="ltr" style="text-align: left;" trbidi="on">
Dear Readers<br />
This is a belated post to explain that I'm taking a hiatus from the blog. My plate has been rather full in recent months and there have been some health matters to deal with. I look forward to returning to regular posting in the spring.<br />
Best to all<br />
Jim</div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-4757957423679376342017-07-26T09:00:00.000-04:002018-12-08T15:57:38.565-05:00Encouraging democratic values in English class<div dir="ltr" style="text-align: left;" trbidi="on">
On July 21 I conducted a workshop with a group of teachers who are students at the Bread Loaf School of English, a Middlebury College program in which they can get a Master's degree in English in the course of 4-5 summers. We'd set as the topic the question of whether and how teachers should bring their own moral and political perspectives into the classroom.<br />
<br />
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To my surprise we didn't address the question head on. After the session I realized that we'd stepped back from the explicit question to discuss the issues that underlie it and from which it arose. Unfortunately, I wasn't smart enough to recognize what was happening during the session, so I couldn't connect the discussion we had with the question we'd posed.<br />
<br />
In retrospect I believe the question we posed arose from a sense on the part of a number of teachers that self-disclosure was necessary (a) to advance important goals for the class or (b) to counter what the teachers saw as seriously "wrong" student values. The National Conference of Teachers of English (NCTE) <a href="http://www.ncte.org/positions/statements/academic-freedom">statement on Academic Freedom</a> presents fostering democratic values as a central objective for English teachers:<br />
<blockquote>
<i>NCTE maintains that students have the right to materials and educational experiences that promote open inquiry, critical thinking, diversity in thought and expression, and respect for others. [Academic freedom] not only serves the common good but also enhances academic integrity and the overall quality of education </i></blockquote>
But the statement warns teachers and schools against indoctrination:<br />
<blockquote class="tr_bq">
<i>Educators and educational institutions must not require or coerce students to modify their beliefs or values. Efforts to convince students to modify their beliefs or values must be academically justifiable.</i></blockquote>
If promoting open inquiry, critical thinking, diversity in thought and expression, and respect for others is a central goal for English class, the question of whether to bring our own moral and political perspectives into the classroom should be judged by whether doing so is needed to promote those underlying goals. What happened in the workshop is that the teachers jumped past the question of self-disclosure to focus on techniques that promote the democratic values. They referred to the <a href="http://www.kipp.org/">Kipp School</a> approach, the <a href="http://www.q2l.org/">Quest to Learn</a> Schools, and others. The implicit message was - if we can develop a classroom environment that encourages the values of democratic deliberation, self-disclosure is not required.<br />
<br />
A teacher gave an example of a student who espoused highly discriminatory attitudes towards immigrants. The teacher was tempted to offer his own different values as a "corrective" to the student's views, but over time the student came to recognize that some painful experiences of his own had led him to views he could no longer accept. In this way the aim the teacher contemplated pursuing via self-disclosure was achieved without self-disclosure.<br />
<br />
A comment made by one of the participants - "<span style="font-family: "times new roman" , serif; font-size: 12pt; line-height: 107%;">I think less about what I’m saying and more about what structures I’m
setting up</span>" - reminded me of a key lesson I learned many years ago from Irving Yalom's superb book <i>Theory and Practice of Group Psychotherapy</i>. According to Yalom
the most valuable contribution by group therapists was fostering a
culture of inquiry, diversity of thought and expression, and respect for
others, not their insights into psychodynamics. I took from Yalom's
teaching that if a therapy group developed and maintained a
constructive therapeutic culture, the healing process would, in effect,
take care of itself. <br />
<br />
The teachers in the workshop suggested that something similar was true for English class. With regard to the character development goals for the class, a constructive democratic ethos would generally lead to the desired results.<br />
<br />
Although we did not discuss the initial question at any length, one participant strongly supported the view that teachers could bring their own moral and political perspectives into class discussion without squelching students in their independent reflection or violating the NCTE guardrail against indoctrination. This is a question I've thought about a lot from the perspective of medical ethics. Perhaps we'll come back to it in another workshop next summer.<br />
<br />
<br />
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="line number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="page number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of authorities"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="macro"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="toa heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/>
<w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/>
<w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
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Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-14090909126159685432017-07-20T08:00:00.000-04:002017-07-20T08:37:55.958-04:00Self-Disclosure in the Clinic and the Classroom<div dir="ltr" style="text-align: left;" trbidi="on">
<div>
As I mentioned in a recent <a href="http://healthcareorganizationalethics.blogspot.com/2017/07/teaching-ethics-in-high-school-and.html">post</a>, I'm in Vermont while my wife teaches at the Middlebury College Bread Loaf School of English, a program in which the students are primarily high school and middle school English teachers.<br />
<br />
Tomorrow I'll be leading a second workshop on "Making Ethics Part of High School and Middle School English Class."At the workshop on June 30th the teacher/students identified a topic they wanted to come back to: should they bring their own moral and political selves into the classroom, and if the answer is "yes," how should they do it?<br />
<br />
I've never taught in high school or middle school and can't claim any direct expertise on how to deal with the question the teachers raised. But I've given a lot of thought to what is typically called "self-disclosure" in medical care and have written about it (see <a href="http://journalofethics.ama-assn.org/2011/12/ccas1-1112.html">here</a>). In contrasting the issue as it comes up in the clinic and the classroom, I see self-disclosure as a vastly tougher question for high school and middle school teachers than it is for physicians and other clinicians.<br />
<br />
In the clinic, self-disclosure occurs largely in a 1:1 setting - the patient and the doctor. The major question for the physician is whether self disclosure will further the clinical objectives. Research suggests that the impulse behind self-disclosure is often fulfillment for the doctor more than benefit for the patient. The commonest risk is that the patient will feel <i>less</i> listened to and <i>less</i> rapport. The most serious risk is that physician self-disclosure will lead to a slippery slope of increasingly intimate interactions. Many situations that end with doctor-patient sex began with physician self-disclosure.<br />
<br />
When we physicians contemplate self-disclosure we should ask ourselves three relatively straightforward questions. First, a bit of introspection: do we tend to talk about ourselves too much? If so, we should be especially on guard. Second, is there anything special about our relationship with this patient - such as a wish to impress the patient or to be his friend - that draws us towards self-disclosure? Finally, what is the rationale for anticipating that self-disclosure will help the patient?<br />
<br />
In high school and middle school, the teacher is an adult dealing with a classroom with 15 - 30 youngsters. Student reactions, of course, are likely to vary, so there's no way to guage the potential impact on every student in advance. But the most challenging aspect is the school setting itself. Even if the patient-physician dyad occurs in an organizational setting like a clinic or group practice, it's primarily a two person relationship. By contrast, English class is just one piece of the student's relationship with the school. And in the background, the students' families properly regard themselves as having a central role in their child's education.<br />
<br />
To prepare for the workshop I tried to imagine myself as a new high school or middle school teacher thinking about self-disclosure in the classroom. I pictured a series of steps to help me develop an approach:</div>
<ol style="text-align: left;">
<li>Talk with my experienced colleagues. How have they handled self-disclosure in their classes? What guidance can they give me?</li>
<li>Talk with my department chair and perhaps the principal. They are responsible for and most knowledgeable about the school's relationship with its community. Are there issues of particular sensitivity to be aware of?</li>
<li>Consider the environment the students come from. What is the cultural starting point for the class likely to be? How will this influence how the students hear me?</li>
<li>Examine my own skills. Am I someone who students can feel comfortable questioning or challenging? Can I model a stance of curiosity and mutual respect?</li>
</ol>
I'm looking forward to learning from the teachers who will participate in the workshop. What a privilege it is to be able to explore ethics in the classroom with a group of experienced and devoted teachers! </div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-43991421495026833612017-07-08T09:00:00.000-04:002018-05-30T20:37:45.001-04:00Psychiatrist-Patient Sex - plus a detective<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-size: large;">When I was looking for audio books for my drive to Vermont, how could I resist <i>Shrink Rap</i>, especially since the author was the wonderful <a href="https://www.robertbparker.net/">Robert B. Parker</a> of "Spenser" fame. Here's the blurb from the jacket:</span><br />
<blockquote class="tr_bq">
<i><span style="font-size: large;">Boston P.I. [private investigator] Sunny Randall is working as a bodyguard for popular romance writer Melanie Hall, who is being stalked by her psychiatrist ex-husband. Melanie was a patient before becoming his wife, but now she is absolutely terrified by him. To find out why, Sunny puts on a disguise and goes to the shrink for therapy.</span></i></blockquote>
<span style="font-size: large;">The most-read posts on this blog are those under the tab of "doctor-patient sex," and I was eager to see Parker's take on the topic.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Melanie Joan Hall is a wildly successful chick lit writer and, like her heroines, a romantic soul. She falls in love with her psychiatrist (Dr. Melvin) whose practice is entirely composed of needy female souls like herself. Dr. Melvin allows an erotic transference to form, but then instead of using it as an opportunity to minister to Melanie Joan, he exploits it for sex and control. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Melvin has sex with many patients, but he singles Melanie Joan out for marriage. Although he's a thoroughly evil character, Melanie Joan only catches on when he invites two of his friends to participate in what the narrative calls a "gang bang." Until the "gang bang" moment Melanie Joan has been entranced by what she calls the "master/slave" relationship. But when the potential "gang bang" shocks her into recognizing Dr. Melvin's evilness, she flees. Melvin goes off the deep end and stalks her. Enter private eye Sunny Randall.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Sunny seeks out Dr. Max Copeland, a skillful and ethical psychiatrist, to help her strategize about Melvin. Sunny tells herself she's seeing Copeland for advice, not therapy, but Copeland engages her in self-reflection as well. He's a superb therapist - respectful, insightful, and entirely focused on helping his detective-patient. He obviously likes and admires Sunny, who is brave, honest, funny, and emotionally open, but unlike Melvin he is scrupulous in using his interaction with her to develop a therapeutic alliance.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Parker has excellent insight into the ways patients may idealize a therapist who listens to them attentively. Sunny herself feels the pull when she becomes a "patient" in Melvin's practice. I won't give away how she cracks the case - it's scary and humorous. But when she expresses her puzzlement at how in the early phase of their "therapy" Melvin was actually helpful to her, Copeland responds as I have to comments on earlier posts - physicians who exploit patients A, B and C may also have skills that allow them to practice very competently with patients D, E, and F.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><i>Shrink Rap</i> brought to mind <a href="http://www.rogerebert.com/reviews/dressed-to-kill-1980"><i>Dressed to Kill</i></a>.<i> </i>a Brian DePalma film I saw in 1980. I'd not heard of the film until a young woman patient brought it up in a therapy session. She said it reminded her of her treatment. When she went on to mention that the psychiatrist in the film murdered his patient, I remember feeling horrified. Alas, I can't remember what I said to my patient, but I resolved to see the film. I won't give away DePalma's Hitchcockian plot in case you decide to see it, but my patient got the film story right. The psychiatrist really does murder his patient.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Parker and DePalma render the dark side of our <a href="http://www.nytimes.com/1981/01/25/movies/the-psychiatrist-in-today-s-movies-he-s-everywhere-and-in-deep-trouble.html?pagewanted=all">fantasies about psychiatrists</a>. The cultural figures who - in our upbeat moods - we see as wise and powerful healers, turn into monsters when they choose to use their power for evil aims. It's the same dynamic as the wolf in <i>Little Red Riding Hood</i> - a loving grandmother on the outside but ravenous wolf within.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Sadly, the stories Parker and DePalma tell so well aren't restricted to myth. The reason my posts on doctor-patient sex have garnered so much readership is that the myth plays itself out in life. The problem isn't new. 2500 years ago <a href="https://en.wikipedia.org/wiki/Hippocratic_Oath">Hippocrates </a>asked physicians to pledge fidelity to their patients' well-being, and to eschew sexual exploitation. Hippocrates understood that just as the wolf gives in to temptation when he sees Little Red Riding Hood and her basket of food as tempting morsels, physicians of his day, and ours, are exposed to temptation as they practice their art.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">The reason the Hippocratic oath has survived for 2500 years is that Hippocrates saw medicine as a sacred calling that requires an impeccable standard of ethics. Parker and DePalma's engaging stories show what can happen when the oath is ignored.</span></div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-46201714217817117912017-07-02T14:00:00.000-04:002017-07-25T15:15:58.958-04:00Teaching Ethics in High School and Middle School<div dir="ltr" style="text-align: left;" trbidi="on">
I'm again in Vermont at the <a href="http://www.middlebury.edu/blse/">Bread Loaf School of English</a>, a Middlebury College program in which the students, primarily high school and middle school English teachers, can get a Master's degree in the course of 4-5 summers. My wife has been teaching here every summer since 1992 and I enjoy the potential for (a) telecommuting and (b) swimming and hiking in Vermont.<br />
<br />
For the past five summers I've been doing a workshop on "Making Ethics Part of High School and Middle School English Class." The idea for the workshop came from recognizing that my <a href="http://healthcareorganizationalethics.blogspot.com/2012/07/teaching-ethics-in-high-school-and.html">underlying goals for teaching medical ethics were similar to the teachers' goals for their students in English class</a>. Working with the teacher-students at Bread Loaf is a pleasure and a privilege. Their commitment to fostering development in their students is similar to the commitment to fostering health and well-being I see in the medical students and residents I work with.<br />
<br />
This year the topic we chose to focus on was an experience several of the teachers had (a) teaching courses that explicitly included "justice" or "ethics" in the course objectives and finding (b) that the courses didn't work well. We asked: what was the problem and what could be done about it?<br />
<br />
The group identified three main reasons the "justice"/"ethics" courses fell flat:<br />
<ol style="text-align: left;">
<li><b>Adolescent cognitive development.</b> Kids of every age show great variation, but teen age thinking tends to be black/white, with the result that for many the idea that thoughtful people may reasonably differ is a foreign notion. Discussions of ethical and political dilemmas may seem to them like a "politically correct waste of time." I'm still embarrassed at a piece of my own black/white thinking from when I was 17. My parents, born in 1905 & 1907, were from a martini-drinking generation, and the practice they and their friends had of drinking several martinis after work and forgetting that there was a child in the home (me), led me to a very moralistic view of alcohol. So when my friends proposed going out for beer when I was a first year college student, I replied "If we're going out for alcohol, why stop there? Why don't we go directly to heroin?"</li>
<li><b>The school environment.</b> Kids recurrently encounter high stakes tests. Many feel that their future depends on getting good grades, which means "getting the right answer." Their anticipation of being judged inhibits curiosity and limits the pleasure they might take in deliberating about moral dilemmas. Some years ago when medical ethics was an elective at Harvard Medical School (now it's part of the required curriculum) I had designed a session on "personal mission in medicine." I thought it was a great plan, so when the class completely bombed I was puzzled and asked the students to help me figure out what the problem was. The students told me what I'd missed: "This is our first semester in medical school. Our mission is not to flunk out. We have no interest in speculating about what our mission should be 5-10 years from now!"</li>
<li><b>Culture of narcissism.</b> Several teachers commented on a culture of narcissism symbolized by the popularity of "selfies." This isn't a new idea. Christopher Lasch popularized it in his prescient 1979 <a href="https://www.amazon.com/dp/B00DI29D82/ref=dp-kindle-redirect?_encoding=UTF8&btkr=1">book </a>subtitled "American Life in an Age of Diminishing Expectations." The teachers felt that social media reinforced the longstanding cultural pattern. I was especially struck by the observations of two teachers who also coached high school sports teams. Both commented on the decline of "teamness" and the tendency for young athletes to be preoccupied with their own goals and achievements.</li>
</ol>
<div>
The participants exchanged tips on what teachers can do to bring moral reflection to life for their high school and middle school students:</div>
<div>
<ol style="text-align: left;">
<li><b>Careful planning. </b>It's important to find works of literature that entice teenagers into moral reflection. Two teachers mentioned <i><a href="https://www.utilitarianism.com/nu/omelas.pdf">The Ones Who Walk Away from Omelas</a></i>, a short story by Ursula Le Guin I'd never heard of, no less read. It's a moral fable that can be seen as challenging capitalism and the division between the rich and the poor. (The story is just 4 pages - I encourage you to follow the link.) Other teachers emphasized the value of "warm-up exercises" like improv to get the students loosened up and readier to experience curiosity about themselves and others.</li>
<li><b>Role modeling.</b> It's important for teachers to <u>demonstrate </u>open mindedness, readiness to be questioned & challenged, and interest in the views of others in their interactions with the class.</li>
<li><b>Drawing on established frameworks.</b> One of the teachers leads a course called "<a href="http://www.ibo.org/programmes/diploma-programme/curriculum/theory-of-knowledge/what-is-tok/">Theory of Knowledge</a>," which is part of the <a href="http://www.ibo.org/">International Baccalaureate</a> curriculum. The course focuses on what it means to claim to "know" something and what forms of evidence apply in different realms of activity. It encourages students to examine their own presuppositions and to recognize their biases. Another teacher uses the <a href="http://www.exeter.edu/exeter-difference/how-youll-learn">Harkness </a>approach - a discussion method developed at Phillips Exeter Academy. Since a central goal in ethics teaching is to cultivate the habit of thoughtful inquiry into the basis of views held by self and others, it makes sense for teachers to do this themselves by learning from each other about how best to pursue this important goal.</li>
<li><b>Trust the students.</b> Open, thoughtful deliberation requires activity on the part of the high school/middle school students. Telling them what's required doesn't do this, just as telling an athlete how to carry out a skill doesn't take the place of practice. The term "safe space" was used to describe the aim of fostering an environment that supports curiosity and inquiry. Of course, teenagers, like all human beings, are not always trustworthy. This part of the discussion reminded me of one of my clinical rules of thumb - start with the most optimistic hypothesis that is safe and prudent and retreat from it as necessary. Thus if a patient with depression was not suicidal or at risk in other ways, we could start with the hypothesis that the condition would be readily reversible. If that proved true - great! If it didn't we'd move on to a more demanding approach.</li>
</ol>
<div>
Over the years of my work with high school and middle school teachers, I've come more and more to </div>
see their work as similar to health care in the shared aim of enhancing human capacity. If health care is a sacred calling, which I believe it very much is, so is the work the teachers are doing!<br />
<br />
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Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-43744810270172884032017-05-14T08:30:00.000-04:002017-05-14T08:30:15.303-04:00Medicine and Mysticism<div dir="ltr" style="text-align: left;" trbidi="on">
Even before I knew that Guanyin was the Bodhisattva of Compassion I was drawn to her image in the Boston Museum of Fine Art. (In Buddhist tradition, Bodhisattvas are beings who delay reaching nirvana out of the wish to alleviate human suffering.)<br />
<br />
My own recent experience with medical care leads me to see concepts like Bodhisattva and Guardian Angel as telling us something important about medicine.<br />
<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhr5O_xnL-e3w2DsaHKfOvbUkRgb2Kr333JwYZEzcGgj0pwQDci_M5ygI1977hWa5yLd7eDtR_pAPGrIh8GDXg-nwnvktBAPFgVSsXoVWDt3m2uo9IFBoPAK2XEKqgR-WFrJT-nP-jSZmAZ/s1600/Guanyin.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhr5O_xnL-e3w2DsaHKfOvbUkRgb2Kr333JwYZEzcGgj0pwQDci_M5ygI1977hWa5yLd7eDtR_pAPGrIh8GDXg-nwnvktBAPFgVSsXoVWDt3m2uo9IFBoPAK2XEKqgR-WFrJT-nP-jSZmAZ/s320/Guanyin.jpg" width="217" /></a><b style="text-align: left;"> </b></div>
<b> Guanyin - </b><br />
<b> Bodhisattva of Compassion</b><br />
<br />
Two months ago I wrote about the condition that had given me many months of pain, severely disturbed sleep, and difficulty walking (see <a href="http://healthcareorganizationalethics.blogspot.com/2017/03/health-system-ethics-and-my-left-foot.html">here </a>and <a href="http://healthcareorganizationalethics.blogspot.com/2017/03/chronic-pain-identity-and-health-system.html">here</a>). My primary care physician referred me to a hematologist who made a presumptive diagnosis of a <a href="http://www.mayoclinic.org/diseases-conditions/thrombocythemia/basics/definition/con-20034386">platelet dysfunction</a> and prescribed a medication that acts on the bone marrow to slow down the platelet production process.<br />
<br />
Prior to the diagnosis I'd assumed that the mysterious condition was not going to go away, but now, two months after starting the medication, the symptoms have almost entirely cleared up. I'll have to take the medication for the rest of my life, and some complications could emerge, but I feel like "myself" again.<br />
<br />
So what do these experiences have to do with Guanyin?<br />
<br />
The medication I'm taking requires careful monitoring to make sure it's doing what it's supposed to do with the platelets, but not causing too much decrease in white & red blood cells, which the bone marrow is also busy producing. We've checked the blood nine times between the day I started the medication and this week. The results go to my hematologist who writes to me on the secure email her practice uses to interpret the results and suggest how to handle the medication.<br />
<br />
I counted her messages in my inbox: 13 messages and a total of 386 words. That's less than 50 words/week.<br />
<br />
From my own experience as a physician I doubt that our exchanges required much time. But in addition to the instrumental importance of the guidance I received, I was aware of a strong sense of emotional support and of being <i>cared for</i> that the 386 words conveyed. I identified two sources for that feeling. The promptness and reliability of the hematologist's response after my blood tests elicited a sense of <i>security</i>. And the happiness she expressed as my symptoms improved elicited a sense that my well-being <i>mattered</i>.<br />
<br />
That's what Guanyin stands for in Buddhist culture, and likewise for Guardian Angels since they first appeared in the Hebrew Bible. Within the theologies, Bodhisattvas and Guardian Angels were vehicles for conveying divine love to us vulnerable mortals.<br />
<br />
Health care workers tap into the same psychological and cultural substrate. The feelings I've had as a <i>patient</i> are the reciprocal of the sense of mission I had as a <i>physician</i>. Recently, at the end of an appointment, a patient said "thank you," to which I replied with the same two words. When my patient asked me why I said "thank you," I explained that being a physician (or a nurse, social worker, physical therapist...) is a privilege, and that the act of healing required collaboration between the involved parties.<br />
<br />
I believe that if we could interview Guanyin and Guardian Angels, they would tell us that they were grateful for their opportunity to minister. There's a "mystical" element in health care that market concepts like "consumer" and "provider" are woefully inadequate for understanding.<br />
<br />
(See <a href="http://healthcareorganizationalethics.blogspot.com/2016/04/bringing-best-of-religion-into-medicine.html">here </a>for a post about why secular clinicians might want to use religious language in their practices, and <a href="http://healthcareorganizationalethics.blogspot.com/2013/11/the-right-kind-of-love-between-doctors.html">here</a> for a post about love in the patient-doctor relationship.)<br />
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Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com1tag:blogger.com,1999:blog-7476621888383604834.post-88927522629738755442017-04-17T09:00:00.000-04:002017-04-17T11:26:19.502-04:00More Pharmaceutical Industry Price Gouging`<div dir="ltr" style="text-align: left;" trbidi="on">
A recent New York Times <a href="https://www.nytimes.com/2017/04/14/business/lannett-drug-price-hike-bedrosian.html?emc=edit_tnt_20170414&nlid=42430906&tntemail0=y">article </a>tells us that Lannett, a large generic drug maker, is echoing other companies I have written about in raising prices on its products by several hundred percent. Here's what Arthur Bedrosian, Lannett CEO, told a group of investors:<br />
<blockquote class="tr_bq">
According to the investors, Mr. Bedrosian was asked if the price-hike business model in the drug industry was over. He chuckled and said no, adding that he had tripled the price of one of Lannett’s drugs that very morning. He did not identify which one, the investors said.</blockquote>
Mr. Bedrosian's "chuckle" may remind you of Donald Trump's cheerful boast about how he could grab women by the "pussy."<br />
<br />
The market loves Lannett, which provides yet another example of market failure. In the future the market may ultimately punish Lannett the way it punished Valeant (see <a href="http://healthcareorganizationalethics.blogspot.com/2016/03/more-details-on-disgraceful.html">here </a>and <a href="http://healthcareorganizationalethics.blogspot.com/2016/04/robber-baron-capitalism-victimizes.html">here</a>) and <a href="http://healthcareorganizationalethics.blogspot.com/2015/10/how-three-competing-ethics-frameworks.html">Turing Pharmaceuticals</a>, but by the time that happens patients will have been hurt and public and private payers will have been bilked of billions.<br />
<br />
The NYT cites studies showing that when there are fewer than five competitors, our national theology of the wisdom of markets doesn't hold. That suggests a regulatory strategy that allows price regulation in the absence of adequate competition. Let's hope that Congress is prepared to act on the basis of protecting patients and the public from the kind of legal larceny the Mr. Bedrosian is chuckling about!<br />
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Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-7759365585986990912017-04-08T14:00:00.001-04:002017-04-09T10:14:35.753-04:00A Personal View of the Medical Home concept<div dir="ltr" style="text-align: left;" trbidi="on">
Into my mid 70s I felt remarkably fit. I was still playing tennis and taking my favorite hikes during the summer in Vermont. That changed when a mysterious problem I've written about in a couple of posts (<a href="http://healthcareorganizationalethics.blogspot.com/2017/03/health-system-ethics-and-my-left-foot.html">here </a>& <a href="http://healthcareorganizationalethics.blogspot.com/2017/03/chronic-pain-identity-and-health-system.html">here</a>) set in.<br />
<br />
As a result of the problem that developed, I've had more medical appointments in the last six months than in the previous 25 years. As someone with an interest in health policy & systems, my experience has sharpened my sense of what's required to make a "medical home" work. (For those who aren't familiar with the medical home concept, I've copied material from the <i><a href="https://www.pcpcc.org/about/medical-home">Patient-Centered Primary Care Collaborative</a></i> at the end of my post.)<br />
<br />
Here's my patient's eye view of my experience:<br />
<ol>
<li>In the fall of 2016 I was floundering as to what to do about the problem, Whatever was causing pain and discoloration of my left foot/ankle/lower leg was still a mystery. My primary care physician (PCP) suggested seeing a dermatologist, something I hadn't thought of myself.</li>
<li>The dermatologist said what she saw was unusual. She did a biopsy which, alas, came back as "non-specific changes," That meant we were still unsure. She could simply have sent me back to my PCP, but to her credit, she suggested that we get a second opinion from someone at the hospital my care group is associated with.</li>
<li>Initially the referral went to the referral coordinator and an appointment was set with a presumably thoroughly competent dermatologist, but one who did not have more experience than the one I had seen. I discussed this with my PCP. He called the chief of the department who recommended a senior colleague who he said "is especially good with complex cases."</li>
<li>I saw the recommended dermatologist who had some hypotheses about obscure possibilities and did two further biopsies which showed (a) clotting in the tiny blood vessels and (b) no inflammation. </li>
<li>With a narrower set diagnostic possibilities, the second dermatologist wrote to my PCP, recommending that I see a hematologist and suggesting some further blood tests. My PCP agreed, and referred me to an excellent hematologist with whom I had shared patients before I retired from practice ten years ago.</li>
<li>By this time my blood count showed something new - an abnormal level of platelets, which are crucial for clotting. The hematologist prescribed a medication that acts on the bone marrow with the aim reducing the platelets. We've used the group's secure email to follow the counts and adjust the medication. We've only met in-person once, but the email communication has been very reliable.</li>
<li>As the platelets have come down, the lower leg and ankle problems have completely cleared up. But the toes have not, and in particular my left fourth toe was exquisitely painful. Last weekend I saw an ugly open sore on the toe. I didn't know what gangrene looked like, but my imagination ran away with unpleasant possibilities.</li>
<li>On Monday morning I was able to see an urgent care physician who allayed by fears and prescribed oral and topical antibiotics. </li>
<li>I informed the hematologist and my PCP about the situation to make sure we were all "on the same page."</li>
<li>Happily, the wound is improving, and the pain is markedly reduced. </li>
</ol>
So what's the point of all these details?<br />
<br />
For me it's this: in the same way that it takes a village to raise a child, it can take an "extended family" to treat a chronic condition. My <b><u>experience</u></b> has been one of receiving excellent continuity of care even though I've been bouncing between clinicians the way a pin ball bounces. But the clinicians were part of the same "family." They had access to the same electronic health record and communicated with each other - either directly or via my sending "FYI" updates to them. For the underlying chronic problem I've had my blood drawn at the practice's laboratory. The results get to the hematologist and to me within a few hours, and she has followed up with email advice very promptly.<br />
<br />
My guess is that my treatment in the past few weeks has not occupied much physician time, but as a patient I have <u style="font-weight: bold;">felt</u> very attended to. When I was worried about toe pain and an open wound I was able to see a clinician promptly, and her findings went to my PCP and the hematologist I am working with.<br />
<br />
I believe my experience shows how a "medical home" and "team care" can be more than euphemisms. Continuity of care doesn't require continuous appointments with a single physician. When a "medical home" functions the way a harmonious extended family does, it works!<br />
<br />
Here's the material about the medical home concept for those who want to read about it in more detail:<br />
<br />
<div style="background-color: #fdfdfd; color: #6f6f6f; font-family: "PT Sans", "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 15px; margin-bottom: 20px; outline: none;">
The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system, and is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions. It is a place where patients are treated with respect, dignity, and compassion, and enable strong and trusting relationships with providers and staff. Above all, the medical home is not a final destination instead, it is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient's needs.</div>
<div style="background-color: #fdfdfd; color: #6f6f6f; font-family: "PT Sans", "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 15px; margin-bottom: 20px; outline: none;">
In 2007, the major primary care physician associations developed and endorsed the <a href="http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf" style="color: #27638c; outline: none; text-decoration-line: none;">Joint Principles of the Patient-Centered Medical Home</a>. The model has since evolved, and today the PCPCC actively promotes the medical home as defined by the <a href="http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/pcmh_defining_the_pcmh_v2" style="color: #27638c; outline: none; text-decoration-line: none;">Agency for Healthcare Research and Quality (AHRQ)</a>. </div>
<h3 style="background-color: #fdfdfd; color: #6f6f6f; font-family: Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 24px; font-weight: 400; line-height: 33.6px; outline: none; text-rendering: optimizeLegibility;">
Features of the Medical Home</h3>
<div style="background-color: #fdfdfd; color: #6f6f6f; font-family: "PT Sans", "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 15px; margin-bottom: 20px; outline: none;">
Adapted from the AHRQ definition, the PCPCC describes the medical home as an approach to the delivery of primary care that is:</div>
<ul style="background-color: #fdfdfd; color: #6f6f6f; font-family: "PT Sans", "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 15px; margin: 0px 0px 20px 20px; outline: none; padding: 0px;">
<li style="line-height: 20px; outline: none;"><strong style="outline: none;">Patient-centered:</strong> A partnership among practitioners, patients, and their families ensures that decisions respect patients’ wants, needs, and preferences, and that patients have the education and support they need to make decisions and participate in their own care.<br style="outline: none;" /> </li>
<li style="line-height: 20px; outline: none;"><strong style="outline: none;">Comprehensive:</strong> A team of care providers is wholly accountable for a patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.<br style="outline: none;" /> </li>
<li style="line-height: 20px; outline: none;"><strong style="outline: none;">Coordinated: </strong>Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports.<br style="outline: none;" /> </li>
<li style="line-height: 20px; outline: none;"><strong style="outline: none;">Accessible: </strong>Patients are able to access services with shorter waiting times, "after hours" care, 24/7 electronic or telephone access, and strong communication through health IT innovations.<br style="outline: none;" /> </li>
<li style="line-height: 20px; outline: none;"><strong style="outline: none;">Committed to quality and safety:</strong> Clinicians and staff enhance quality improvement to ensure that patients and families make informed decisions about their health</li>
</ul>
</div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-69578108023469559102017-03-21T08:30:00.000-04:002017-03-21T08:30:06.496-04:00Adding Value by Talking More<div dir="ltr" style="text-align: left;" trbidi="on">
A recent article in the New England Journal of Medicine - <i><a href="http://www.nejm.org/doi/full/10.1056/NEJMp1607079#t=article">Adding Value by Talking More</a></i> - caught my eye. For me, having practiced psychiatry for 43 years, the authors' argument was preaching to the choir. But what is special about the article is the hard-nosed way it cites data that demonstrates cost savings from investing time and money in well-planned conversation.<br />
<br />
Here's the final paragraph of the article:<br />
<br />
<blockquote class="tr_bq">
<span style="background-color: white; color: #333333; font-family: arial, sans-serif;"><i>As these examples illustrate, increased physician communication is time very well spent when it leads to better patient outcomes and lower total costs. Clinicians who are reimbursed under new value-based payment plans should seize the initiative to determine how much of their valuable time should be spent in the various types of productive conversations, especially as they become more accountable for their results. Physicians now have the discretion, incentives, and accountability to use their time wisely and productively to reduce the total costs of patient care and improve the outcomes they deliver.</i></span></blockquote>
The otherwise excellent article omits one crucial element. <b>Talking more with our patients also increases physician satisfaction</b>. In conversations and CME sessions, when physicians are asked about meaningful clinical experiences, relationships with patients and moments of empathic connection predominate.<br />
<br />
I encourage readers to go to the NEJM article. The three authors are all from the business school and the consulting world. They makes the kind of case for "talking more" that administrators will understand and be influenced by. I also encourage readers to go to the website of <i><a href="https://www.avantgardehealth.com/">Avant -garde Health</a></i>, a health care technology and analytics company founded by one of the authors.<br />
<br />
Some harried physicians, unhappy in practices in which talking with their patients feels like a luxury they can't afford, choose to move into a <a href="http://healthcareorganizationalethics.blogspot.com/2011/04/concierge-medicine.html"><i>concierge</i> </a>model of practice, in which they (a) limit the number of patients they care for and (b) charge an "entry fee" to be part of the practice. This solves the morale problem for the individual physician, but it weakens the health system itself by reducing the number of available primary care physicians.<br />
<br />
The kind of work behind <i>Adding Value by Talking More</i> is addressed to the same problem concierge physicians are dealing with, but at the population level. As such it is a more socially responsible approach to the effort of making our health system more "patient centered."</div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-35790895590193894712017-03-19T17:30:00.000-04:002017-03-28T13:35:34.091-04:00Access to health CARE vs access to health INSURANCE<div dir="ltr" style="text-align: left;" trbidi="on">
A dear friend who follows this blog sent me an email about the two posts I wrote last week about my own recent medical experiences (<a href="http://healthcareorganizationalethics.blogspot.com/2017/03/health-system-ethics-and-my-left-foot.html">here </a>& <a href="http://healthcareorganizationalethics.blogspot.com/2017/03/chronic-pain-identity-and-health-system.html">here</a>). With my friend's permission I've copied the message s/he sent [I'm deliberately disguising gender], edited to protect confidentiality and to highlight the themes I want to emphasize:<br />
<blockquote class="tr_bq">
<i>Thank you for the very informative posts. In general, however, I think the blog doesn't describe the experience of
patients who are not MDs and/or are not in an integrated group practice such as
the one you belong to. In my own experience, PCPs defer to specialists and
won't contradict them. Further, the placebo effect of the PCP relationship is
reduced if not nullified by the patient's difficulty in contacting the PCP over
the phone. I can never get an appointment on short notice with my PCP; I can
only count on seeing him if the appointment is made months in advance, or if I
am in an emergency ward or am admitted to a hospital as an inpatient. If I have
an immediate problem that is not an emergency (e.g., burn, sprain/suspected
fracture, bronchitis), I have to work through two layers on the phone
(secretary, medical assistant) -- and then the outcome will be an examination
by a nurse practitioner. I therefore now prefer to use the XYZ Hospital's
Walk-In Clinic rather than even trying to reach my PCP's office by phone.
Finally, your encomium to the email system doesn't apply to the sharing of
medical records between hospital<span style="font-size: 10.0pt;">s </span><u1:p></u1:p>on
different systems (e.g., XYZ hospital and ABC, where I have also had care) or to practice
groups that are located in one and the same hospital office building but that
don't share the same medical records system.</i></blockquote>
My friend is well insured - s/he has no problem with insurance access. And the community where s/he lives is replete with medical services.<br />
<br />
In a follow up conversation I will ask my friend about experience with the nurse practitioner. Over the decades of my clinical practice, and in my own care, I've had terrific experiences with nurse practitioners and physician assistants. Assuming that the NP is indeed a skillful clinician, the PCP can foster trust and comfort with the NP by explaining how they collaborate and demonstrating how they work together.<br />
<br />
My positive experiences have definitely been fostered by the fact that I'd been a clinician in the group practice from which I was getting my care. But I'm convinced that a patient who had not had a career in health care and had not been part of the group could have a comparably positive clinical experience <b><i>if they had the same skills I have in managing my care experience.</i></b><br />
<b><i><br /></i></b>
I anticipate that in the future, patients will routinely have <a href="http://healthcareorganizationalethics.blogspot.com/2011/12/why-patients-should-have-easy-access-to.html">electronic access to their own medical records.</a> That kind of access, combined with a robust secure communication system with and within the practice, would promote more secure connection to the medical home than my friend experienced.<br />
<br />
From 1975 until I ended my clinical practice I was paid a salary. That meant I was not dependent on billing for each in-person service for my compensation. One of my patients who had significant depression and was dealing with major stressors strongly preferred the convenience of electronic interchange rather than coming to my office. After we had gotten to know each other in 5-6 in-person appointments, we switched to email, which we used for ten years. When we met to say goodbye in person when I retired from practice, we felt we knew each other very well, but neither remembered what the other looked like, which made for some amusing uncertainty in the waiting room. Being paid by salary meant that I was not "penalized" for providing care to my patient with so few in-person meetings.<br />
<br />
It's not likely that we will have enough PCPs to ensure prompt access for all patients in the foreseeable future. To provide the kind of secure connection my friend was looking for we'll have to manage the process of team collaboration better than s/he has experienced, and make use of electronic forms of communication to augment connection between the patient and the team.<br />
<br />
The generation moving into adulthood is schooled in making electronic connection with their peers. They will demand that kind of opportunity in their medical care.<br />
<o:p></o:p></div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-36522699677948738442017-03-15T09:00:00.000-04:002017-03-16T18:20:23.119-04:00Chronic pain, Identity, and Health System Ethics<div dir="ltr" style="text-align: left;" trbidi="on">
Prior to this past year my experience of pain had been with acute episodes. An especially painful and amusing episode occurred when I started a new job at the Massachusetts Mental Health Center after residency and fellowship. Between painting rooms in the house we were moving into and carrying boxes hither and yon I threw out my back. I lay on the floor, hardly able to move. A helpful neighbor called his PCP who came to the house. (It was 1970 and house calls actually happened.) I could see that he was regarding me with suspicion. Perhaps I was a newly arrived addict who was seeking an opiate fix. And when I started my new job, in some of my meetings I again lay on the floor, giving a rather odd impression of the new hospital ward supervisor.<br />
<br />
The pain was severe - perhaps 9 or even 10 on the ubiquitous 0-10 scale. But I knew it would clear up before too long, and it didn't burrow into my psyche and sense of self. In the (slightly altered) words of the old spiritual, it "pained the body but not the soul."<br />
<br />
Not so with the chronic pain I <a href="http://healthcareorganizationalethics.blogspot.com/2017/03/health-system-ethics-and-my-left-foot.html">wrote about</a> 3 days ago! It's not as severe as the back spasm, but the (a) chronicity and (b) uncertainty about if and when the pain will go away has (c) taught me lessons I only understood from the "outside" during my years of practice and (d) challenged my sense of identity.<br />
<br />
Like many physicians, my default mode is to help others. Over the years, when asked "how are you?" my typical answer has been a hearty, upbeat "excellent!" So for the simplest of tasks - taking out the garbage and even putting on my pants (I have to protect the toes from contact with the pants leg - not easy to do) - to become difficult or impossible is a shocking change. My wife has taken over my "chores" cheerfully and uncomplainingly, but I feel ashamed at (my words) "not doing my part."<br />
<br />
Before the foot/ankle/lower leg problem set in, I took an extended walk whenever the weather permitted, and played tennis with friends weekly. Sacrificing these activities isn't just a matter of losing forms of "recreation." Being an active, out-of-doors person has been part of who I am. These losses take another bite out of my sense of identity!<br />
<br />
In a similar vein, I enjoy being at both of the two offices I use. But parking and walking to the office is difficult, and I can actually do most of my work from home, so I have been largely invisible at my work sites. My "productivity" may not be reduced, but collegiality is down, and loneliness is up.<br />
<br />
Coping mechanisms are crucially important and put to the test. As an example, the toe/foot/ankle/lower leg pain is worst at night. When I try to sleep it wakes me up every 60-90 minutes. My initial reaction to these awakenings was anger, but that accomplished nothing useful and made it harder to get back to sleep. By an act of will I substituted humor - laughing at myself sitting in the dark massaging my foot and hobbling around to reduce the pain. Rather than saying "why the <span style="color: red;">bleep</span> is this happening to me" I say various forms of "what a ludicrous situation this is!"<br />
<br />
This is a blog about organizational ethics. Readers may reasonably ask "what on earth does a painful foot and difficulty taking out the garbage have to do with organizational ethics?"<br />
<br />
A lot!<br />
<br />
Nowadays, organizations toot the horn about their commitment to "evidence based practice." Since the Hippocratic era, the practice with the strongest evidence of effectiveness is <u>empathic listening</u>. Organizations can encourage this stance or - all-to-often - squelch it with bureaucratic demands and processes that treat patients as targets for efficient "throughput."<br />
<br />
Time pressure is a fact of life everywhere in health care, but there are skills we clinicians can develop to use time well, rather than having time use us. When I joined the mental health practice at the Harvard Community Health Plan HMO in 1975, the insurance limited the number of appointments we could have with our patients. Some clinicians put this limit front and center when they met new patients, by stressing what they couldn't do. Wise clinicians, however, approached new patients differently - "Let's first figure out what you need, and then see how we can best meet those needs." The HMO encouraged me and my colleagues to struggle with the challenge of remaining true to our mission while doing what was needed to make the necessary margin to keep the program going. (See <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3330273/">here</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/1864570">here</a> for examples of that work.)<br />
<br />
Medical care ultimately comes down to the patient-clinician dyad, but more and more often the dyads occur in an organizational setting. Empathic listening is carried out by individuals, but organizations can encourage or thwart this deeply human process. That's where organizational ethics comes in!<span style="font-size: 7pt; font-stretch: normal; line-height: normal; text-indent: -0.25in;"> </span><br />
<span style="text-indent: -0.25in;"><br /></span>
<span style="text-indent: -0.25in;">(A friend who knew about my left foot problem brought to my attention a superb article by the distinguished primary care physician Thomas Bodenheimer - "Lessons From My Left Foot." It's available at </span><a href="http://www.annfammed.org/content/8/6/550.full.pdf" style="text-indent: -0.25in;">http://www.annfammed.org/content/8/6/550.full.pdf</a>)</div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-73453312414338189342017-03-12T10:00:00.000-04:002017-03-13T14:13:36.744-04:00Health System Ethics and my Left Foot<div dir="ltr" style="text-align: left;" trbidi="on">
I haven't written a post for more than 6 weeks. My left foot/ankle/lower leg are a big part of the reason for the lapse. So I decided to write about my experience and connect it to the topic of this blog - health system ethics.<br />
<br />
Many physicians have written about their own experiences of illness. Here's my story.<br />
<br />
In the fall of 2015 my left big toe itched. I didn't pay much attention until it began to hurt and develop redness. My primary care physician (PCP) was on a medical leave for a serious medical problem, so I saw another physician in his practice group. By that time I had red blotches on my foot as well. The physician had two hypotheses:<br />
<br />
(1) It might be an early stage of "vasculitis" (inflammation of the blood vessels). She did some blood tests, all of which were normal, and referred me to a rheumatologist (a specialist in autoimmune and musculoskeletal conditions).<br />
(2) It might be a circulatory problem, and she referred me to a vascular surgeon.<br />
<br />
The <u>rheumatologist</u> did a thorough evaluation with many blood tests. Except for two minor abnormalities, all were normal. He concluded that I did not have a systemic illness.<br />
<br />
The <u>vascular surgeon</u> also did a thorough evaluation and a CT scan to visualize blood flow to my legs and feet, which showed adequate circulation with no visible blockage.<br />
<blockquote class="tr_bq">
<u style="font-style: italic; font-weight: bold;">Lesson # 1</u>: The specialists were excellent, but when they didn't find a problem within their purview, I was left with a "what now?" question. Given the absence of my long term PCP I decided to be my own case manager. I believed more than ever in the importance of primary care as the key hub of the health care system.</blockquote>
The pain was better during the summer. Perhaps the warmer weather explained it. Whatever the explanation, I enjoyed the summer.<br />
<br />
In the fall of 2016 the areas of red discoloration spread onto my left ankle and lower leg. Happily, my PCP returned to practice from his long term medical leave.<br />
<blockquote class="tr_bq">
<u style="font-style: italic; font-weight: bold;">Lesson # 2</u>: Apart from all of the valuable things PCPs <u>do</u>, at least for me, and I would guess for many others as well, there is a powerful placebo effect from having a solid relationship with a clinician one trusts for skill, knowledge, and a genuinely caring attitude.</blockquote>
On examining me and hearing my history, my PCP said - "This is really weird. I have no idea what's going on. I think we should involve a dermatologist." A couple of weeks later I saw a dermatologist who suggested a few possibilities and did a biopsy. The biopsy came back "non-specific" - i.e., it didn't tell us anything. She thought we should get a second opinion.<br />
<br />
It took several weeks for this to be arranged. The very knowledgeable consultant I saw put forward some additional possibilities and recommended repeat biopsies. These showed (a) tiny clots in the small blood vessels and (b) no signs of an inflammatory/autoimmune process.<br />
<br />
This told us <u>what</u> was happening, but not <u>why</u> it was happening.<br />
<blockquote class="tr_bq">
<u style="font-style: italic; font-weight: bold;">Lesson # 3</u>: Humility is a virtue. My PCP acknowledged having no idea of what was going on, but did have an idea of what to do next. The first dermatologist suggested getting a further consult within her own specialty. Their non-arrogance paid off!</blockquote>
On the basis of seeing blood vessel clots, the second dermatologist suggested that I see a hematologist, who put together (a) the presence of clots and (b) the fact that in the previous month I had a mild elevation of my platelets (blood cells involved with clotting) that was (c) a bit higher on repeat measure. Before our appointment she had me do further blood tests. We'd been colleagues in the past and she sent me the following email:<br />
<br />
<i><span style="color: #1f497d;">"</span>I had you do some
special blood tests beforehand and, indeed, you have a JAK2 mutation which is
present in people with Polycythemia Vera and Essential Thrombocythemia.
This likely explains your elevated platelet count. I will be suggesting
starting Hydroxyurea pills – very easy and well tolerated, to bring down the
platelets and hopefully prevent more problems in the future."</i><br />
<div class="MsoNormal">
<span style="color: #1f497d;"><i><o:p></o:p></i></span></div>
<blockquote class="tr_bq">
<u style="font-style: italic; font-weight: bold;">Lesson # 4</u>: In the previous 14 months I'd seen 10 different physicians. Without good coordination, this would be a surefire recipe for chaos. When my PCP returned he carried out the coordination function very well, but throughout the 14 months the secure email system my practice group uses was invaluable. I could write to one physician and copy the note to others. This aspect of the electronic infrastructure really paid off.</blockquote>
I've started the new medication (Hydroxyurea), but I'm very aware that we're still proceeding on the basis of <i>hypotheses</i>. Blaming the elevated platelets is a plausible explanation, but two elements don't fit. A year ago, after the problem was clearly underway, a blood test showed normal platelets. The hematologist speculated that "perhaps your platelets are more 'sticky' and clot more easily." That could be true, but it's a speculation. And if the platelets are the villains of the situation, why are the symptoms limited to my left foot/ankle/lower leg?<br />
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<u style="font-style: italic; font-weight: bold;">Lesson # 5</u>: In 1865, the French physiologist Claude Bernard, who, among other discoveries formulated the concept of homeostasis, wrote “physicians make therapeutic experiments daily on their patients . . . . [M]edicine by its nature is an experimental science, but it must apply the experimental method systematically.” When faced with illness and suffering, patients and physicians want <i>certainty</i>. But as Bernard recognized 150 years ago, certainty of the kind we can have in mathematics is not to be had in medicine. Patients, physicians, and the public, need to learn how to work with and live with the absence of bedrock certainty.</blockquote>
In this post I haven't touched on the powerful psychological impact of chronic pain and disability. I'll do that in future posts. If you've read this far - thank you for your attention!<br />
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Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0tag:blogger.com,1999:blog-7476621888383604834.post-1567316984023654702017-01-26T17:00:00.000-05:002017-01-27T08:42:29.928-05:00Retirement from Clinical Practice<div dir="ltr" style="text-align: left;" trbidi="on">
Next week I have the privilege of facilitating a meeting on retirement sponsored by the Massachusetts Psychiatric Society. On two counts I was happy to be invited to do this.<br />
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First, from the perspective of this blog, medical societies are significant organizational players in the world of health care ethics. A well-functioning medical society helps newly minted physicians find their way into practice, provides guidance throughout the active phases of clinical careers, and supports colleagues in concluding their practices in ways that work as well as possible for our patients and for our own well-being. If a medical society isn't strengthening the ethics of its members it's not doing its job!<br />
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Second, the invitation prodded me to review my own experience of retirement from clinical practice, with the aim of distilling some comments to launch a group discussion. These are my major thoughts so far:<br />
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<u style="font-weight: bold;">DREAD</u>: Even though I was only practicing 1/3 time, I was frightened at the prospect of clinical retirement. My fear showed up in two visual images. I identified with King Antaeus, the figure in Greek mythology who derived his strength from the earth. He challenged Hercules to a wrestling match. Each time Hercules threw Antaeus to the ground, Antaeus's strength was renewed. Hercules caught on, held Antaeus in the air and crushed him to death. In one version of the story he hurled Antaeus into space, where he became a constellation. In the other image I saw myself as a sailboat utterly becalmed and helpless. Both images conveyed a feeling that my vitality and worth as a human being came from my role as a practicing physician.<br /><br /><u style="font-weight: bold;">MENTORING</u>: I asked to meet with a colleague who was 10-15 years older, who to my eye was negotiating his life in an admirable manner. I told him about my fear of ending clinical practice. He told me he'd had similar concerns, but was surprised to find an element of relief when he stopped practicing, even though he'd never thought of practice as a strain to be relieved. He gave me some other practical tips, but I still remember with gratitude his reassurance about my fears.</blockquote>
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<u style="font-weight: bold;">MONEY</u>: The meetings my wife and I had with our financial advisor were crucial. Confidence that we wouldn't go down the tubes financially was <i>necessary </i>for proceeding with the retirement plan, but not <i>sufficient</i> in itself to assuage my fears.</blockquote>
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<u style="font-weight: bold;">ENERGY</u>: When on Friday August 31, 2007, I acknowledged to myself that I was <u>really</u> going to end my practice at the turn of the year, a surprising thing happened. In a desultory way I'd imagined starting a blog about ethics at an undetermined time in the future. But when I pinned down the date by which I would end my practice, without any forethought I went to Google and put in "start a blog." The inner experience was as if a stream that had been flowing in one direction (clinical practice/identity as a clinician) shifted into a new direction (the blog and the beginning of a new identity). I <a href="http://healthcareorganizationalethics.blogspot.com/2007/08/why-start-this-blog.html">started </a>this blog that day.</blockquote>
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<u style="font-weight: bold;">DISORIENTATION</u>: When I was working full time my days were organized - especially on days when I saw patients. For clinicians, our schedule of patients tells us why we should get up in the morning. Trying to help people who are suffering assuages doubts about our purpose in life. </blockquote>
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<u style="font-weight: bold;">LONELINESS</u>: Retiring from clinical practice didn't mean retiring from professional activities. I continued my cherished academic position and leadership of the <a href="http://healthcareorganizationalethics.blogspot.com/2007/09/harvard-pilgrim-health-cares-approach.html">Harvard Pilgrim Health Care ethics program</a>. These activities provided important and valued human connections. But I missed the richness of clinical life - connections with my long term patients and colleagues.</blockquote>
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I'm proud of the Massachusetts Psychiatric Society for its attention to the penultimate phase of clinical career and grateful for the opportunity to participate. The health professions are devoted to the well-being of patients and the public health. If clinical retirement is handled well, these values can be pursued in new ways after physicians hand up their clinical hats.</div>
Jim Sabinhttp://www.blogger.com/profile/03087828142188534542noreply@blogger.com0