The Enduring Wisdom of Franz Ingelfinger

On May 5, 1977, Dr. Franz Ingelfinger, editor of the New England Journal of Medicine, delivered the George W. Gay lecture on medical ethics at Harvard Medical School. I was in full time practice at the time and, alas, was not at the lecture.

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:

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."

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?"

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.

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.

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.

I don't know if my friend's physicians felt rushed. My brilliant colleague Dr. Amy Ship recently wrote 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.

(Dr. Ingelfinger's lecture, published in 1980 after his death, is available here. "Physicians as counsellors," a previous post on a related topic, is here. )

Ethics education and democratic values in high school and middle school

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 Bread Loaf School of English, 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 here, here, here, here and here if you're interested.)

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. 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.

The National Conference of Teachers of English (NCTE) statement on Academic Freedom urges teachers to cultivate democratic values in the classroom as a central objective:

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.

At the same time, the NCTE directs teachers not to proselytize or preach to their students:   

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.

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!

The teachers asked each other - "how can we best deal with this dilemma?" Three examples illustrate the kinds of strategies they suggested:

•  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. 
• 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..."
• Another teacher described how she used "kindness" in dealing with cruel comments: "that might be hurtful...let's put it aside."

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. 

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.

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."

Recalling his comments put me in mind of Francis Peabody's 1927 address to Harvard Medical Students on "The Care of the Patient" 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."

Transmission of Values within a Profession

Last night I had the pleasure and privilege of having an extended conversation about medical ethics with Laurie Patton, 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.

Laurie explained that two months ago she’d invoked the Hippocratic oath and the influence of her surgeon father in an essay 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:

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… 

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.

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 influences were the surgeons who took care of him – their empathy, competence, positive attitude and the pleasure they took in their work. And in an essay 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.

In my first year of medical school I experienced the process of value transmission directly. I was in a tutorial group that met with Dr. William Castle, 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:

Teacher: Dr. Castle, if you had a patient with pneumonia, and you did ABCD, but the patient died, how would you feel?

 

Dr. Castle: I would feel terrible!

 

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! (reconstructed from my memory)

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 love for them, and at the same time to have enough internal "insulation" to maintain our own stability when our patients do not do well.

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. 

That's a large element of what professions are all about!

The Moral Vision of Primary Care

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.

An article 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 community clinic 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 clinic in Connecticut 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.

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 Guanyin at the Boston Museum of Fine Arts. In Buddhist tradition, Bodhisattvas are enlightened beings who choose to remain among mortals to alleviate suffering.

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.

Addendum: The July 5th issue of the New England Journal of Medicine has an excellent article 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.

Doctor-patient sex and professional self-regulation

The topic that has attracted the largest readership on this blog is doctor-patient sex. In the past 10 years the 30 posts I've written on the topic have received 75,000 hits. An article in today's Boston Globe focuses on an aspect I've discussed only briefly thus far - professional self regulation.

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."

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.

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.

In dealing with complaints of the kind Ms. Grover brought, a board must consider three values:

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.

But second, a board must also recognize that complaints are not necessarily true. The board must consider fairness to the accused.

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.

To the credit of the Boston Globe, 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.

Finally, a professional board should conduct itself in a way that fosters trust in the profession. The story reported in the Boston Globe does the opposite.

(In addition to the Boston Globe article describing Ms. Grover's allegation, readers may be interested in an interview with Dr. Rabin in which he describes himself and his approach to therapy.)

Self-Disclosure in the Clinic and the Classroom

As I mentioned in a recent post, 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.

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?

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 here). 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.

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 less listened to and less 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.

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?

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.

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:

1. Talk with my experienced colleagues. How have they handled self-disclosure in their classes? What guidance can they give me?
2. 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?
3. 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?
4. 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?

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!

Psychiatrist-Patient Sex - plus a detective

When I was looking for audio books for my drive to Vermont, how could I resist Shrink  Rap, especially since the author was the wonderful Robert B. Parker of "Spenser" fame. Here's the blurb from the jacket:

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.

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.

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. 

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.

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.

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.

Shrink Rap brought to mind Dressed to Kill. 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.

Parker and DePalma render the dark side of our fantasies about psychiatrists. 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 Little Red Riding Hood - a loving grandmother on the outside but ravenous wolf within.

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 Hippocrates 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.

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.