The ethics of the medical student
Gonzalo Herranz, departmentde HumanitiesBiomedical, University of Navarra
Final talk at the III National Student Bioethics congress
Alicante, 11 April 2003
But first, some necessary considerations
II. The student-student relationship: fellowship
Greetings and thanks.
I have to talk about the ethics of the medical student. To tell you the truth: these are big words. I will do so with a great deal of respect - that is how we professors must always speak to students - and in the hope that I will pass on to them a little passion for it.
And I am going to speak very freely. This is not going to be a standard lecturefrom congress. It will try to be a simple talk, but with frankness and demand. We old people, like children, can take a lot of liberties, because we have nothing left to lose.
What can be said about the ethics of the medical student?
Lots of things: a waterfall born of the sourcethat Osler opened with his famous lecture"The Student Life" of 1905, and the super-famous "A Way of Life" of 1913.
Lots of theory, but you've had enough of that these days.
I could bring up many datafrom the empirical research, and present some of the much research that is being done on topic. But I know that this congresshas saturated you with programs of study, statistics and graphs.
I prefer a change of air and a move to narrative.
In medical ethics, narrative is increasingly used: personal stories are told, tales are told, cases are discussed, scenarios are composed.
Narratives in medicine are priceless in highlighting a basic aspect of medical ethics. Ethics has much to do with the relationships of the physician and the medical student, with their relationships with things, with patients and their families, with peers and colleagues, with teachers, with society as a whole, and in particular with God.
After spending quite some time selecting the ones that could be of most use to us, I chose three, particularly because they are told by students.
I will count them and try to add as little commentary as possible.
But first, some necessary considerations
The ethics of the medical student is common ethics, which has to do with the decisions we make every day, the reasons we give, the ends we pursue, the intentions that motivate us, the means we use. It is a matter of reflection.
Above all, it seems to me, the student's ethics, like that of every person, is a matter of examination: of sitting down at the end of the day to do the maths. Plato put a tremendous phrase in Socrates' mouth: that a life without examination is not worth living.
Ethics is also learning to do things by watching those who do them very well. And then trying to do them ourselves.
Ethics is also to set oneself a north, to have a reference letterto guide us. It was also Plato who said that one goes nowhere if one goes guideby the prow of one's own ship. You have to look at others, you have to choose models.
You have to put yourself before God. That is what has saved medicine. The medical oath is ultimately a commitment by the physician to make God a witness to what he does to patients. It is saying to him: You see what I do.
Ethics is a light that illuminates a lot, that makes one walk straight. Ethics makes life more conscious, more deliberate, more chosen. Much more human, infinitely more human.
Fortunately, medical ethics is growing, both as disciplineand as an environment. You are fortunate to be studying now. Today, to speak of ethics is no longer, as it was a few years ago, extravagant or ridiculous. Medical ethics has been almost dead for decades.
There is still a long way to go. If there is little interest among students, it is partly because many of their teachers don't know how to speak, they didn't study, there was no atmosphere, they lived off the old rents.
Moreover, spanish medical residency programputs pressure. It forces one to memorise more than to understand. The testspanish medical residency program is a powerful determinant of personality: it forces one to memorise more than to understand; it presents the science of medicine as a recipe book of solutions, not as a universe of problems.
The empirical programs of studyhas shown something obvious: that there seems to be a close correlation between what one is ethically as a student and what one will be ethically as a doctor.
In ethics, it has been said, with humour and truth, that medical students are undifferentiated yatroblasts, maturing in the decisive years of the Schooland the specialised training.
Most moral psychologists think, with Kohlberg, that ethical differentiation, the moral personality, is almost fully forged by the time one enters university. It cannot be changed.
I think not: there is always time to sharpen one's sensitivity to ethical issues, to study them more carefully, to oppose cynicism, and to file away the calluses of conscience.
It will be a wonderful time for them: the time of the new culture of medical error. To exchange concealment, censure and punishment for confession, analysis and remedy.
Living in this new era requires a great deal of ethical robustness.
To deal with a few points of student ethics, I am going to use the collage technique. I will mix two ingredients: I will make some considerations, I will make some comments.
Three stories from medical students. They tell us their stories.
Let's start by talking about something vital for the medical student: this first story should leave each one with a sincere
We are not born ethically mature: we need to study, to cultivate our conscience, to reflect. And for that, there is nothing better than asking questions, getting down to business, and applying one's intelligence. It is not enough to let oneself be carried away by intuition.
Let us look, for example, at the question of conscience. Important: science and conscience, that is what the life of the doctor is all about.
The consciousness of some, few, doctors or medical students is intuitive, emotional. This is not enough. The physician needs a robust, rational, finely tuned conscience. If he does not have it, he can do a lot of harm without realising it.
Awareness is refined as well as clinical habits. The good cardiologist no longer has to auscultate tone by tone, analyse every sound and every silence, as the student does: he listens and interprets the auscultation as a whole that responds to specific diagnostic patterns. To get there, there are many hours of phonendoscopy.
To have a fine, sensitive ethical conscience, one needs hours of intelligent reflection, of intelligent conversation with others, on moral issues. One needs to stubbornly ask oneself questions and stubbornly revise one's answers. It is like putting it on the table, taking it apart, cleaning it, changing a module, adding a sensor: that is, taking problems, reading articles, participating in seminars. Tuning.
In this way, the ability to discover nuances and not to condemn certain conduct en bloc is achieved. Ethical reflection is not the exclusive preserve of philosophers or experts: it is incumbent on all of us, because medicine is an intrinsically ethical business. Ethics is as consubstantial to medicine as science itself.
This is the case with which I began seminar on medical ethics. It is written by a medical student (JAMA 1985;254:3314). It is titled From the Bridge, and, it seems to me, it may be helpful in learning to ask questions. It goes like this:
At the last minute, almost at midnight, on a very busy Saturday work, a girl was brought to the emergency room who had tried to commit suicide by cutting her radial artery. We put a tourniquet on her, cannulated a vein, started giving her saline and, as soon as her haematocrit came back, we transfused her blood. Once she was stabilised, the surgical resident came in and I had to help her.
I felt sorry to see the despondency on the girl's face and in her eyes. From time to time, she would sob and say that life sucked. I imagined that something terrible had happened to her, a heartbreak or something like that. Suddenly, the resident said, "Next time, why don't you jump off the bridge? And stop whining. I can't take it. Hearing that, I was speechless, as devastated or more than the patient.
The resident, with great skill, finished repairing the artery, and left without saying a word to anyone. I tried to console the girl. I told her to understand, that the man was exhausted, that he had had too much work, and that he was like that because a patient had just died. But that he hadn't really meant what he said. She understood.
When, afterwards, I told the resident, he told me that who was I to correct him, who had believed me: that yes, he had said what he had said to purpose, and that he had no regrets. That it was because of the girl that he had not been able to finish a workfor a congress, that it was not right that he should have to waste his time and talent on fixing useless people, who were disgusted with themselves, who were determined to end their lives, and who did not even know how to commit suicide. I tried to tell him I wasn't agreementwith him. But he turned his back on me.
When, the next day, I discussed this with the head of the service, he was not the least bit interested. He told me that he was not in the mood for stories, that he had other things to worry about.
For several days, the thing didn't go out of my head. The resident fixed the artery, but he shattered the Hippocratic injunction that says first do no harm. But why did he do it? Can one be so self-centred that other people's suffering doesn't matter a damn? Was he so exhausted that the woman's crying made him unhinged? I don't know why he did it.
But since then, I have never stopped wondering whether I might one day be incapable of understanding a tragedy like that woman's and deliberately offend my patients.
This is the end of the story. The student of our story closes it with a series of questions. Therein lies the value of the story. For in order to lead an ethical life, asking questions is essential. Therein lies the secret of ethical growth.
One has to ask oneself, why did the resident behave in this way? What could his motives have been? What was he doing it for, what was his intention, what was his aim? What subjectperson was the surgical resident? A racist, a self-possessed show-off, a petty philosopher of power, who despises the weak? Or simply a poor man, a very unhappy man, a victim of an inferiority complex, covering himself with a shell of arrogance?
What is more serious, what he did and said, or his lack of repentance? Not repenting means that, in a similar status, he will act the same way again. And why, after his mistake, did he not want to admit it? How long does it take for one's conscience to grow calloused? And how long does it take to say that what is bad is good? How long is it possible to go back, to rectify, to ask for forgiveness? This is essential: the mere fact of not recognising one's mistakes predisposes one to continue making them.
But in the scene being told, there are other protagonists. Ethical narratives require us to get inside them. It is not enough to reduce the characters to abstract, unreal entities, mere concepts. In fact, the girl was a woman of flesh and blood, a very real and unfortunate human being. It is necessary to make an effort to give her a face, to give her a human identity, to turn her into a real person: she could have been a well-to-do, drug-addicted girl. She could be an AIDS patient, an immigrant from the Dominican Republic, or, for that matter, a medical student.
There are more questions to be asked about the Resident. We have already thought about it a little, but we must continue, because we must be fair: what is the fatigue of a weekend shift, full of emergencies and shocks, for a young doctor? Isn't a superhuman effort being demanded of someone who is also flesh and blood, someone who may be going through the crisis of realising that he was not as good a doctor as he thought, who has just lost a patient, perhaps because of a technical blunder? What part of the blame should be assigned to the poor organisation of the hospital, to the shortage of staff? And what part of the blame should be assigned to the aggressive lifestyle of the weekends, socially accepted as normal? Why, on those days when it is most needed, is there a shortage of staffin hospitals and emergency departments?
From the study of a case like this, many ethical resolutions can be deduced, some of them impossible for the time being, such as reforming the emergency care system or the lifestyle of large social groups. Other resolutions, if not impossible, are very difficult: for example, regulating the maximum hours of workfor resident doctors. Others are almost as urgent as suturing the severed artery, such as helping the woman to overcome her life crisis and thus prevent a new suicide attempt.
Ethical analysis is always fruitful: the core topicof the medical student's ethical life is to ask questions, to seek answers.
Let us now turn to another point
II. The student-student relationship: fellowship
Relationships between medical students are the school where one learns to live the relationships between doctors: they are relationships between peers, between colleagues.
The Code of Ethics tells us that fellowship among physicians is a primary duty, over which only the rights of the sick can take precedence.
It is curious that the term fellowship has been chosen as guideto inspire relations between colleagues. Fellowship, the feeling of being brothers, has its roots in the Hippocratic tradition: I will regard my master's children as my brothers, says the Oath; I will regard my colleagues as my sisters and brothers, proclaims the Declaration of Geneva; A physician shall behave towards his colleagues as he would wish his colleagues to behave towards him, prescribes the International Code of Medical Ethics, which, to inoculate us against corporatism, adds that Physicians shall treat their colleagues honestly and are obliged to report poor physicians to skill, and those who engage in fraud or deceit.
If not fraternal, then friendly relations should exist between doctors and medical students. They share ideals, they cooperate in the businessof serving humanity in the sick, they should help each other.
However, apart from small groups of close friends, the course and Schoolpartners tend to be simple acquaintances, whose names are sometimes ignored. The course, the promotion, acts as a mere entity management assistantand management, to schedule exams, edit notes, or go on trips of profilemore touristic than professional.
Today, relationships of antagonism or indifference between students, imported from abroad and specifically from the United States, are becoming commonplace. The fact that they are future contenders competing for a good placefrom spanish medical residency program may be more important than the friendly cohesion of feeling that they are colleagues who will live together for many years of professional practice.
Sometimes abusive situations arise. I present a narrative of great professional and human interest. (I take it, abbreviate it and adapt it from Murphy RE. The first day. JAMA 1989; 261:1509). It is an account of a doctor who goes to hospital on her first day, to make the transition from student to professional. But she is treated as if she had never stopped being a student. Besides, we doctors are lifelong learners.
It was my first day. I arrived at the hospital with averagean hour's notice and perfectly equipped. In my pockets I had the infallible ECG diagrams, the emergency cards, the phonendo, the torch, the reflex hammer. Suddenly, a clinic assistant snapped at me: "You must be the new one". Before I could so much as nod, she continued: "Don't forget that all requests for tests must be here before nine o'clock, signed by the resident, and marked in red if they are urgent. Put them, neatly sorted, in these trays. For X-rays, you fill out a yellow form, sign it and give it to me, is that clear? For ECGs or echoes, you fill in the green forms, stamp them and leave them in this other tray. If you are asked to take blood, don't forget, if you don't want the Chief to slit your throat, to fill out, apart from the three tubes in the big tray, a little blue tube if they ask for the TPTP, and this one with a purple cap for a researchthey are taking. If you need blood cultures, use the yellow capped tubes, at least two, but it's better if you go overboard: fill three, and make sure you clean the cap well with betadine. OK?
He disappeared from my sight before I could react. I couldn't check if I had written down the instructions correctly. I was going over the notes when the medical team arrived. The introductions were so fast that I couldn't remember names or positions. I was lost. Someone told a macabre anecdote that was apparently dedicated to the interns on their first day in hospital. The resident whispered in my ear: "Get ready. Things have been getting worse lately".
One resident presented the first case. He spoke at incredible speed, firing off abbreviations and figures like a machine gun. Everyone seemed to understand and digest them, but they made me dizzy. I had stood in the second row, and was trying to imagine what was wrong with the patient, when the first question fell on me: "At summary, this patient has one leg warmer than the other, the skin is oedematous and reddened, and Homan's sign is positive. What would you do?"
Twenty eyes were fixed on me. Like an idiot, I mumbled something about congestive heart failure and diuretics. They all looked up at the ceiling as if imploring heaven's protection. Before I could react, the Resident was already talking about the problems of deep vein thrombosis. I wanted to interrupt him to say that I knew the answer to that problem very well, but it was obvious: I had been eliminated.
The rest of the morning was a nightmare. As new sick people came in, I felt more and more lost. Every intern and resident, every nurse and orderly, and even the orderly would call me aside and make recommendations. I had to learn how to operate the floor control computer, how to determine arterial blood gases, where to go to find x-rays, how to put charts in place, and how to file ECGs. I didn't have time to eat.
At four o'clock I found myself at my notebook with six pages of hieroglyphs, of things that had been dictated to me and which I now had to turn into stories. In addition, two urgent things I had written down in pen in the palm of my hand had been wiped away in my sweat. I was desperate.
I tried to move from notes to stories. The nurses kept interrupting me with questions: The patient in 7 has been nauseous since early afternoon, do you want us to stop treatment? What do you want us to do with the cirrhotic in 27? What about the diarrhea in the lady in 62? I would answer that I had to check with the resident. As the evening approached, I felt more stupid and began to seriously think that medicine was not my thing. The 6 p.m. resident seminar was another torture session.
At 8 o'clock I was told to go and take blood from the patient in 32, for serial cardiac enzymes. I had only taken blood from three of my colleagues at class(and one of them I had failed). I decided to make that last effort to prove to myself that I could do it. I felt a great vein in my left forearm and was about to puncture it when the patient said, "I don't think it's good to draw blood above where the drip is connected. Besides, the blood is passing into the drip tubing". Even the patients seemed to know much better than I did what to do. As I prepared the right arm and looked for a vein, I began to explain why we had to stick him every six hours. He wanted to know the difference between angina pectoris and a heart attack, what you see on an ultrasound scan when you examine the heart, and how it was possible to tell from reading an ECG where the heart attack was located. I really enjoyed explaining it to him.
I failed. I apologised and told him I was going to look for the intern, that today was not my day. "No, no way," he said. "Let's give it a second try. I'm sure you're going to get it."
I was shattered by his confidence. I tried again and failed again. "Last time," he said. "Third time's the charm.
And so it was, thank God. I apologised once again. I wished him a good night, and was on my way out when he said, "You're studying to be a doctor, aren't you?" I said yes, and added that he was my first patient.
"Look here," he said. "No one has ever sat here on the edge of the bed to say a word to me before. And I've been here for two days. I know you're going to be a good doctor. I assure you.
It really fixed my catastrophic first day.
This is a story from which, despite its rosy ending, conclusions must be drawn. The story is saved by the immense humanity of the patient in 32. But it further highlights the cruel lack of fraternity with which some doctors act.
Why do some colleagues, comrades, take pleasure in humiliating? Why do they project their little sergeant-major's superiority onto the novices? Why this humiliating and humiliating, traumatising attention, which seeks, under the cloak of black or yellow humour, to disillusion, to make people self-deprecating?
That could perhaps fit in a training barracks of the US Marines. But that's not what we doctors are for: the healthy and strong. We are there for the sick and the sickly.
By vocation, it is natural for us to always take the side of the weak, the vulnerable, the one in need financial aid.
Especially when the weaker is a younger brother in the profession. Relations between colleagues, a crucial issue.
There is a whole pathology of the interprofessional relationship, which, at one extreme, manifests itself in the form of abuse, exploitation or intolerance towards the colleague. And which, at the other, is expressed, paradoxically, in complicity with negligence, in bad corporatism, in concealment of incompetence.
Let us leave it at that, but not without reminding ourselves that relations between students prefigure relations between doctors.
Let us move on to the last point. An important chapter of the student's ethics is that of his or her relationship with teachers.
The relationship between teacher and disciple, between teacher and student, has a long and glorious deontological tradition. The Hippocratic Oath speaks of veneration and respect for the teacher. And the Declaration of Geneva modernises that mandate.
The student/teacher relationship is somewhat paradoxical: it is made up of distance and proximity, of mimicry and rejection, of admiration and criticism.
It is a pity that it does not ordinarily give rise to much more attentionstaff , to repeated conversations, to opportunities for influencing character upon character: that it is not carried into the realm of experiences that are communicated, of intellectual habits that are passed on, of advice that is freely given and freely received.
There is one aspect of the teacher/student relationship that I would like to comment on and illustrate. It is the role of the student vis-à-vis the teacher mentor.
This is a rich vein, almost unexplored, in Spanish universities. Professors and students tend to limit their contactto the anonymous formalism of the class, when the best possibilities for their mutual influence are in conversation staff, in small talk group, in the corridor, in the column, in the cafeteria.
A good argument in favour of this thesis , a memorable argument, and I will end my talk with it, is in a few excerpts I take from a article, published in the American Journal of Medicine, by Michael A. LaCombe, graduateRecent advances (Am J Med 1990;88:407-408).
"On the cafeteriaof the School, two students discuss which has been the most important findingin the history of medicine. They are up to date, they follow the fashionable ideas. Everything old (Harvey's observations, Koch's postulates, Cajal's ideas about the texture of nervous tissue) seems trivial to them. One of them argues in favour of antibiotics. "They have given medicine its raison d'être: they have opened the way to understanding disease as a biochemical process. They have shown us that we are a formidable biochemical reactor. From what antibiotics revealed to us have come psychopharmaceuticals, antineoplastic chemotherapy, calcium antagonists. And now proteomics - it all comes from there!
The second student laughs with an air of superiority at his friend's idea and argues:
"The findingcomputer is the Rosetta Stone of medicine. Look at the applications of informatics in medical research. Think of the microchips used in autoanalysers, in monitoring devices, in the axial tomography scanner, in ultra-modern radiotherapy devices. And that's when we are still starting out. We will implant microchips to make the blind see and the deaf hear, and prostheses for the lame and the one-armed will be precision instruments. There will be portable artificial kidneys controlled by microcomputers, programmable pacemakers. And with the genome sequenced, we will do whatever we want.
The second student felt victorious. The other was a little taken aback. At the far end of the table sat an old professor who had been following the discussion with amusement. The first student asked him, "What do you think, Professor, what do you think has been the greatest achievement in medicine?"
The professor looked at the students with a blank stare and began to speak while looking out of the window. "You are both right, but the truth is that you have not got to the heart of the matter. Therefore, you are both wrong. It may be that the correct answer to that question is to be found in the very fact that you have asked it of me. That is, that they felt the need to ask me. And even, and better perhaps, in the fact that I feel compelled to answer it".
"Jo. This subjecthas Alzheimer's," thought the first student.
"He's a nutcase," the second one suspected just as quickly.
"But, well, where do we stand?" asked the first.
"Please can you speak to us more clearly," the second asked.
"The greatest advance in medicine is the teacher," said the professor. "The thing must have been invented before Hippocrates, I'm sure. But it was Hippocrates who took the cake. There he sat, wrapped in his robe, surrounded by colonnades, his chin resting on a fist. Observing the sick and thinking intensely, he managed to draw science and ethics from where before there was only magic and whimsy.
Soon he found a groupof young people sitting around him, who wanted to learn what he, Hippocrates, knew was important. He taught them everything he knew, which is what a teacher is supposed to do. And he sent them out into the world. And each of them became, in turn, a teacher to other students, just as Hippocrates had been to them. And wherever they went and treated the sick and taught the students, just as Hippocrates had taught them to do, there Hippocrates was at their side, seeing to it that they did things right, with science, with style, with ethics.
And so the centuries went by: from Herophilus to Galen, from Vesalius to Claude Bernard, from Pasteur to Whipple.... Well, you know the history of medicine as well as I do.
It was clear from the look on their faces that they didn't know her, so the old professor continued.
"You see what happens with teachers. You have teachers, each with pupils numbering in the thousands, all linked to each other over the centuries, forming the gigantic, dendritic, dendritic branch of medical knowledge, and it's a funny thing: we are all proud to belong to it. And it's funny: we are all proud to be part of it. What will happen to you when you go off to God knows where to practise medicine? Will your teachers abandon you? They never will. Look: a student, a young doctor, finds a patient with congestive heart failure, and there is Withering by his side telling him how much digital he has to give him. Or a young doctor comes across a complex case, with a maze of signs and symptoms, and suddenly Sydenham appears, sits next to him, makes sure that the young colleague takes a good history, does a good examination, notes down the observations accurately, and, little by little, light and order are created where there was darkness and chaos.
And so it has happened to me all my life. I have taken my teacher with me. It occurs to me to duck a difficult case, but I wonder what he will think of me, and I wake up, I go to Library Servicesand he financial aidhelps me to solve it. I lose patience with my patients, and I remember the patience he had. They ask me to teach, and I do it because that's what he did. When I start to doubt myself, I remember the confidence he had in me. And when I am about to give up, I see him in front of me, with his white coat, his steady gaze, his phonendo in his hand, and I continue.
He has been like a father. And even more: like a companion, who has helped me to get by when I was alone, who has made me share in the great joy that comes from practising medicine well. My teacher, through me and the students I have taught, has cared for countless patients with dignity, skilland compassion".
"Yes, the teacher is medicine's greatest invention. Doctors, every one of us, need one. That's all: I hope you will find yours".
The old man stood up. As he spoke, the students at other tables had started to listen. He greeted them all with a slight bow, straightened his shoulders, lifted his chin, and, about to leave, turned to say:
"Observation, reason, human understanding, courage, ethics: that's what doctors are made of".
We must finish. But first draw a couple of conclusions.
The first: that the medical profession is a community of science and ethics. It is a dendritic branch through which an intense flow of values runs, which enliven us, which do not allow us to become inadequate.
The second: that you have compassion for your professors and force them to become teachers. A medical school Schoolis worth, not what its teachers are worth, but what its students are worth. And the students are worth as much as they make their teachers lead a life of role models, of sincere and true role models. That is the tremendous responsibility of students who love the ethics of the profession.