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Department of Medical Humanities

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Medical Humanities Curriculum

DOCTORING: MEDICAL HUMANITIES CLERKSHIP-YEAR 3
THE PHYSICIAN-PATIENT RELATIONSHIP

INTRODUCTION

The Doctoring: Medical Humanities curriculum is designed to provide students with core knowledge in the humanities, emphasizing understanding and application of the perspectives, methodologies and content of humanities disciplines to the practice of medicine. Substantive areas of teaching emphasis include ethics, health policy, law, medical history, and psychosocial care. During Year Three, the Doctoring: Medical Humanities Clerkship is a two-week learning experience entitled, "The Physician-Patient Relationship."

The physician-patient relationship in American society has been characterized by complex and sometimes contradictory forces — codified in laws and ethical codes and defined by customary practices as well as by cultural and historical expectations. Since ancient times, physicians have recognized that the health and well-being of patients depend upon a collaborative interaction between patients and physicians. This historical regard for the physician-patient relationship underlies current recognition of the physician-patient relationship as a central strength of American medical practice.

Over the years, many forces have shaped the nature and scope of the relationship between physicians and patients—forces as diverse as technological advancement, economic trends, legislative enactments, and cultural and religious values. These forces will continue to have significant impact on the physician-patient relationship, particularly as the health care system in the United States undergoes major changes. Because the physician-patient relationship serves as the cornerstone for achieving, maintaining, and improving health, it will be essential for physicians to maintain clear commitment to strengthening that relationship. In this regard, physicians are well served to understand and subscribe to the fundamental elements of the relationship.

This Doctoring: Medical Humanities Clerkship is designed to allow students to explore the physician-patient relationship from a variety of perspectives: to look at ethics-based and psychosocial underpinnings of the relationship; to examine how laws impact the rights and responsibilities in the relationship; to consider the importance of meaningful communication between physicians and patients; to look at forces that influence professional judgment, clinical and patient decision-making; and to examine certain compelling aspects of the relationship, including end-of-life care.

GENERAL LEARNING OBJECTIVES

Students will be able to:

Analyze physician-patient encounters for “microethical” or moral moments.

Discuss important ethical, historical, and legal perspectives on the physician-patient relationship.

Identify legal rights and responsibilities within the physician-patient relationship, with emphasis on the standard of care and professional liability in the context of medical malpractice litigation.

Describe ethical and legal principles that give rise to and shape the doctrine of informed consent as well as the informed consent interchange between physician and patient.

Discuss ethical and legal considerations that bear upon privacy and confidentiality within the physician-patient relationship.

Describe the value of meaningful communication between physicians and patients in the clinical setting and its importance in strengthening the physician-patient relationship.

Identify and discuss issues of bias that affect the physician-patient relationship.

Discuss the clinical, ethical, legal, and psychosocial aspects of decision-making relative to withholding/withdrawing life-sustaining treatment from patients who are terminally ill or permanently comatose.

Describe clinical, ethical, and psychosocial considerations that bear upon assessment and treatment of pain in situations where patients are terminally ill, with emphasis on palliative care and hospice care.

Discuss ethical and legal issues arising out of the controversy surrounding physician participation in assisted death.

Describe ethical, legal, and policy considerations relating to organ donation and transplantation as an aspect of the physician-patient relationship.

Discuss the effects of an impaired physician-patient relationship and describe available legal and professional responses.

FORMAT

Four teaching approaches will be used throughout this Doctoring: Medical Humanities Clerkship: (1) plenary sessions (e.g., seminars, panel discussions, and case studies); (2) tutor groups; (3) standardized patient interactions; and (4) a structured critical reflection exercise. During plenary sessions, core material will be presented. The information provided during these sessions complements required reading assignments. In conjunction with assigned readings, the content of plenary sessions will constitute the major basis for the final written examination.

Tutor group sessions are designed to allow in-depth exploration of material covered during plenary sessions. Approximately seven students are assigned to each tutor group, which will meet with the same tutor during all sessions. Each student will be responsible for presenting certain assigned cases in the tutor group setting. Because tutor group participation constitutes an important part of the overall performance evaluation, students will be evaluated on the basis of their case presentations as well as their interaction as informed participants in the discussion of cases presented by other students.

The standardized patient interaction involves a 15-minute, video-taped, physician-patient encounter during which students must individually demonstrate adherence to the applicable standards of care, conformity with principles of informed consent, recognition of issues of confidentiality and privacy (including public reporting obligations), and effective physician-patient communication, with emphasis on psychosocial care. Students should prepare for the standardized patient interaction by undertaking a review of plenary session notes and assigned readings, as well as through self-directed study. Following the standardized patient interview, students are required to prepare a written report setting forth the strengths and weaknesses of their individual physician-patient interactions and detailing the issues involved in the case as described on page x. Each student will participate in a scheduled faculty-student feedback session involving formal interactive review of the videotape.

Attendance at all scheduled activities is mandatory.  A sign-in sheet will be utilized for each class period.  Students with unexcused absences during the two-week Doctoring Clerkship will receive consequences, such as a lower overall grade for the Clerkship.

TUTOR GROUP SESSIONS AND ASSIGNMENTS

Tutor Group assignments and room designations are listed on page ix. Students will be expected to identify and define pertinent issues for discussion based on the General Learning Objectives. Students will be responsible for formally presenting assigned cases. Case assignments will concentrate on issues that are discussed during plenary sessions or emphasized in assigned readings. Students will be expected to undertake independent research in support of their case presentations. Students will also discuss other issues based upon individual perspectives drawn from experiences in clinical clerkships. 

EVALUATION

Evaluation of performance assumes full participation in and attendance at all scheduled activities. Criteria for evaluation include performance in the context of the following activities: participation in tutor group learning activities; formal case presentations; standardized patient interactions; a written critical reflection assignment; and a final case-based essay examination.  In evaluating student performance, faculty will assess student knowledge of course material, critical thinking and problem-solving ability, application of knowledge, oral and written communication skills, self-directed learning, interpersonal relationships, personal/professional maturity, and motivation/dependability/responsibility.

Tutors will evaluate students on the basis of preparation for and participation in tutor group discussions. Standardized patient interactions and case write-ups will be assessed against the evaluation criteria specified in that assignment. The final written examination will consist of several patient cases that focus on issues relevant to core material presented during the course. Students will be asked to respond to certain features of these cases in detailed written essays (3-4 pages). The examination will be "open book." However, only class notes, the course document, handouts, and suggested readings may be brought for use in responding to essay questions.  Laptop computers, cellular phones, PDAs, etc., may not be utilized.

Students receive a performance rating for each of the following: tutor group participation (40%); the standardized patient interaction (20%); the final written examination (40%); and the critical reflection written assignment (pass/fail). The rating scale for student performance is as follows: 5 = Excellent; 4 = Commendable; 3 = Meets Expectations; 2 = Marginal; 1 = Unsatisfactory. Students who receive an overall performance rating of "Excellent" (average of 4.5 or greater in the three evaluated areas) will be awarded Honors. Students who receive an unsatisfactory rating for any aspect of the course will be required to make up the deficiency. Failure to complete the written critical reflection assignment, or minor deficiencies in other assignments may result in an incomplete ("I") transcript notation until the deficiency has been corrected. A time frame for completing assignments and/or making up minor deficiencies will be established by the Clerkship Director in cooperation with Department faculty. Significant performance deficiencies will be identified by Department faculty and the Student Progress Committee will be informed of specific faculty recommendations for formal remediation.

Student performance in the areas of non-cognitive behavior and professionalism will be evaluated on an ongoing basis via faculty, tutor group, peers, staff, standardized patient feedback, and Clerkship assessment tools.  A student identified as committing acts of unprofessional behavior or raising non-cognitive academic performance concerns will be dealt with on a case-by-case basis, in accordance with the Student Progress System document.

All students shall be entitled to ask for a review of a final clerkship grade by the department and receive a timely response.

When the final grade for the clerkship is assigned, students will receive e-mail notification from the department indicating that the evaluations are complete and have been sent to the Office of Student Affairs. Students will receive a second e-mail notice when the final evaluations have been officially recorded; this notification will include a reminder of the Grade Review Policy.

If a student believes there has been an error in the grading process, or believes the final evaluation does not accurately reflect the performance, the student may speak informally with the faculty to find a resolution. However, the student is not required to pursue an informal review, but instead may request a formal review.

To begin the formal review process, a student must provide the Clerkship Director/Department Chair with a written document that outlines the basis for the request. Unless there are unusual or compelling circumstances, the written request, along with any supporting documentation, must be filed by the student within 30 working days of the official recording of the final grade. The request for review will prompt a review of the student’s portfolio. The outcome of this review will be shared with the student before any change in evaluation is submitted to the Office of Student Affairs. The Clerkship Director/Department Chair, in writing, must respond to the student’s request within 10 working days of receipt of the request for review. 


Should the student wish to have further review of the Clerkship Director/Department Chair’s decision, a written request for grade review will be submitted to the Chair of the Year 3 Curriculum Committee within 10 working days of the decision of the Clerkship Director.  The Year 3 Curriculum Committee Chair must respond, in writing, to the request for review within 10 working days of receipt of the request for review.  The decision of the Year 3 Curriculum Committee Chair will be submitted as the final grade.