DOCTORING: MEDICAL HUMANITIES CLERKSHIP

YEAR THREE: THE PHYSICIAN-PATIENT RELATIONSHIP

Ross Silverman, J.D., Clerkship Director
Department of Medical Humanities

Southern Illinois University School of Medicine
PO Box 19603
913 N Rutledge Street
Springfield, IL 62794-9603

 TABLE OF CONTENTS

The Physician-Patient Relationship

• Introduction
• General Learning Objectives
• Format
• Tutor Group Sessions and Assignments
• Evaluation
• Schedule
• Simulated Patient – The Case of Joan Wentworth
• Description of Assignment and Patient History
• Simulated Patient Interaction Schedule
• Simulated Patient Tutorial Schedule

MODULES

1. Historical Perspectives on the Physician-Patient Relationship
2. Ethical Perspectives on the Physician-Patient Relationship
3. Legal Perspectives on the Physician-Patient Relationship
4. Standard of Care -- Legal Rights and Responsibilities
5. Informed Consent in the Physician-Patient Relationship
6. Confidentiality and Privacy -- Ethical and Legal Considerations
7. Communication in the Physician-Patient Relationship
8. Issues of Bias in the Physician-Patient Relationship
9. Legal, Ethical, and Psychosocial Aspects of Withholding/Withdrawing Treatment
10. Clinical Case Studies in Withholding/Withdrawing Treatment
11. Palliative Care -- Clinical Decision Making
12. Palliative Care -- Hospice Considerations
13. Assisted Death -- Legal and Ethical Issues
14. Organ Donation
15. The Impaired Physician-Patient Relationship

INTRODUCTION

The Doctoring: Medical Humanities curriculum is designed to provide students with core knowledge in the humanities, emphasizing application of the content and methodologies 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 Segment 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 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 Segment is designed to allow students to explore the physician-patient relationship from a variety of perspectives: to look at the ethical underpinnings of the relationship; to examine laws that set forth 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 and clinical decision-making; and to examine certain compelling aspects of the relationship, including end-of-life care.

GENERAL LEARNING OBJECTIVES

Students will be able to:

• 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 procurement 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

Three classroom approaches will be used throughout this Doctoring: Medical Humanities Segment: (1) plenary sessions (e.g., seminars, panel discussions, and case studies); (2) tutor groups; and (3) simulated patient interactions. 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 simulated 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 simulated patient interaction by undertaking a review of plenary session notes and assigned readings, as well as through self-directed study. Following the simulated 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 ix. BEach student will participate in a scheduled faculty-student feedback session involving formal interactive review of the videotape.

Attendance at all scheduled activities is required.

TUTOR GROUP SESSIONS AND ASSIGNMENTS

Tutor Group assignments and room designations are listed on page viii. 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 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; simulated patient interactions; 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. Simulated 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 concise written essays (2-4 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 may not be utilized.

Students receive a performance rating for each of the following: tutor group participation (40%); the simulated patient interaction (20%); and the final written examination (40%). 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" will be recommended for Honors. Students who receive an unsatisfactory rating for any aspect of the course will be required to make up the deficiency. Minor deficiencies may result in an incomplete ("I") transcript notation until the deficiency has been corrected. A time frame for making up minor deficiencies will be established by the Segment Coordinator 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.