The Hidden Curriculum

Faculty Development

UBC Family Practice

Postgraduate Program

Tammy Attia

Faculty Development Coordinator

Prince George Site

An Incriminating Question

Case 1• Man in early 20’s, IQ 160, Dx: TB• Psychologist noted subtle changes in mental status.

Feared TB entered CNS, alerted clinical clerk• Clerk phoned attending: attending hung up• Chased resident down the hall

“What’s the point? We did a neuro consult. They gave him a clean bill of health. So some half-assed psychologist thinks otherwise.”

• Next pt encounter: near-catatonic state… irreversible

» Charles LeBaron, Gentle Vengeance

Case 2• On the third day post-op fractured hip repair a 72 year old

woman is switched from morphine to acetaminophen and codeine for pain. (routine orders)

• Later that day the family practice resident notes that the patient seems to be in a lot of pain with little relief from the T#3.

• The senior surgical resident sees the patient and finds no infection or other problems and tells the FP resident that the patient is fine.

• The FP resident checks the chart but avoids the patient because she is uncomfortable and the encounter is unpleasant.

• The patient spends 6 days in uncontrolled pain before it gradually settles on its own.

Outline• Red flags (warnings) that our current

medical culture has problems.• The history of these problems in our

medical culture. • Implications of our medical culture on

intellectual and emotional development.• Consequences of introspection and

dehumanization

Red Flags 1 Internal to the Profession External to the Profession• 40% of residents reported impaired performance > 4 wks due to poor mental health ~ 1/3 this sample had depression

• 5% of residents who require leave do so after suicide attempts. • ~ 40% of residents have relationship problems with their significant other. • 31% of doctors would not go through medical school again knowing what they know now.

•Doctors described as cold, uncaring, impersonal & distant

•Increasing trend toward alternative medicine: most important reason is how the patients feel they are treated

• Patients let initially correctable disease get out of hand (barrier to seeking help is fear of doctor!)

History• Education

Behaviour training at par with teaching knowledge

Assumption that appropriate behaviour follows appropriate knowledge

• Patient Perceptions Deficiency in ability

Deficiency in character

Admission to Medical School

• Intellectual Fitness FIRST– Then screen for emotional fitness and

character.

Once admitted the student must then be ACCEPTED into the medical culture.

Demonstrating our Values

Admitted but not yet Accepted

Proving your

“Intellectual Fitness”

Case 3: Intellectual Fitness• Learning session on heart sounds• Student A:

– “Well, I think I heard S1 and S2... There might have been a systolic murmur...”

• Preceptor Response: – “I’m not interested in your opinion. You are to report your

findings. Did you hear the heart sounds or did you not?”

• Student B: confident report• Preceptor Response:

– “You know, I don’t even care if you’re wrong. That was perfect.”

Admitted but not yet Accepted

Proving your

“Emotional Fitness”

Case 4: Emotional FitnessI think it is very ugly that this lab should come along so

early in my medical education… Isn’t there something wrong with starting off by causing pain without an intention to cure?…

Meanwhile…the students… are beginning to say… “How are you ever going to be a doctor if you’re too sensitive to do dog lab?…” It’s a confirmation of all my worst suspicions - this lab is intended to toughen me, to divide me from ordinary normal people.

» P. Klass, A Not Entirely Benign Procedure p.30-33

Case 4: Emotional Fitness

I went upstairs… took a shower. But nothing could… get that doggy smell out… I sat down on my bed… And thought…You came to medical school to learn how to heal people, save them pain…But if you do wake up somewhere years from now and much to your amazement they want explanations for why you tortured and killed a dog today, you better get your story all good and rehearsed because you’ll have a lot of explaining to do.

» C. LeBaron, Gentle Vengeance, p. 191

Case 4: Emotional Fitness“… I’m allowed little time to squander on

such mawkish reflections. In the twinkling of an eye, it’s midterm week, four exams in jackhammer succession.”

» C. LeBaron, Gentle Vengeance, p. 191

- Frederic W. Hafferty

“Introspection and reflection are terminal diseases in medical

school.”

Case 5: The Heirarchy• 64 y.o. man, dicharged home after a triple bipass surgery• Presents to Emergency room short of breath• Medical student in ER takes history and physical

– Preceptor briefly stated suspicions of CHF and intent to consult cardiology

• Cardiology resident takes thorough history and physical– Preceptor announces suspicion of pneumonia. Consults

Infectious Disease• ID resident spends good deal of time; repeats history and

physical– Preceptor suggests diagnosis is Dressler’s Syndrome,

therefore, consults cardiac surgery• Cardiac surgery resident takes history and physical

“We seem to prefer a cold or even disturbed physician with

full command of current medical science to the most sensitive and compassionate

bumbler.”- Dr. Melvin Konner

?!

FIFE! Wait! I haven’t FIFEd you yet!

Case 6: Role Modeling• Difficult, complex history• Poor eye contact, standing at foot of

bed.• Interview interrupted• Preceptor response:

– “I’d be far more impressed if you made a real connection with this person, than if you got a perfect record of all her facts.”

Charles LeBaron:

• “It seems to me I had a little vial of sweetness and kindness around stomach level. It’d been full when I was born; half of it had sloshed out in miscellaneous events since then, but I was hanging on for dear life to those remaining couple of ounces…Anyhow, serendipity had bailed me out on more than one occasion… Maybe serendipity would do it again and save that sloshing bit of enthusiasm and innocence. But when it’s all over, years from now, will I know?”

Good luck with your teaching. The next generation of doctors are

watching you!

References1. Allan D. Peterkin, 1998. Staying Human During Residency Training, 2nd ed2. Jean-Charles Sourina, The Illustrated History of Medicine, Harold Starke Publishers Limited,

London, 1992.3. Thomas Neville Bonner. Becoming a Physician - Medical Education in Britain, France, Germany,

and United States, 1750 - 1945, Oxford University Press, MY, 1995.4. Montaigne, Essais, Extraits, Univers des Lettres Bordas, Bordas, Paris, 1985.5. Moliere. Oevres Complètes I, Garnier-Flammarion, Paris, 19646. Melvin Konner. Becoming a Doctor. Elisabeth Sifton Books, NY, 1987.7. Frederic W. Hafferty. Into the Valley, Yale University Press, NY, 19918. Attia, T. Personal Experience. 1997.9. Merriam-Webster Online. 2005. http://www.m-w.com/10. Klass, P. A Not Entirely Benign Procedure: four years as a medical student. Penguin Books. 1987. 11. Charles LeBaron. Gentle Vengeance, Richard Marek Publishers, NY, 1981.12. Author Unknown. March 19, 2007. Debated Studies: Animal labs for medical student.

http://studentdoctor.net/blog/2007/03/19/debated-studies-animal-labs-for-medical-students. SDN . Hands-on Clinical Rotations in the United States for international MDs www.americlerkships.com.

13. Attia, T. Personal Experience. 2004.14. Attia, T. Personal Experience 1999.

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Thank You

• This module was written as an aid to the Preceptors in the Postgraduate Family Practice Program at the University of BC.– Study credit is available to groups of preceptors

who complete the module– Please give us your feedback on the module so

that we may improve it for others.• Email your comments to Dr. Christie Newton,

Faculty Development, UBC Family Practice• christie.newton@familymed.ubc.ca