Dilemmas in Clinical Medicine

Dilemmas in Clinical Medicine, IDM-701

Course Description, 1998-99

A. Course Synopsis:

The Dilemmas in Clinical Medicine (DCM) course is designed as a year-long experience in addressing ethical and humanistic issues in medicine and the decision-making process. By design, it occurs within the major clinical clerkships of the third year curriculum, with each clerkship providing a minimum of 2 two-hour sessions dedi cated specifically to this (required) course. Specific syllabi, including subject matter, required reading and student responsibilities will be distributed at the start of each clerkship. The design of the course is intended to emphasize small-group indep endent learning and discussion. One written case report will be required of each student in each clerkship. The case report must be based upon a patient seen during that clerkship. Student grades will be based upon the written case reports. Course evalua tions will be completed by each student.

An important goal of the course is to develop the ability to discern and identify ethical issues and value judgements in a variety of clinical settings. It is for this reason that students are expected to choose one of their own patients for case discussi on. This is also the case in ambulatory settings, which comprise a growing segment of the clinical clerkships. There is sometimes a tendency to focus upon high profile issues involving seriously ill hospitalized patients (such as withdrawal of life sustai ning treatment). While such cases certainly may present serious ethical dilemmas, one must not lose sight of dilemmas in less dramatic settings. Chronic illness, or well- patient encounters are often the backdrop for dilemmas relating to the doctor-patien t relationship, particularly in the ambulatory setting. These dilemmas can be just as vexing, and are certainly more common.

Ethical dilemmas arise in a wide range of clinical encounters, cutting across every medical specialty. The student is expected to select a case to present and analyze from each clerkship. If you have difficulty identifying or analyzing a case, do not hesi tate to contact the clerkship DCM coordinator, Dr. Wear, or Dr. Freer.

B. Course Objectives:

The student will be able to recognize an ethical dilemma, and clearly characterize the problem, as well as define the roles of the various parties involved.
The student will be able to analyze such cases with the goal of resolving the dilemma. In many cases, this resolution will consist of a statement of recommended action. In others it will be a clear plan for gathering specific information needed to tak e the proper action.
The student will be able to articulate the relevance of values and value judgements in any given clinical case, whether or not it is identified as an "ethical dilemma".
The student will be become familiar with the major ethical issues specifically related to the individual clinical clerkships.
The student will be able to access and utilize applicable medical literature in course of meeting the other objectives.

C. Course Materials:

There is a required text for the course: Resolving Ethical Dilemmas : A Guide for Clinicians by Bernard Lo MD. This book should be read by the end of the year and used as a reference for case write-ups.

Course readings and syllabi will be distributed to the students at the beginning of each clerkship. The specific nature of the experiences within the clerkships will be introduced by clerkship coordinators and course faculty. A standard protocol for the c ase reports is included with this Course Description, but more specific guidelines may also be distributed at the beginning of the individual clerkships.

D. Course Communication:

University/medical school e-mail will be periodically used to communicate information about the course. Because of the structure of the course (nested within each clerkship), it is particularly difficult to disseminate announcements or contact individual students when necessary. It is the student's responsibility to identify the public access computers in each hospital, and to periodically check E-Mail while on the clerkship. Ambulatory rotations still include at least some group sessions in an affiliat ed hospital or in the South Campus. Hospital librarians are available for assistance in all hospitals.

E. Course Faculty:

The course is coordinated by a steering committee comprised of clinical faculty, along with Dr. Stephen Wear, Dr. Scott DeVito and Dr. James Bono. Problems or questions about the course can be addressed to Drs. Freer or Wear. Most faculty are available on e-mail.

NOTE: All medical school E-Mail addresses are now on the University ACSU system.

Address general course questions to Drs. Freer or Wear:

Dr. Jack Freer (course coordinator) MFH 887-4600 (Page), 887-4852 (leave message), 871-1571 (Hertel-Elmwood Office) E-mail: jfreer@buffalo.edu

Dr. Stephen Wear at VAMC 834-9200 (Page) or 667-2728 (home). E-mail: wear@acsu.buffalo.edu

The clerkship DCM faculty are:

Psychiatry:
Dr. Miriam Shuchman shuchman@acsu.buffalo.edu

Medicine:
Dr. Jack Freer jfreer@buffalo.edu
Dr. Stephen Wear wear@acsu.buffalo.edu
Dr. Susan Schwartz suschwar@buffalo.edu,
Dr. Susan Gallagher DR0575@po2.bgh.edu, and
Dr. Eric TenBrock DR0206@po2.bgh.edu

Gynecology/Obstetrics:
Dr. Laurel White lwhite@mfhs.edu, and
Dr. Stephen Wear wear@acsu.buffalo.edu

Family Medicine:
Dr. Peter Kowalski pkowalsk@mfhs.edu,
Dr. Jim Bono hischaos@acsu.buffalo.edu, and
Dr. Scott DeVito sdevito@acsu.buffalo.edu

Pediatrics:
Dr. Wayne Waz, waz@buffalo.edu or wwaz@upa.chob.edu

Surgery:
Dr. Robert Milch morphdoc@aol.com
Dr. Rosa Cuenca
Dr. Syed Raza

E. Course Grades and Remediation:

Grading will be based on the individual clerkship case reports, and classroom participation. Note: a final examination had been discussed for this year but will NOT be given. Instead, the final grade will be based upon the six case write ups in the clerkships. One case report will be completed for each clerkship. Grades for the reports will be based on their written character. Students will be expected to identify the relevant issues, applicable legal and professional guidelines, and a process for decision- making and management. Citation of relevant literature references is not required but recommended and will weigh in the grading. Students must present their position or decision and defend it. In no sense, will the personal views of the student be tested or evaluated.

It is expected that students will be present at the relevant class sessions so that he or she can present their case report to the clerkship group and discuss it, if called upon to do so. Course failures will be remediated on an individual basis, and must be completed by December of the senior year. All students are reminded that they are always welcome to discuss any issues with the course faculty. If the student feels there are any areas of the course which are unclear, or confusing, we want to hear about it as soon as possible. Dr. Freer can always be reached at the above numbers, and E-mail address, if there are questions.

F. Bibliography:

Databases:
MEDLINE contains a number of Medical Subject Headings (MeSH) in the field of clinical ethics including: Ethics, Life Support Care, Euthanasia, Informed Consent, Resuscitation, Patient Participation, Confidentiality, Physician Patient Relations, and Bioethics. BIOETHICSLINE is devoted exclusively to these issues and is available on-line via Ovid Search Software on the new HUBNET2. Any Health Sciences Library or hospital librarian can assist you. A printed version for each of the past few years (Bibliography of Bioethics) is also available at many hospital libraries.
Medical Journals:
Most mainstream medical journals regularly publish articles related to ethical issues including some very useful review articles. These include New England Journal of Medicine, Annals of Internal Medicine, Archives of Internal Medicine, and JAMA.
Specialty Journals:
A number of specialty journals deal with ethical issues in medicine. The most readable are Hastings Center Report, and Journal of Clinical Ethics. Others include Journal of Medicine and Philosophy, Kennedy Institute of Ethics Journal, and Journal of Law, Medicine & Ethics.
ACP Annotated Bibliography:
An excellent annotated bibliography is regularly prepared by the American College of Physicians. The latest edition was published in Annals of Internal Medicine : Dunn PM. et al Medical ethics: an annotated bibliography, Annals of Internal Medi cine. 121(8):627-32, 1994 Oct 15.
Books:
NOTE: The required course text ("Resolving Ethical Dilemmas : A Guide for Clinicians" by Bernard Lo is available at the University Medical Bookstore on Main Street).
- Jonsen AR, Siegler M, Winslade WJ (1992): Clinical Ethics: a practical approach to ethical decisions in clinical medicine, New York, Macmillan. Although best taken with a grain of salt, this "manual" of medical ethics makes specific comment and has recommendations on many issues in the field.
- Beauchamp TL, Childress JF (1994): Principles of Biomedical Ethics, New York, Oxford University Press. This theoretical review of the principle-based approach to medical ethics also includes a number of case discussions (including many classic cases of historical interest).
- President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.
  New York State Task Force on Life and the Law. These two commissions each published a series of well referenced reports largely dealing with public policy on the issues we are dealing with.
On-line Information:
There are a growing number of electronic resources available in many fields including medical ethics. A large number of these resources are available via the UB Center for Clinical Ethics WWW site using any web browser. http://wings.buffalo.edu/faculty/research/bioethics/

Revised 3/20/99