2001-2002 DCM FAQ

(Dilemmas in Clinical Medicine Frequently Asked Questions)

 

  1. What is DCM?
    • DCM is the required 3rd year medical ethics course.
    • Although it is blended into the 6 required clinical clerkships, it is a separate course with a separate grade.
    • There are two sessions per clerkship: the first is semi-didactic; the second is a discussion of cases presented by students.

     

  2. Who are the faculty for DCM?
    • The faculty is comprised of clinical faculty from the clerkship departments along with Stephen Wear PhD and James Bono PhD

     

    Address general course questions to Drs. Freer or Wear:

    Jack Freer MD (course coordinator)

    MFH 887-4600 (Page), 887-4852 (leave message), 871-1571 (Office)

    E-mail: jfreer@buffalo.edu

    Stephen Wear PhD 460-2943 (pager) or 667-2728 (home).

    E-mail: wear@acsu.buffalo.edu

     

    Psychiatry:

    Miriam Shuchman MD shuchman@acsu.buffalo.edu

    Medicine:

    Jack Freer MD jfreer@buffalo.edu

    Stephen Wear PhD wear@acsu.buffalo.edu

    Gynecology/Obstetrics:

    Laurel White MD lwhite@kaleidahealth.org, and

    Stephen Wear PhD wear@acsu.buffalo.edu

    Family Medicine:

    Peter Kowalski MD pkowalski@kaleidahealth.org, and

    Jim Bono PhD hischaos@acsu.buffalo.edu

    Pediatrics:

    Wayne Waz, MD waz@buffalo.edu

    Surgery:

    Robert Milch MD rmilch@palliativecare.org, and

    Syed Raza MD syedtraza@worldnet.att.net

     

    Important course information may be sent by faculty to the class via UB e-mail. 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.

     

  3. How is the DCM grade determined?
    • The grade is based upon the case write-ups and classroom participation (both sessions are mandatory). There is no examination. Unlike previous years, there will not be a required case write up in the first clerkship, although the student will be required to bring a case to discuss in class. The second session in the first clerkship will provide instruction about how to identify cases, and organize a case write-up. Course failures will be remediated on an individual basis, and must be completed by December of the senior year.

     

  4. Is there a required textbook for the course?

     

  5. If there is no final exam, why should I buy a copy of the text and read it?
    • It is clinically oriented, well written, and discusses many of the vexing dilemmas in patient care that are glossed over or ignored in standard medical texts.
    • Unlike most medical texts, this book will remain relevant and timely many years from now.
    • It is a helpful tool in selecting a case of yours to write up.
    • It provides a framework for case discussion in your write up.

     

  6. Are any resources (other than the text) required or recommended?

     

  7. What should I do if I can’t find a patient with an ethical dilemma to write up?
    • Look through Lo’s book for ideas that might relate to one of your patients
    • Consider writing up a case that avoided a problem through the use of sound ethical reasoning, competent communication skills, or shared decision making principles, Such cases need to be carefully selected and discussed particularly in explaining the justification for the actions and the common errors that were avoided.
    • Select a case that demonstrates how "preventive ethics" can avoid problems (discussing advance directives, decisional incapacity, proxies etc). This is particularly appropriate for ambulatory rotations which offer the opportunity to head off major dilemmas in the hospital at a later time.
    • Discuss case selection with your clerkship DCM faculty or with Dr. Freer
    • DO NOT write up cases from the news, or anecdotal reports or embellish your own cases with false facts to "make a better case."
    • DO NOT plagiarize cases from the literature or any other sources.

DCM Case Report Protocol

 

Protocol for Case Reports:

 

Case reports should be drawn from the student's own experience during the Medicine clerkship; the report should be kept to a maximum of two sides of a single sheet of paper and, as long as it is legible, may be handwritten.

A. Selecting a Case.

 

The case should be selected from the student's experience on the clinical rotation, since ethical analysis should be a routine part of medical management. The student should be familiar with all aspects of the patient's medical condition as this is necessary for a meaningful analysis. The case should pose an ethical dilemma for the physicians on the case (that is, a difficult decision involving ethical issues or principles). This ordinarily represents a conflict over values; patient and family, patient and physician, etc. Specifically, you should exclude cases that focus on clearly inappropriate, unprofessional, or immoral behavior.

 

There is sometimes a tendency to focus upon high profile issues involving seriously ill hospitalized patients (such as withdrawal of life sustaining 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-Patient Relationship, particularly in the ambulatory setting. These dilemmas can be just as vexing, and are certainly more common.

 

B. Writing Up a Case

 

The write-up itself should begin with a brief summary of the medical facts of the case. This summary should be brief, although the student should be sufficiently familiar with the case to answer more detailed questions at the time of the presentation in class. Particular attention should be paid to clinical details which relate to the ethical issue (e.g. mental status or prognosis).

 

Following the clinical data, the dilemma itself should be identified. This is a 3 step process in which you identify the issue, a problem and a specific question:

 

  1. Decide what issue best describes the ethical dilemma or characterizes the main problem in the case. The earliest sense we may have is that there is an ethical issue lurking within the case (but we are not quite sure what that is). An important step is identify the issue explicitly. This is important because it focuses the theme of the write-up, and it gives you a topic to use in searching (in Lo or in the literature). It may be helpful to scan a list of common issues such as found in Lo's table of contents or University of Washington website: http://eduserv.hscer.washington.edu/bioethics/topics/index.html
    or the Library Classification Scheme of the National Reference Center for Bioethics Literature.
    Another way to identify relevant issues is to familiarize yourself with the MEDLINE MeSH headings found in ethics-related articles. An index of many of ethics related MeSH headings has been developed using the "tree" function of Ovid MEDLINE.

     

    For example, a student's case concerned a patient whose urine was sent for drug screening without the her permission. The issue here would be: "Informed Consent."

     

  2. Narrow down the issue to a specific problem for your case. Having first categorized your case broadly (in a particular issue or topic). now identify a specific problem (within that topic) that applied directly to your patient's case.

     

    Possible problems for the above example might be:
    • Is explicit consent needed for a specific lab test, or is a general blanket consent sufficient?
    • How much information needs to be provided to patients when obtaining consent for diagnostic or therapeutic interventions?
    • Do patient's best interests ever justify testing without consent?

    [You only need to provide one problem in your write-up]

     
  3. Convert this problem into an "ought" or "should" question. Come up with a question whose answer will guide your behavior.

 

Again using the same example, a "should question" might be:
Should we cancel the test, and/or ignore the lab results when they arrive for this patient?

 

Once you have an issue identified, a problem to solve and a specific question to answer, you can begin to analyze the case. There are a number of different approaches, but they tend to conform to the outline in the Lo textbook. This approach is explained in detail in the first 2 chapters of the book (pages 3-18). Although not required for the write-ups, relevant citations are welcome, particularly when the student has found them helpful in discussing the case.

A sample write up is available for reference.

 

Gathering Information

Clarify the Ethical Issues

Resolve Dilemmas

 

Contact Dr. Jack Freer to discuss any questions or unclear directions.
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