Latest / Health Ethics Podcast / A Matter of Trust (with Guest Dr. Thomas Nasca)

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A Matter of Trust (with Guest Dr. Thomas Nasca) · Health Ethics Podcast

0:08
Speaker 1: Welcome to Health Ethics, a series of conversations with leading
0:12
Speaker 1: experts about ethical considerations associated with health and healthcare, both
0:17
Speaker 1: locally and globally. I am Brian Pilkington, Professor of Bioethics
0:21
Speaker 1: in the Department of Medical Sciences at the Hackensack Meridan
0:24
Speaker 1: School of Medicine. This series, like its predecessor, which focused
0:29
Speaker 1: on the COVID nineteen pandemic, relies on the idea that
0:32
Speaker 1: challenging ethical issues are best addressed by folks from diverse
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Speaker 1: backgrounds practically reasoning together, and complements the Health Ethics series
0:41
Speaker 1: with its panel of leading experts from medicine, nursing, politics, economics, philosophy,
0:47
Speaker 1: and the law. Thank you and enjoy the episode. It
0:58
Speaker 1: is my great pleasure today to be speaking with doctor
1:01
Speaker 1: Thomas A.
1:01
Speaker 2: Naska. Doctor Naska is the President and Chief Executive Officer
1:07
Speaker 2: of the Accreditation Council for Graduate Medical Education. Doctor Nasca
1:12
Speaker 2: is also Professor of Medicine at Jefferson Medical College and
1:15
Speaker 2: Senior Scholar in the Department of Medical Education at the
1:18
Speaker 2: University of Illinois at Chicago School of Medicine. He graduated
1:23
Speaker 2: from the University of Notre Dame, go Irish with high
1:26
Speaker 2: honors and is an ALFA Omega Alpha graduate of Jefferson
1:30
Speaker 2: Medical College prior to joining the ACGME and his tenure
1:35
Speaker 2: he'll be wrapping up in a month or so. So
1:37
Speaker 2: it's we're very, very fortunate to have doctor Naska. Prior
1:42
Speaker 2: to joining the ACGME, he served as Senior Vice President
1:46
Speaker 2: Fracket at AMICA Affairs at Thomas Jefferson University and as
1:50
Speaker 2: the Anthony and Gertrude de Palmer Dean of Jefferson Medical College.
1:55
Speaker 2: Doctor Naska became the founding President of the ac GME
1:59
Speaker 2: International in two thousand and nine. Tom, thank you so
2:03
Speaker 2: much for joining me today.
2:05
Speaker 1: Well, it's wonderful to be here, Brian, and so Tom
2:08
Speaker 1: and I are going to be talking about trust in
2:10
Speaker 1: medicine and a lot of ethics and ethics concerns. For
2:15
Speaker 1: me start locally and then move globally. So what really
2:18
Speaker 1: got me thinking more and more about trust and medicine
2:21
Speaker 1: was our medical school's commencement last year and the faculty
2:25
Speaker 1: speaker who's our advice Dean of Research, doctor Stanterlecki, talks
2:30
Speaker 1: often about how medicine moves at the speed of trust,
2:32
Speaker 1: and you delivered a nice talk sort of around this,
2:35
Speaker 1: and it really got me thinking. Lots of folks have
2:37
Speaker 1: conversations about trust in medicine, especially in graduate medical education.
2:42
Speaker 1: Your working graduate medical education over the last number of
2:45
Speaker 1: years has focused on trust, but in a different way,
2:50
Speaker 1: sort of adds a new dimension that I hadn't seen before,
2:53
Speaker 1: or at least not focused on as much, which has
2:56
Speaker 1: to do with trust between faculty and students, not just
2:59
Speaker 1: trust between pats and providers. So could you say something
3:02
Speaker 1: about the importance of trust in your own work and
3:05
Speaker 1: your own thoughts, and especially as it relates to trust
3:08
Speaker 1: of faculty in students.
3:11
Speaker 3: Sure, Brian. Let me just reflect on the title of
3:16
Speaker 3: the commencement talk medicine moves at the speed of trust.
3:21
Speaker 3: I probably would rephrase that a little and say medicine
3:24
Speaker 3: moves at the speed of science, but healthcare moves at
3:27
Speaker 3: the speed of trust. And I think the pandemic would
3:32
Speaker 3: be a primary example of that, with healthcare lagging behind
3:38
Speaker 3: science and its ability to deliver on the promises of science,
3:42
Speaker 3: for instance vaccination and public health. So a really complicated
3:47
Speaker 3: and I appreciate the opportunity to think about that speed
3:50
Speaker 3: of trust concept. One of the challenges for medical students
3:55
Speaker 3: and understanding what happens when they move into the clinical
3:58
Speaker 3: sphere is that they fail to recognize that the faculty
4:05
Speaker 3: of necessity need to develop trust in their abilities and
4:10
Speaker 3: in their motivation. And the reason for this is that
4:13
Speaker 3: in the clinical phase of undergraduate medical education and in
4:16
Speaker 3: graduate medical education, increasing responsibility is delegated to trainees by
4:23
Speaker 3: faculty in the care of real patients, patients whose lives
4:27
Speaker 3: depend on the care that's being rendered by the healthcare
4:31
Speaker 3: delivery team. And so the physician who is supervising, whether
4:36
Speaker 3: it be a medical student or a resident, needs to
4:39
Speaker 3: be able to increasingly trust and that trust is built
4:45
Speaker 3: by observation, feedback, and growth of the trainee in that relationship.
4:52
Speaker 3: So your remarks about the mentor and the importantship of
4:55
Speaker 3: that mentoring very is very germane here and their needs
4:59
Speaker 3: to to be a trusting relationship. Indeed, the common parlance
5:04
Speaker 3: around evaluation and progress in these circumstances require entrustments or
5:09
Speaker 3: assessment of performance, and in trustable professional activities, trust is
5:13
Speaker 3: used appropriately in those terms. And I think there's another
5:18
Speaker 3: concept that comes into play in the educational sphere is
5:22
Speaker 3: the movement of the relationship between the trainee and the
5:26
Speaker 3: faculty member from reliance reliability to trustworthiness. It's a fundamental
5:32
Speaker 3: difference in the way that one views that relationship and
5:35
Speaker 3: the growth of the individual.
5:37
Speaker 1: I want to pick up on two things there because
5:38
Speaker 1: it's really interesting. Could you, on the last point say
5:42
Speaker 1: a little bit more about how you understand reliability and
5:47
Speaker 1: the sort of what the positive moon move towards trustworthiness.
5:51
Speaker 1: I mean, what makes a good trainee or a new
5:54
Speaker 1: member of the medical profession, what gets them to the
5:57
Speaker 1: trustworthiness space as opposed to just merely be relied on.
6:02
Speaker 3: Reliance to me is is the willingness to engage with
6:07
Speaker 3: someone else in order to accomplish a goal. And reliability
6:11
Speaker 3: then would be the ability of the individual to be
6:14
Speaker 3: judged worthy to be relied upon. Okay, so that's the
6:18
Speaker 3: first phase in the development of the relationship between the
6:21
Speaker 3: supervising faculty member and the student or the resident. What
6:25
Speaker 3: are the elements of reliability, timeliness, truth telling, Having the
6:30
Speaker 3: core skills to accomplish the task that is promised to
6:33
Speaker 3: be provided, and the ability to identify one's weaknesses and
6:38
Speaker 3: seek out help in order to accomplish the trusting the
6:42
Speaker 3: reliable relationship. The movement from reliance to trust in the
6:46
Speaker 3: faculty student or faculty resident relationship is layered upon that
6:50
Speaker 3: as a foundation. If you think about the internship, what
6:54
Speaker 3: are most medical students graduating medical students most worried about
6:58
Speaker 3: how hard they can work or how long it can work,
7:00
Speaker 3: or how many hours it's going to be demanded of them.
7:03
Speaker 3: Why is that important? Because those are the reliance building blocks,
7:07
Speaker 3: that continuity of presence that the faculty expect to go
7:11
Speaker 3: from reliability to trust. It's one of the building blocks
7:15
Speaker 3: of that reliance relationship. Ultimately with the goal of a
7:18
Speaker 3: trusting relationships.
7:19
Speaker 1: The distinction is a good one and it's helpful sort
7:22
Speaker 1: of the way that trainees may build up into being
7:25
Speaker 1: trusted by, you know, those that they're learning from. And
7:27
Speaker 1: you had mentioned a conversation we had had previously around
7:30
Speaker 1: sort of the notions of a good mentor. And I
7:33
Speaker 1: think that that's essentially I mean, I'm not a clinician,
7:36
Speaker 1: but I have the pleasure of teaching ethics to our
7:38
Speaker 1: medical students at the Hackensacrity and School Medicine, and we
7:41
Speaker 1: have a session or a series of sessions before they
7:43
Speaker 1: go out into their clerkships. And my stick as you know,
7:47
Speaker 1: sort of posting a little bit of Aristotle here and there.
7:50
Speaker 1: So this question for you is partially about virtues and
7:53
Speaker 1: partially about good mentors. And so the line that I
7:56
Speaker 1: throw at the students comes from aristotles nicomaky and ethics
8:00
Speaker 1: and talks about the importance of the person with practical wisdom,
8:04
Speaker 1: and I use it as a way to highlight rules
8:06
Speaker 1: are great in lots of respects. We want the best consequences.
8:09
Speaker 1: But as I from the outside with a good amount
8:12
Speaker 1: of privilege because I don't have to go through the
8:13
Speaker 1: day to day tasks of physicians, as I sort of
8:16
Speaker 1: follow some of our students who have graduated and going
8:19
Speaker 1: on doing great things. What they've done is they've been
8:21
Speaker 1: able to find a good mentor reading the books. Isn't
8:24
Speaker 1: enough of following an excellent surgeon or an excellent internal
8:28
Speaker 1: medicine doc around to see right and to sort of
8:33
Speaker 1: become the kind of person who is trustworthy seems to
8:36
Speaker 1: be what medicine needs and what the future of medicine
8:39
Speaker 1: would benefit from. So now I've talked too much of
8:43
Speaker 1: any Do any of those thoughts connect up well with trustworthiness?
8:48
Speaker 1: Reflections from you on good mentors or the virtues that
8:53
Speaker 1: trustworthy students might have as connected to the intrustable professional standards,
8:58
Speaker 1: or just yeah, wax philosophically for us for a moment
9:01
Speaker 1: on virtues and good mentorship and trust.
9:05
Speaker 3: Well, if you take a step back, what are the
9:08
Speaker 3: mentors that you describe modeling In addition to the clinical
9:12
Speaker 3: skills of the discipline and the way that they manifest
9:16
Speaker 3: those clinical skills in excellent outcomes for their patients, they
9:20
Speaker 3: are modeling physician identity formation, and those the outward manifestations
9:26
Speaker 3: of that identity, that honesty, that integrity, that trustworthiness, and
9:32
Speaker 3: that's what we call professionalists. They are modeling professionalists. And
9:36
Speaker 3: my definition of professionalism can be a detailed one or
9:40
Speaker 3: a simple one, and I prefer the simple one, and
9:43
Speaker 3: that is that professionalism are the outward manifestations of the
9:47
Speaker 3: individual that allow patients to move from alliance to trust.
9:51
Speaker 3: And then you can speak about the virtues, because I think,
9:53
Speaker 3: you know, I'm Aristotilian kind of a guy as well,
9:58
Speaker 3: and I think about the outward manifestations of virtues, of
10:03
Speaker 3: virtuous behaviors, and Aristotle spoke about the need to practice
10:07
Speaker 3: the virtues, and that's exactly what we do during residency,
10:11
Speaker 3: and that's what the mentors should be demonstrating during their
10:13
Speaker 3: life of care, and as a matter of fact, they
10:16
Speaker 3: do it without consciously doing it. They teach because you
10:19
Speaker 3: learn as a student when no one is expected to
10:23
Speaker 3: be teaching. You learn all of the subtleties, and occasionally
10:27
Speaker 3: you also learn what not to do by observing individuals
10:31
Speaker 3: in the clinical learning environment because you will see maladaptive
10:34
Speaker 3: behaviors in any societal circumstance, and medicine is no different,
10:38
Speaker 3: and you can learn what not to do as well
10:40
Speaker 3: as what to do by observing those around you.
10:43
Speaker 1: It's a great point, and you mentioned the decide who
10:46
Speaker 1: should jump back as I sort of go through this
10:48
Speaker 1: conversation thinking about how this conception of trust that you're
10:52
Speaker 1: working with in the importance of this relationship connects up
10:54
Speaker 1: with considerations of trust and the social contract and variety
10:58
Speaker 1: of things. But I want to focus on I think
11:00
Speaker 1: an important topic that you touched on that listeners to
11:02
Speaker 1: the podcast would have run into because we had Fred
11:06
Speaker 1: Hafferty on a while ago who talked a bit about,
11:09
Speaker 1: among other things, the hidden curriculum, and so this, I
11:12
Speaker 1: think is one of the important and interesting and maybe
11:15
Speaker 1: challenging features of the kind of model you describe, which
11:18
Speaker 1: sounds exactly right to me, But there are some potential
11:22
Speaker 1: costs if we put so much steak in excellent mentorship.
11:26
Speaker 1: That's a high bar for mentors because given you know,
11:29
Speaker 1: and I'm sure the listening to the podcast is familiar
11:32
Speaker 1: with concerns about the hidden curriculum, those maladaptive behaviors you
11:37
Speaker 1: had mentioned. Learners are going to learn through observation and
11:40
Speaker 1: they're going to pick it all up. So that's that
11:44
Speaker 1: might be a tough bar. Any sort of can you
11:47
Speaker 1: say anything more about sort of avoiding concerns rooted in
11:51
Speaker 1: the hidden curriculum high bars for mentors to always be
11:54
Speaker 1: on and doing well? Are those concerns too big of
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Speaker 1: a cost for the importance of observation and of virtues
12:03
Speaker 1: as opposed to just here's the manual.
12:05
Speaker 3: And go yeah. I don't think that there is a
12:07
Speaker 3: manual in medicine. I just the circumstances are too complex.
12:12
Speaker 3: Every patient and every circumstance deserves unique attention. I think
12:18
Speaker 3: the words may be getting in the way here. I
12:21
Speaker 3: don't think that it's reasonable to expect perfection from everyone
12:25
Speaker 3: in the clinical care environment because the clinical care environment
12:28
Speaker 3: is the clinical learning environment or residence, and it is
12:31
Speaker 3: for the clinical phase of medical students education. What one
12:35
Speaker 3: needs to have, though, is a shared set of expectations
12:40
Speaker 3: and when behaviors fall below that, appropriate feedback is provided
12:45
Speaker 3: so that we can continue to strive because none of
12:48
Speaker 3: us are perfect, and expecting perfection, I think is unrealistic
12:51
Speaker 3: and sets people up for cognitive dissonance and dissatisfaction. I
12:56
Speaker 3: think we need to be honest that the clinical enterprise,
12:59
Speaker 3: artificial intelligence notwithstanding, it's still a very human interaction and
13:05
Speaker 3: a very human enterprise, and we expect that people do
13:08
Speaker 3: their best the best that they can and accept quality
13:12
Speaker 3: feedback as part of the responsibility of being a profession,
13:15
Speaker 3: of being a physician or a nurse or other professional
13:19
Speaker 3: in the healthcare delivery system, we all need to have
13:23
Speaker 3: that sense of accountability and willingness to accept suggestions for improvement,
13:30
Speaker 3: and that can come from everywhere and should come from everywhere,
13:32
Speaker 3: not just from superiors. And it requires one of those
13:36
Speaker 3: other virtues occasionally called courage.
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Speaker 1: It's a great point. I mean, the kinds of learners
13:41
Speaker 1: that we hope, at least patients like me hope that
13:44
Speaker 1: physicians are. I mean, everyone talks about lifelong learning, but
13:47
Speaker 1: what you've described as someone who's this isn't the best language,
13:50
Speaker 1: but able to be vulnerable and say, hey, you know
13:53
Speaker 1: I got this wrong. Let me make it better the
13:54
Speaker 1: next time. And I think points that you've raised here
13:57
Speaker 1: also connect up to the literature around trust and social
14:01
Speaker 1: contracts and trust in particular institutions. When folks, specifically in medicine,
14:05
Speaker 1: but I think this folds more generally are able to
14:07
Speaker 1: own up to their mistakes and are open about them.
14:10
Speaker 1: By and large, people respond well. The patient when something
14:14
Speaker 1: goes wrong might not be very happy, but at least
14:18
Speaker 1: when I've been in these circumstances, when someone says, hey,
14:20
Speaker 1: this is what happened, here's what we're going to do
14:21
Speaker 1: to fix it, and one's up to then you move
14:23
Speaker 1: forward together, right, and you can maintain that trust. Whereas
14:27
Speaker 1: in other kinds of situations, if you're not open to correction,
14:30
Speaker 1: if you're covering up errors, if you're sort of stuck
14:33
Speaker 1: on that path, that seems like the sort of perfect
14:37
Speaker 1: situation to break trust.
14:38
Speaker 3: Well, yeah, I think that the relationship between a physician
14:43
Speaker 3: and a patient can't be fully developed if the physician
14:46
Speaker 3: is defensive for one reason or another. The physician, by
14:50
Speaker 3: virtue of being in the clinical care environment, announces to
14:53
Speaker 3: the world that they are available to meet help an
14:56
Speaker 3: individual who is in need of their assistance achieve their goals,
15:01
Speaker 3: even at the risk of what's in best interest for
15:04
Speaker 3: the individual physician in that circumstance. And it's the altruistic
15:08
Speaker 3: dimension of the expectation of a professional, which, within limits,
15:13
Speaker 3: is one of the foundational elements of the trust that
15:18
Speaker 3: is built between patients and physicians if they sense and
15:24
Speaker 3: we've had numerous examples of that where the physician is
15:27
Speaker 3: behaving in their own best interest as opposed to the
15:29
Speaker 3: best interests of the patient. Even if the outcome is fine,
15:32
Speaker 3: the trust is completely eroded. So it's not just an
15:35
Speaker 3: outcomes relationship, it's a foundational motivational assumption relationship. The largest
15:41
Speaker 3: example of that occurred in the well There's numerous The
15:44
Speaker 3: Tuskegee experiment would be one, but the experiment in managed
15:48
Speaker 3: care in the nineteen nineties, where the gatekeeper physicians had
15:51
Speaker 3: economic incentives to withhold care. That concept was roundly rejected
15:55
Speaker 3: by the population at a political level. So the importance
16:00
Speaker 3: of trustworthiness and this altruistic dimension to trustworthiness is really important,
16:06
Speaker 3: and I think the profession clearly manifested that in the pandemic,
16:09
Speaker 3: with the willingness of doctors and nurses and other caregivers
16:13
Speaker 3: to stand the line in the presence of life threatening
16:16
Speaker 3: illness that could affect them and their families was a
16:19
Speaker 3: tremendous manifestation of altruism.
16:22
Speaker 1: That's a great point and a case that still looms large.
16:25
Speaker 1: I want to get to a little bit more about
16:28
Speaker 1: sort of the trusting relationship, but that raises the thing,
16:31
Speaker 1: so we'll jump back to that. That raises big questions
16:34
Speaker 1: about trust between society and between medicine. So and I
16:40
Speaker 1: think it raises some interesting and challenging questions about social
16:43
Speaker 1: contracts and what are expected of others in generally but
16:47
Speaker 1: specifically physicians. So, as you mentioned, and I think this
16:50
Speaker 1: is the case for most conceptions or definitions of profession,
16:53
Speaker 1: surely of healthcare professions. Right, altruism looms large. If you're
16:56
Speaker 1: not behaving in an altruistic manner, this raises questions about
16:59
Speaker 1: whether you're properly a professional, or whether the kinds of
17:03
Speaker 1: endeavors you're engaged in are the endeavors of a profession,
17:06
Speaker 1: and I think the pandemic highlighted this well. We had
17:09
Speaker 1: the healthcare heroes movements and just sort of story after
17:12
Speaker 1: story of physicians and other healthcare folks just constantly putting
17:16
Speaker 1: other people before them. Do you think this sort of
17:20
Speaker 1: throwing throws something in from la field? Are there obligations
17:24
Speaker 1: that patients or other members of society like myself aren't clinicians?
17:30
Speaker 1: Have I've thought about this a bit. I mean, physicians
17:33
Speaker 1: are doing a great and other healthcare folks, especially during
17:36
Speaker 1: the pandemic, we're doing a great deal. Occasionally, I've spoken
17:38
Speaker 1: with students of mine who have graduated and have been
17:42
Speaker 1: plagued with concerns of burnout more quickly than they anticipated
17:47
Speaker 1: they would, And I think part of this may have
17:49
Speaker 1: to do with an idea that other folks aren't holding
17:52
Speaker 1: up their end of the bargain. So given that you
17:55
Speaker 1: sort of that, you open the door to sort of
17:56
Speaker 1: the society considerations in medicine. I know you've thought a
17:59
Speaker 1: lot about this, any thoughts about what other folks owe
18:02
Speaker 1: to physicians and healthcare workers.
18:04
Speaker 3: This is a complicated topic and there are many dimensions
18:07
Speaker 3: to it. There is a reasonableness, expectation on the part
18:13
Speaker 3: of clinicians that the context of clinical care within which
18:17
Speaker 3: they function will provide them with the tools as best
18:21
Speaker 3: as available to meet the needs of the public that
18:24
Speaker 3: they serve, and when those needs are not met in
18:29
Speaker 3: the initial phase, we usually see heroic behavior on the
18:32
Speaker 3: part of caregivers, but at some juncture the caregiver cannot
18:36
Speaker 3: sustain that effort because there's a reasonableness component to altruism.
18:41
Speaker 3: For instance, we don't expect heroic behavior in a sustained
18:46
Speaker 3: fashion except in dire circumstances. In non dire circumstances, the
18:52
Speaker 3: expectation is that society has needs. Physicians and nurses are
18:57
Speaker 3: there to meet those needs, and the needs of the
19:00
Speaker 3: physician and nurses in order to meet the needs of
19:03
Speaker 3: the patients that they serve the public that they're serving
19:06
Speaker 3: need to be provided in some way, shape or form
19:09
Speaker 3: as best as it is possible. In later phases of
19:12
Speaker 3: the pandemic and in the post pandemic period, many physicians
19:16
Speaker 3: and nurses have felt that those needs were not met
19:19
Speaker 3: when they could have been met, and certainly in the
19:22
Speaker 3: post pandemic period, recognition of the need to rest or,
19:27
Speaker 3: the need to recover from the pandemic were not met.
19:30
Speaker 3: I think the other dimension because this is a multifaceted
19:34
Speaker 3: question and probably the question of our the next generation.
19:39
Speaker 3: The design of healthcare delivery is increasingly out of the
19:42
Speaker 3: hands of the professionals who provide care, and the design
19:46
Speaker 3: of the healthcare delivery system in the United States is
19:50
Speaker 3: some by some felt to be toxic. In other words,
19:54
Speaker 3: let me pause it to you the following. We have
19:56
Speaker 3: an industry where that fifty five to sixty percent of
20:00
Speaker 3: the employees in the industry have what are clinically described
20:04
Speaker 3: as burnout from the work that they're doing. Twenty five
20:07
Speaker 3: to thirty percent have clinical depressive symptoms. Some number of
20:12
Speaker 3: individuals have profound depression and their lives by suicide. In
20:18
Speaker 3: any other industry in the United States, OSHA would be
20:22
Speaker 3: up to their knees and hips wading in to that
20:27
Speaker 3: environment to try and find out what's wrong. What's happening
20:31
Speaker 3: is that clinicians are being asked to provide care in
20:34
Speaker 3: circumstances where they do not feel that they can offer
20:38
Speaker 3: their professional best. And that is to a professional who
20:43
Speaker 3: has promised society to give their best and promises each
20:48
Speaker 3: individual patient to give their best. The setup for cognitive disonance, depression,
20:53
Speaker 3: and burnout. And that's exactly what we're seeing in the
20:56
Speaker 3: United States, and it's escalator as the economy, economization of healthcare,
21:01
Speaker 3: the consumerization, the commoditization of healthcare, the marketing of healthcare
21:07
Speaker 3: dominates the provision of healthcare. This is damaging the individuals
21:13
Speaker 3: and collectively the ability of the profession to manifest the
21:17
Speaker 3: trustworthiness that it needs to manifest in order to meet
21:21
Speaker 3: the needs of the public gets sworn to serve. I
21:24
Speaker 3: think this is the issue of the next generation that
21:28
Speaker 3: needs to be solved.
21:29
Speaker 1: You've put it so well, and there's so many different
21:32
Speaker 1: facets of this. I mean again from students that I've taught,
21:36
Speaker 1: who you know, have faced some of these kinds of challenges.
21:39
Speaker 1: You you know, even from the outside, right as someone
21:41
Speaker 1: who's never and will never be in that situation, it's,
21:44
Speaker 1: you know, I feel the power that they feel of
21:48
Speaker 1: the oath, right or sort of you know, the promise
21:50
Speaker 1: that they've made to do certain kinds of things. Many
21:53
Speaker 1: of them, not all, many of them might be described
21:55
Speaker 1: as Type A individuals, and so they really they want
21:58
Speaker 1: to do the thing that they're supposed to do, and
22:00
Speaker 1: they want to do it well, and in fact, on
22:01
Speaker 1: many definitions of a profession my favorite is Alan Buchanan's
22:06
Speaker 1: work and sort of it's and he'd, like many others,
22:09
Speaker 1: highlight that professionals are those who strive for excellence in
22:13
Speaker 1: their particular area. We've done a bunch of word for
22:16
Speaker 1: folks who are listening to this podcast and also listen
22:18
Speaker 1: to the predecet of Serve podcast, the covid Ethics series
22:22
Speaker 1: on expertise. And I'm a big fan of deferring for
22:25
Speaker 1: experts and make as long as they're in their lanes.
22:27
Speaker 1: I mean, this is it seems in many ways like
22:29
Speaker 1: the perfect recipe, which is probably why the percentages are
22:32
Speaker 1: so high, the perfect recipe for burnout, for moral distress,
22:37
Speaker 1: and sort of job distress generally. And I had been thinking,
22:40
Speaker 1: I'll stop talking in a moment, and you know, get
22:42
Speaker 1: off my soapbox. But I had been thinking that reflecting
22:46
Speaker 1: on your comment, adjusting doctor Trelecki's point about medicine moving
22:51
Speaker 1: to the speed of trust really about the scientific folkus
22:53
Speaker 1: in healthcare not being able to catch up. I've been
22:55
Speaker 1: thinking a lot about whether members of society owe something
22:59
Speaker 1: to medical professionals, to healthcare professionals in light of acceptance
23:03
Speaker 1: of the best that science has to offer. And I'm
23:05
Speaker 1: thinking about those who might be done not access challenges,
23:08
Speaker 1: but sort of hesitant to embrace vaccines and putting lots
23:11
Speaker 1: of folks in danger and sort of what's owed. But
23:15
Speaker 1: I mean you've laid out I think an even bigger,
23:17
Speaker 1: more challenging, right, it's for the whole generation, turning medicine
23:20
Speaker 1: into you know, just another economy. And sort of how
23:25
Speaker 1: professionals who take an oath, right, this is the promised
23:27
Speaker 1: one taken oath. Other folks don't take an oath, right
23:30
Speaker 1: even And you had mentioned, you know, the algorithms that
23:32
Speaker 1: will be coming on AI algorithms don't take oaths, and
23:36
Speaker 1: so I don't there should be a question in there.
23:38
Speaker 1: But I mean, I think you've packaged and posed the
23:41
Speaker 1: challenge really really well. What's do you want to point
23:46
Speaker 1: our listeners in a direction to start thinking about how
23:50
Speaker 1: we all physicians, other healthcare folks, members of society, how
23:54
Speaker 1: we can address this or start to think about addressing it.
23:56
Speaker 3: Well, let me start with the clinician well being question,
24:00
Speaker 3: because it's not just doctors or physicians, it's all of it.
24:04
Speaker 3: And indeed, nurses have felt this for probably twenty five years,
24:09
Speaker 3: beginning in the late nineteen eighties when prospective reimbursements began
24:13
Speaker 3: to have an impact on hospital budgets. And hospital budgets
24:17
Speaker 3: are largely personnel budgets, and the largest group of that
24:20
Speaker 3: personnel budget are the nurse's budget. And so you've seen
24:25
Speaker 3: this concept of moral distress or moral injury in the
24:30
Speaker 3: nursing literature really since the late late nineteen eighties. It
24:34
Speaker 3: has come to the physician's literature really over the last
24:37
Speaker 3: fifteen or so years, as physicians' ability to cope with
24:41
Speaker 3: the economization of healthcare by increasing volume and increasing productivity
24:46
Speaker 3: has reached its limits. You can't drive length to stay
24:49
Speaker 3: down below much below four days for patients with congestive
24:53
Speaker 3: heart failure, for instance, sort of asymptotically reached productivities, and
25:01
Speaker 3: to driving physicians to do more in less time is
25:06
Speaker 3: resulting in the same kind of things that happened to nurses,
25:09
Speaker 3: where fewer nurses were expected to provide more care because
25:13
Speaker 3: of the economic imperatives. So these pressures brought us together
25:18
Speaker 3: at the National Academy of Medicine level in twenty sixteen,
25:22
Speaker 3: and myself Daryl Kirch and Victor Zoal in twenty twenty,
25:28
Speaker 3: then added VIVEK Murphy, the Surgeon General, have been heading
25:31
Speaker 3: up an effort to build awareness around and understand in
25:36
Speaker 3: great depth the challenges that are bringing about this burnout,
25:41
Speaker 3: depression and suicide problem in healthcare delivery personnel. And the
25:46
Speaker 3: consensus study was completed and clearly identified the system of
25:51
Speaker 3: care delivery as the major culprit in this problem and
25:55
Speaker 3: issued a number of recommendations around improvement. We have a
26:00
Speaker 3: national campaign of awareness that is actually underway right now.
26:05
Speaker 3: So if you go to the National Academy of Medicine
26:09
Speaker 3: and look for search for well Being, you'll see a
26:12
Speaker 3: wealth of resources about the ideology as well as ways
26:16
Speaker 3: to improve the circumstances and commitment of all the major
26:20
Speaker 3: medical and nursing and other professional organizations to this effort.
26:24
Speaker 3: So it's been a tremendous effort at Victor Ziud, the
26:27
Speaker 3: leader of the National Academy, deserves special credit for picking
26:31
Speaker 3: this up with us and helping us develop a national
26:35
Speaker 3: plan for trying to ameliorate this problem. The challenge for us,
26:39
Speaker 3: of course, is that even the National Academy does not
26:42
Speaker 3: design healthcare delivery in the United States, and we are
26:45
Speaker 3: going to have to come to grips with the fact
26:48
Speaker 3: that we're designing a system purely based on economics and
26:51
Speaker 3: not putting the patient at the center. Someone you mentioned
26:54
Speaker 3: a little earlier at both of our friend Fred Hafferty
26:57
Speaker 3: and I and Paige Amadon are just putting the final
27:00
Speaker 3: touches on an article that will go in the graduate
27:02
Speaker 3: of a journal of graduate medical education speaking to this
27:05
Speaker 3: issue because it's clearly influencing trainees. Resident unionization is on
27:10
Speaker 3: the rise, and we see that as a symptom of
27:14
Speaker 3: a maladaptive clinical learning environment. It's physicians don't want to unionize.
27:19
Speaker 3: They are driven to unionization by the environment within which
27:24
Speaker 3: they find themselves, where they can't provide for the quality
27:27
Speaker 3: of care necessary to honor their professional oath and to
27:31
Speaker 3: assure the trustworthiness. And what's interesting then, is the needs
27:34
Speaker 3: of the professions and the needs of the patients are
27:37
Speaker 3: aligned because the patients are not happy about the way
27:39
Speaker 3: healthcare is designed in the United States either.
27:42
Speaker 1: I mean, yeah, and we will all look out and
27:44
Speaker 1: I'll be sure once it's out to post it for
27:46
Speaker 1: listeners of the podcast. For that article, I mean, what
27:49
Speaker 1: you describe as a huge challenge and makes me think
27:52
Speaker 1: this will not surprise you of some work broadly within
27:55
Speaker 1: the virtue theory in Arisitilian Vain from the Notre Dame
27:58
Speaker 1: professor Alistair McIntyre, and at one point when he's taught
28:01
Speaker 1: out for listeners, won't give you too much philosophy. But
28:06
Speaker 1: when macnatarire sort of lays out conceptions of practices and medicine,
28:10
Speaker 1: I think fits us really well. He distinguishes between institutions
28:13
Speaker 1: and practices, and at one point he talks about institutions
28:17
Speaker 1: being interested in external goods and practice is being interested.
28:20
Speaker 1: Folks who are practitioners are interested in internal goods. I
28:23
Speaker 1: mean the goods that come out of greater health and
28:26
Speaker 1: better health for patients in the len of their relationship
28:29
Speaker 1: with clinicians. Generally, I mean, these are huge. But so
28:33
Speaker 1: the critique goes, and I'm generally with you, But you
28:35
Speaker 1: know the critique we go, well, but you still need
28:38
Speaker 1: an office, you still need an O R table, you
28:40
Speaker 1: still need scalpels, you still need all of these tools.
28:44
Speaker 1: And so McIntire's concern is that institutions might always corrupt practices,
28:49
Speaker 1: and so physicians are unionizing not because that's, you know,
28:52
Speaker 1: their first choice, but because they have to in response
28:55
Speaker 1: to the kind of models of healthcare delivery systems. What
28:59
Speaker 1: about the what might you say or where might you
29:01
Speaker 1: point folks who are more in favor of current models,
29:07
Speaker 1: whether they be sort of blind to well being concerns
29:10
Speaker 1: or just focused on other kinds of things When they say,
29:13
Speaker 1: but look, you know, somebody's got to pay for the table,
29:16
Speaker 1: somebody's got to pay for this, I mean, what's the
29:19
Speaker 1: Is there a good response that or can you point
29:21
Speaker 1: listeners who might have been thinking this? Can you point
29:23
Speaker 1: them where to go to sort of think more about it?
29:25
Speaker 3: Well, there's a high level way to respond to that.
29:29
Speaker 3: The United States spends in excess of four trillion dollars
29:33
Speaker 3: for trillion dollars a year on healthcare in the United States,
29:40
Speaker 3: for trillion dollars, it is more than any other developed
29:45
Speaker 3: country in the world, is probably more than any two
29:47
Speaker 3: or three of them put together in any country in
29:50
Speaker 3: the world, and certainly on a per capita base, it
29:52
Speaker 3: is a multiple of what it costs in other countries.
29:57
Speaker 3: Yet they have better outcomes and their clinic are happier.
30:00
Speaker 3: So I think it is ridiculous to even argue that
30:07
Speaker 3: we could do a better job. It is on its face,
30:11
Speaker 3: clearly demonstrable that we could do a better job with
30:14
Speaker 3: the resources that we have, and we need to figure
30:16
Speaker 3: out how to do that. I think the other is
30:19
Speaker 3: that you are watching the market behave in the way
30:23
Speaker 3: markets behaved, with the predatory activities of private equity, and
30:29
Speaker 3: what's happening into hospitals, especially safety net hospitals and small
30:35
Speaker 3: hospitals around the country looking for capital. The structural design
30:39
Speaker 3: of our delivery system is fundamentally flawed. We can make
30:42
Speaker 3: the argument and society should be the arbor or this,
30:46
Speaker 3: not the professionals, whether this should be designed around an
30:52
Speaker 3: economics platform or the like. But what is inarguable is
30:55
Speaker 3: that healthcare delivery should be designed around patient need and
30:59
Speaker 3: the public's need. The profession is, at its core at
31:03
Speaker 3: the service of the society in which we live. We
31:09
Speaker 3: swear to society to help deliver their health care needs
31:13
Speaker 3: in whatever structure they allow us to function. It It
31:16
Speaker 3: doesn't say whatever structure you allow us to function, as
31:19
Speaker 3: long as we do well economically or as long as
31:21
Speaker 3: it's easy for us. It's what are your needs and
31:25
Speaker 3: how can we meet them? That to me is at
31:27
Speaker 3: the core of professional identity. The profession is designed to
31:32
Speaker 3: meet the societal needs. Society is not designed to meet
31:36
Speaker 3: the profession's needs. We have to understand and work with
31:39
Speaker 3: society to develop a system where all of our patients
31:43
Speaker 3: and all of our members of society have equitable access
31:47
Speaker 3: to quality and safe care that helps them achieve their
31:51
Speaker 3: life's goals. We all have different possibilities, but we all
31:56
Speaker 3: have a core set of rights. One can argue, and
31:59
Speaker 3: I would argue that healthcare is like high school education.
32:03
Speaker 3: It should be part core high school education is provided
32:06
Speaker 3: as a right to every person in the United States
32:09
Speaker 3: as they're growing up. I think core healthcare should be
32:12
Speaker 3: provided to every person as a right of as a
32:15
Speaker 3: citizenship in the United States. Now that's a political statement
32:18
Speaker 3: and an economic statement more, but it is really a
32:21
Speaker 3: healthcare delivery state and a professional state.
32:23
Speaker 1: Again, I mean, you've given forty seven different sort of
32:26
Speaker 1: points that we give write books. I mean, this is great,
32:29
Speaker 1: this is really great, and I see, well, we can
32:32
Speaker 1: just take the last point. I mean, I'm I'm with you,
32:36
Speaker 1: and so we need another interlocutor in this conversation, someone
32:39
Speaker 1: who would push back on claims about right or sort
32:43
Speaker 1: of core healthcare as a right. I think, yeah, I mean,
32:46
Speaker 1: that sounds exactly right to me. And occasionally when I
32:49
Speaker 1: step outside of the US context, it is fairly early
32:53
Speaker 1: in conversations with ethicis who reside elsewhere, Oh well, yeah,
32:57
Speaker 1: you're coming from the US. Oh yeah, no, right to
33:00
Speaker 1: health care. This is seen as just a violation of
33:02
Speaker 1: human rights. It's that basically, and there are arguments after
33:06
Speaker 1: arguments in favor of this. So I think that's what
33:11
Speaker 1: I really appreciated about the answer, was how you situated
33:13
Speaker 1: this in terms of society, Because if the profession, and
33:16
Speaker 1: everyone says that it is, if the profession of medicine,
33:19
Speaker 1: if health care profess, if health professions generally are in
33:22
Speaker 1: the service of members of society, then the last I mean,
33:27
Speaker 1: that's where the conversation should be had. And it's just
33:31
Speaker 1: I mean, I, again, not being a clinician, I see
33:33
Speaker 1: from the outside, mainly through my students, the tension that
33:36
Speaker 1: arises when they come full of compassion for others. And
33:39
Speaker 1: you've spoken about compassion and other context eloquently, but they
33:43
Speaker 1: come full of compassion and then are budding up against
33:45
Speaker 1: a healthcare delivery system or sort of through it, which
33:49
Speaker 1: has other kinds of incentives. It's focused on other kinds
33:53
Speaker 1: of goods.
33:54
Speaker 3: And that cognitive dissonance if not mentored through by by
34:00
Speaker 3: faculty and other clinicians around who can help them understand
34:04
Speaker 3: the realities and not allow them to their energy and
34:09
Speaker 3: their altruism to be damaged by it and have cynicism
34:13
Speaker 3: introduced is really important because otherwise they will become cynical.
34:17
Speaker 3: And a cynical clinician is not a clinician that provides
34:21
Speaker 3: trustworthy care.
34:22
Speaker 1: Yeah, I mean it's as someone who you spend a
34:25
Speaker 1: lot of time with medical students. Is not what I
34:27
Speaker 1: would want for my students as a patient. It's not
34:29
Speaker 1: what I would want, you know, not a clinician. I
34:32
Speaker 1: can see and I imagine for you. You know you don't
34:35
Speaker 1: want this of your colleagues and your future colleagues. I mean,
34:38
Speaker 1: it's a yeah. And the other point of the big
34:41
Speaker 1: answer you just gave is we've seen it happen better elsewhere, right,
34:45
Speaker 1: We're not. There are places which have better outcomes. We
34:50
Speaker 1: put so many resources into health. There's got to be
34:52
Speaker 1: a better way to do it. And on that note,
34:55
Speaker 1: I'm going to get you to the last question that
34:58
Speaker 1: I have for you, which has to do with the
35:00
Speaker 1: future of medicine, right, because you've really really helpfully laid
35:04
Speaker 1: out a number of the challenges, given us some sort
35:07
Speaker 1: of history of how they arose, and they're pressing, right.
35:10
Speaker 1: I mean, you've alrea, we can't do more, you can't
35:13
Speaker 1: get folks, we can't be more efficient, and we're already
35:16
Speaker 1: chipping away at what I think is compassion. So help us,
35:20
Speaker 1: help the listeners point them in the right direction for
35:22
Speaker 1: addressing these problems in the future of medicine. I mean,
35:25
Speaker 1: as you reflect on your time in medicine, and you've
35:28
Speaker 1: been a leader in graduate medical education for a long time,
35:32
Speaker 1: what do you think the future of medicine holds and
35:36
Speaker 1: what do you anticipate in addition what you've said, other
35:40
Speaker 1: stressors and obstacles might be. What are our responses going
35:44
Speaker 1: to be? You've already mentioned the role of artificial intelligence.
35:48
Speaker 1: Give us a few lines or point our listeners in
35:50
Speaker 1: a direction where they might be hopeful for the future.
35:53
Speaker 3: Well, Brian, first of all, I am very hopeful for
35:56
Speaker 3: the future. I see the next generation of physicians, the
36:00
Speaker 3: physicians who are in medical school and who are in
36:02
Speaker 3: residency training right now, as first of all, practicing until
36:07
Speaker 3: the twenty sixties or the twenty seventies, so we need
36:11
Speaker 3: to recognize that their career will be hopefully longer than mine.
36:17
Speaker 3: I've been involved in medicine really since nineteen seventy one,
36:22
Speaker 3: so it's fifty three fifty four years now, and it's
36:28
Speaker 3: been a gift, and I think that they will have
36:30
Speaker 3: the same opportunities to see it as a gift. I
36:34
Speaker 3: think what we have to do as a profession is
36:37
Speaker 3: try to understand as best we can the stress is
36:41
Speaker 3: that the profession will be under not just in the
36:44
Speaker 3: short term, because I think that every technologic advance that
36:49
Speaker 3: we've come up with over the last one hundred years
36:52
Speaker 3: in healthcare delivery has merely opened the opportunity for higher
36:58
Speaker 3: quality patient care and the ability to rescue people from
37:02
Speaker 3: illness and death at a greater rate. I think we
37:05
Speaker 3: need to find out ways for society to create the
37:10
Speaker 3: circumstances where the life circumstances of individuals do not limit
37:16
Speaker 3: their ability to have a full and edifying life. In
37:21
Speaker 3: other words, the question of what zip code you're born
37:24
Speaker 3: and may determine how long you live. Social determinants of
37:27
Speaker 3: health as we speak about them and the equitable distribution
37:31
Speaker 3: of the good that is healthcare are questions that need
37:34
Speaker 3: to be asked and answered over the next hopefully less
37:38
Speaker 3: than ten years, but continuously as we move through. But
37:41
Speaker 3: I don't have a crystal ball. And so with a
37:46
Speaker 3: couple of colleagues and with the blessing and support of
37:49
Speaker 3: the ACGME, where we've created the Center for Professionalism and
37:54
Speaker 3: the Future of Medicine. And for people who don't, who
37:57
Speaker 3: have trouble with the term professionalism, just use trustworthys because
38:01
Speaker 3: I see professionalism as the outward manifestation of the virtues
38:05
Speaker 3: that allow a person to be trustworthy. Trustworthiness in the
38:08
Speaker 3: future of medicine, and to try and use tools that
38:11
Speaker 3: we've used in the planning of graduate medical education over
38:14
Speaker 3: the last twenty years to try and project out to
38:18
Speaker 3: twenty fifty and twenty sixty and understand the future oriented
38:22
Speaker 3: stresses that the profession will be under, and ask the question,
38:26
Speaker 3: the fundamental question, how do we assure the public in
38:30
Speaker 3: twenty fifty and twenty sixty that the clinicians that we create,
38:35
Speaker 3: who create themselves and who promise to serve them, have
38:40
Speaker 3: the values, have the virtues, and have the skill sets
38:44
Speaker 3: to function in that environment and deal with those stresses
38:48
Speaker 3: and still be trustworthy to them. That's the question that
38:53
Speaker 3: we're asking right now. We've asked experts from around the
38:56
Speaker 3: country will help us begin to think about the stress
39:00
Speaker 3: is that might be unleashed on the profession and healthcare
39:04
Speaker 3: delivery in general and the public and try and understand
39:07
Speaker 3: then how we can plan for those and assure that
39:11
Speaker 3: our educational programs and our experiential learning programs prepare people
39:15
Speaker 3: to meet those needs in those future states. That's what
39:20
Speaker 3: I'd like to do with what I have left of
39:23
Speaker 3: my professional career. And I am tremendously grateful to the
39:28
Speaker 3: profession and to the public for allowing us the privilege
39:34
Speaker 3: of professional self regulation in the United States, which is
39:38
Speaker 3: not present in most of the rest of the world.
39:41
Speaker 3: We are truly gifted as a profession and I hope
39:43
Speaker 3: as a public for that. It's manifestation of alexis to
39:48
Speaker 3: toekfol's private entities doing the public good.
39:52
Speaker 1: The center sounds exciting, and I will make sure that
39:56
Speaker 1: folks listening the podcast you have links to web pages
39:59
Speaker 1: and other kinds of information, because it sounds like the
40:01
Speaker 1: work that the center will be doing is exactly what
40:04
Speaker 1: is needed, both for medicine but especially on the heels
40:06
Speaker 1: of the pandemic, where a lot of ethicists spent time
40:09
Speaker 1: sort of thinking through and ultimately arrived at the sort
40:12
Speaker 1: of duty to plan right for future eventualities that we
40:16
Speaker 1: all have and especially with respect to health healthcare institutions have.
40:19
Speaker 1: So the work of the center is essential, and I
40:22
Speaker 1: know everyone who listens to this will be keeping an
40:25
Speaker 1: eye on what you all come up with. So congratulations
40:29
Speaker 1: on founding it and we'll look forward to seeing what
40:33
Speaker 1: comes out of it.
40:33
Speaker 3: Well, if we're lucky, you'll be part of it.
40:36
Speaker 1: That's very kind, very kind. Thank you for listening to
40:41
Speaker 1: the podcast. I've speaking with doctor Thomas Naska about a
40:44
Speaker 1: host of considerations relative to trust in medicine, about ethics,
40:48
Speaker 1: about virtues, about society, and again, thanks so much time
40:52
Speaker 1: for doing it. I really appreciate it.
40:53
Speaker 3: Well, thanks Brian for the opportunity, and thanks for the
40:56
Speaker 3: listeners for listening.
40:58
Speaker 1: This podcast series is a production of the Health Ethics Lab,
41:01
Speaker 1: and I am grateful to colleagues in the Department of
41:03
Speaker 1: Medical Sciences, the IHS Library, and the Hackensack Ready in
41:07
Speaker 1: the School of Medicine for making this collaboration possible. To
41:10
Speaker 1: learn more about our work or to engage with the
41:13
Speaker 1: series content, reach out to me Brian Pilkington at Brian
41:17
Speaker 1: dot Pilkington at hmh N dot org.