This week, 13 final-year male dental students at Dalhousie University in Halifax, Nova Scotia, were suspended from clinical rotations pending further investigation of complaints filed by fellow students and by 4 professors. These men were members of a Facebook group called Class of DDS 2015 Gentlemen on which misogynistic comments about their fellow female classmates were posted. While the student complaints were initially filed in early December, the suspensions, announced on January 5 by the university, have now made national news.
The Facebook page comments that have been included in various articles are definitely misogynistic. These young men publicly discuss which dental anesthetics would best be used for date rape, and voted for which fellow female classmates would be best for hate sex. What is most horrifying is that it appears the social media group was not new, and that these future dentists were just several months away from becoming full members of their profession.
I have no doubt that Dalhousie University will address the investigation of these complaints and follow through with disciplinary action in an appropriate manner. Like many universities, they have instituted policies that will direct the administration in an equitable and through manner. It may be an arduous process (too slow for some—which prompted a complaint by 4 professors who felt that the university was slow in its response). Given the turn of events, it will likely be a much more public process than the university had originally intended. However, this process is still reactive and does not address the underlying problem. How can we teach professionalism to young men and women so that they will graduate not only with the clinical skills necessary to practice in their chosen health care profession but with the tools to conduct themselves as professionals in public?
Medical and dental school admissions have gotten even more competitive since I applied. There are many qualified applicants who do not get a spot and the vast majority of the current student body is superb. However, medical and dental students are generally young and lack life experience. They may have more scientific acumen than common sense. Certainly, students in their 20s make mistakes. How, then, can those of us involved in their education impart to them the necessary skills required to become excellent practitioners?
It is not just a good memory or excellent fine motor skills that are needed. In every clinical rotation, students are evaluated for their professionalism as well as for their clinical knowledge. Faculties of medicine and dentistry certainly value professionalism and understand that these attributes are equally important. Health care professionals need to be reliable, to communicate well, to listen well, and to respect others, be they colleagues, patients or other health care team members. They need to understand that they will be held to a higher standard in exchange for the privilege of interacting with patients when they are at their most vulnerable.
Can we teach professionalism by example? I hope so. I have repeatedly given students feedback about how to address families and patients when we enter rooms. Students need to be reminded to make eye contact, to use lay language, to not speak as if the patient was not in the room and to address any questions openly and honestly. Most appreciate the feedback and incorporate it into their patient interactions. But there is an important part of their education that does not occur at the bedside or in the classroom. Students need to lead by example for each other as well. They are each other’s future colleagues in a self-policing profession. They should not lose opportunities to help each other develop those necessary skills.
The challenge of teaching professionalism will always be there. Like with school bullying, those who remain quiet when witnessing inappropriate behavior can influence the change. Perhaps in a climate where poor judgment and immature behavior is identified early, and where fellow students can promptly and safely report inappropriate behavior, the new generation of health care professionals will hold each other to the high standards required of them.
Dinner conversation topics in my home can vary from the serious to the mundane. My kids (all pre-teens and teenagers) still communicate with me in more than a series of grunts. They acknowledge each other’s existence. It’s fantastic. Imagine my chagrin when we spent a whole meal discussing their fears for my well-being. My kids are pretty aware of the world around them. They listen to and read the news. They also have a clear understanding of what I do every day. So, when they hear about health care workers who have contracted Ebola in Texas, it is no giant leap for them to worry about and for me. As a hospital-based health care worker in a city rich with citizens who hail from hundreds of countries, it is likely that there will be many Ebola scares close to home in the near future. I practice in a hospital that was at the epicenter of the SARS outbreak in Toronto in 2003. While my children were too young at the time to remember it, they have heard about it and have even seen the movies-of-the-week that were based on it.
I remember the first child who had contracted SARS from family members who had already succumbed to the disease. When that child was admitted to hospital, my colleagues and I (all young professionals with young children, except for one single guy) looked at one another and tried to decide who would don the N-95 mask, gown, face-shield and gloves and care for the patient. Those early days in the outbreak were filled with many questions but few answers. We were faced every day with new instructions and new rules about how we were supposed to be screened, to protect ourselves and to care for our patients. One of my colleagues, the unmarried physician in our group, selflessly volunteered to expose himself to that first patient so that the rest of us could minimize our risk to ourselves and to our young families. We all remained healthy throughout the SARS outbreak, which lasted for several months but the memories of working in those conditions are still quite vivid.
Now, my children are old enough to understand what might happen with Ebola. They are concerned for me, and for the fallibility of PPE (personal protective equipment). They ask me about resource allocation, too. What will happen if there are not enough ventilators or ICU beds for all the sick patients? Who will decide who receives intensive care and how will those decisions be made? Are all states and provinces approaching preparedness in a consistent fashion?
These are all excellent questions. Unfortunately, no one yet has those answers. The real risk of an Ebola outbreak in North America is low. However, past experience suggests that we will have to be prepared so that if there is an outbreak, we will have the answers to my kids’ questions before we need them.
Before I went to medical school, I spent 4 wonderful years at college studying the history of science and medicine. I especially loved the books on my reading lists that captured a story about a past medical discovery or epidemic. While I had no medical expertise at the time and simply wanted to do passably well on the MCAT so some medical school would accept me, the stories of the flu epidemic of 1918, the discovery of penicillin, the Wexner report and the development of formal medical education captivated me. They gave me context and allowed me to understand the path the practice of medicine had taken prior to my interest in the profession.
Medical school, residency, medical practice and parenthood do not leave much free time for pleasure reading. While it is still wonderful to escape with a novel, I still gravitate to non-fiction works that focus on medicine. A few years ago, I gave a lecture to my colleagues about books that every doctor should read. While it is still prudent to keep updated on new research to help our patients, these books are designed to help physicians (and non-physicians) maintain perspective. Here are a few of them:
History of Medicine:
- The Immortal Life of Henrietta Lacks by Rebecca Skloot is a well-researched account of the history of HeLa cancer cell line and the woman whose cancer launched a medical revolution.
- Bad Blood by James H. Jones is history of the Tuskeegee Syphilis experiment that the Public Health Service ran from 1932 until 1972. African-American men with syphilis were studied over decades to learn about the natural course of the disease. However, they were never treated with penicillin even after the antibiotic’s availability increased in the 1940s.
- The Emperor of All Maladies by Siddhartha Mukherjee is a biography of cancer. It is long and detailed and clearly shows how recently many advances in cancer treatment have developed and how little oncologists really knew even 50 years ago.
Meditations on the Profession:
- Complications by Atul Gawande, a surgeon and prolific writer, is a collection of honest essays written during and after surgical training.
- The Youngest Science: Notes of a Medicine-Watcher by Lewis Thomas was his third collection of well-written and thoughtful essays reflecting back on his career as a successful academic and physician. I remember reading this in high school and deciding to become a physician.
- The Real Life of a Pediatrician, edited by Perri Klass is a collection of candid stories following the path from student to veteran doctor. While I love every book that Perri Klass has ever written (and can admit that her memoir A Not Entirely benign Procedure allowed me to survive the summer of 1988, also known as the summer of med school applications and MCATs), the many voices in this collection are honest and engaging. Let’s face it: pediatricians are generally nice people and I like reading about them.
Books that can influence the way we practice:
- Forgive and Remember: Managing Medical Failure by Charles Bosk, follows fictional surgical teams in a teaching hospital and is one of the first books ever written on medical error.
- The Checklist Manifesto by Atul Gawande, provides a 21st century approach to patient safety using the expertise of the aviation industry.
- How Doctors Think by Jerome Groopman is an extremely honest and thoughtful look at medical error and cognitive error. It explores why doctors succeed and why they err, how they can embrace uncertainty and how patients can help doctors avoid error. I tell every trainee that I teach to read this book in the hopes that s/he will incorporate these learning points in the practice of medicine.
Last month I had the pleasure of reconnecting with many classmates at the same reunion that Jonathan Miller enjoyed. I went to a panel discussion about health care reform. As a physician who is interested in health policy, I was eager to hear what the panelists had to say. My former classmates were now health services researchers, physicians, and health policy experts. Other audience members were now health insurance executives, policy makers, and health care users with diverse political affiliations. It didn’t take long before I felt as if I had mistakenly walked into a foreign language film without English subtitles. While Canadians may spell and pronounce words differently, understanding American English is usually not a hardship. The language used in public discourse on the Affordable Care Act, however, simply does not resonate with Canadians.
While I have lived in the US, I have never practiced medicine there, nor have I ever been a consistent user of US health care services (unless you count sporadic interactions with the University Health Service in college– but let’s not). I have spent over 20 years as a health care provider and a lifetime as a health care user in Canada. I am not a comparative expert on US vs. Canadian health care models. I have simply experienced the Canadian system both as a physician and a patient/ advocate.
There are three key components of the Canadian universal health care system that are integral to its success and might illustrate the true differences between citizens of both countries (aside from the Canadian propensity to be polite and apologetic). The first is the way in which Canadians view their right to health care. It is an expectation but not one that is felt to necessarily be an immediate one. Canadians are very patient people (unless they are watching an NHL playoff game on TV and the cable goes out). I think it is similar to garbage collection. I pay taxes to the city of Toronto and in return I get my garbage collected on a regular basis. While I might want the garbage collectors to come every day, instead I have to wait patiently to have it removed according to the schedule.
What if there is a chemical spill or a major hazard that would require removal of toxic waste urgently? There is a way to initiate an emergency system to get that garbage removed. Access to health care is seen in much the same way.
Another component of Canadian Medicare that supports its success is the belief of most Canadians that every citizen has the right to access the system. While there may be geographic variations with respect to the services that are offered, those differences are not unique to this country. It is similar to public primary and secondary education. This belief is part of the fabric of the country.
The last characteristic of Canadian Medicare might sound odd. I actually believe that we have less government and third-party intervention in the doctor-patient relationship in Canada when compared to the US. While government involvement in instituting Obamacare has met with resistance from insurance companies and individuals on many levels because of the fear of losing free choice, the recent Supreme Court Hobby Lobby decision suggests that there is a long road ahead. As a physician, I see patients and bill the province’s Ministry of Health, who then pays me for the services that I have provided. Neither the patient nor the physician has to get approval from a third party for the care that is needed. The role of health insurance companies is for extended benefits only, such as dental and psychological services, medical device costs, medication costs, and use of private hospital rooms. While there are government controls on overall costs and resource allocation, there are certainly no government or third parties interfering with moral decision-making for the patient.
Canada has usually been a little behind the times when compared to the US. In a reference to the ‘80s fashions worn by Robin Sparkles in 1994 in an episode of How I Met Your Mother, Cobie Smulders’ character says, “The ‘80s didn’t come to Canada ‘til like ’93.” While that may be the case for access to stores like Target (which finally opened in Canada in 2013), access to health care in Canada is the exception. While uninsured rates for those without health insurance are followed closely south of the border, and are thankfully dropping, they are negligible in Canada and have been for 50 years.
In 2004, the Canadian Broadcasting Corporation (CBC) launched a TV series called The Greatest Canadian. It was a reality show/documentary, of sorts, that encouraged viewers across the nation to nominate the greatest Canadian. The winner was not Mike Myers, Wayne Gretzky, Alexander Graham Bell, William Shatner or Jim Carrey. It was Tommy Douglas, the politician who is rightfully considered the father of universal health care in Canada. This year, the federal government ran an on-line survey asking Canadians which of the country’s accomplishments “make you most proud to be a Canadian?” The answer, not surprisingly, was Medicare. So this Canada Day (yes, July 1 is a real holiday here with beer and fireworks and everything), I will pick up a bottle of Molson Canadian and toast Mr.Douglas.