Ethics in medical schools. New programs focus on human side of a high-tech field

WHEN Duke University Medical School students return to class this fall, an already busy week will have one more hour squeezed into it. A lecture and small-group discussion called ``the Dean's hour,'' has been added. Students will examine in some depth their own attitudes, ethics, and values as these apply to euthanasia, patients' rights, new medical technology, and other biomedical issues.

The Duke program, modest as its sponsors admit it to be, is one more sign of what many medical educators see as a broad and lasting trend in medical schools to institutionalize ``medical humanism'' in the curriculum. It's evidence also of an increasing emphasis on ethical issues in professional education. Many law schools and some graduate business programs now offer such courses.

A 1984 report by the Association of American Medical Colleges challenged medical schools to examine their curriculum in light of current doctor-patient realities.

Titled ``Physicians for the 21st Century,'' the report stated what many med-school deans and older physicians knew to be true: ``The pace of medical education and of technology's increasing permeation of patient care is such that students need special assistance in perceiving the human dimensions of choices and in developing empathy with their patients.''

The report was an effort to get at what ``should not be seen as the soft side of medical school, but the `interactive' side, the doctor-patient relationship,'' says David Rothman, director of the Center for the Study of Society and Medicine at the College of Physicians and Surgeons of Columbia University.

``As formally and traditionally taught, medicine cannot answer a whole range of questions it is now facing,'' says Dr. Rothman. There are four broad areas that medical schools now feel the need to address, he says:

1.The transformation of the field because of the greatly expanded federal role in funding and regulating medical care.

2.The increase in more-litigious and knowledgeable patients.

3.The philosophical and ethical questions raised by advances in medical technology and life support machines.

4.The need for a broad-based liberal and humanistic education to counter increased medical specialization.

Programs seeking to formalize humanistic concerns in the curriculum are ``a self-conscious effort to alert students to the world in which they are going to practice,'' says Rothman. The Columbia center was set up in 1982 to address the ``humanities gap'' in doctoring. Several historians, political theorists, lawyers, sociologists, and professors of literature teach elective courses and a course on society and medicine that all second-year Columbia med students must take.

``This is something of great concern to a large number of people in the profession,'' says Roy Schwarz, dean of the University of Washington School of Medicine. Thirty years of high-tech medical specialization has left many patients asking, ``Who is my doctor?'' he says, hence the focus on the non-cognitive side of a doctor's development.

For Duke, the weekly session is intended ``to be intentional in the values we expose our students to,'' says Doyle Graham, new dean of the medical school. ``We are paying attention to the growth of our students as people as well as future doctors,'' he says. Led by both an adviser and one of four rotating deans, each group of 10 to 13 students will discuss how a doctor can ``lead a fulfilling life while he or she cares for patients,'' says Dr. Graham. ``It is more than just preparation for lifelong learning ... the first focus is on the med student.''

One of the most notable changes made by a medical school to deal with humanistic issues is the New Pathway program at Harvard Medical School. The program is a fundamental reexamination - what its adherents call a ``thinking through'' - of what medical education is about and how it takes place. It tries to avoid establishing a false dichotomy between humanities and science.

New Pathway represents a radical departure from the traditional approach to medical education because of the comprehensiveness of the changes, says Columbia's Rothman. Students still study basic science in large lecture courses during their first two years. In addition, a large portion of their time is concentrated in small tutorials of six to eight students. At least a third of their time is set aside for independent study, electives, and research.

In the usual medical program, students do not meet directly with patients until the beginning of their third year. New Pathway students meet their first patients during the first few weeks of classes.

Students work closely with an experienced physician throughout the four year med-school program. Weekly tutorials draw upon the social sciences and the humanities as they affect the doctor-patient relationship.

One sign of the program's success is that enrollment has gone from 40 in its first year to 165 as it begins its second year this September, says Grahame Feletti, director of curriculum development in the project.

``There are changes of an expanding and challenging nature in bringing principles and [new] curricula to a whole school,'' says Dr. Feletti. ```Humility' is a legitimate word to use to describe a significant reason for introducing New Pathway.''

``We want MDs from Harvard Medical School with competence in science,'' says Gordon Moore, New Pathway's director, ``embedded in a world view that sees the patients as more than biologic entities - [as] individuals who are individually rich.''

Jim Bencivenga is the Monitor's education editor.