Which of the following best characterizes most medical schools in the united states

MEDICAL EDUCATION

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When this subject was addressed in the first edition of this encyclopedia, the paucity of systematic analyses of the ethical issues peculiar to medical education was underscored (Pellegrino, 1978). In recent years, this deficiency has gradually been redressed, so that today, a considerable body of literature is available. This entry is therefore a substantial revision of the first. The emphasis has shifted from underlying values to more specific, normative issues, particularly in clinical education.

Ethical issues arise in medical education because of the special societal role of medical schools, the necessary inter-mingling of patient care with education, and the conflicts that may arise because of the obligations among students, patients, faculty members, and society. Similar ethical issues are present in the education of nurses, dentists, and the allied health professions.

The Social Mandate of Medical Schools

Medical schools occupy a unique moral position in society. They are mandated to meet society's need for a continuous supply of competent practitioners who can care for the sick and promote the public's health. For this reason, medical schools are supported as loci for the advancement and transmission of medical knowledge and are granted authority to select who shall study medicine, what shall be studied, and what standards of performance shall be established.

To achieve these goals, medical schools require certain special privileges, for example, to dissect human bodies, to provide "hands on" practical experience for students in the care of sick people, and to conduct human experimentation. These practices would be criminal were they not socially mandated for a good purpose. When medical schools, students, and faculty avail themselves of these privileges, they enter an implicit covenant with society to use them for the purposes for which they are granted.

To fulfill this social covenant, medical schools and their faculties must perform a tripartite function with respect to medical knowledge: 1) they must preserve, validate, and expand it by research; 2) transmit it to the next generation by teaching; and 3) apply it by practice in the care of the sick. However, these three functions have different aims. The aim of research is truth that requires dedication to objectivity, freedom of inquiry, rigorous design, as well as peer review and publication. The aim of teaching is learning that requires dedication to student welfare, competent pedagogy, and opportunities for students to practice their skills. The aim of practice is the welfare of the patient that requires dedication to compassion, competence, and ethical concern for the vulnerability, dignity, and autonomy of the sick person.

In the past, these three functions were less often in conflict with each other than they are today. This conflict is the result of several factors in the evolution of medical education since the late nineteenth century. The first factor is the realization of the power of the physical and biological sciences to advance medical knowledge and their integration into medical education. Second is the incorporation of teaching hospitals into medical schools for the clinical education of medical students (Flexner). Third is the increasing reliance on practice income to support salaries of medical teachers. Previously, teachers had been self-supporting practitioners from the community, while only a few were university-funded full-time teachers. Today's "tenure track" clinical faculty member is expected to excel in research, to support himself or herself financially through practice and overhead cost recovery from grants, and to teach at the bedside. Each function has its own legitimacy, but taken together, these functions conflict with each other.

Ethical Obligations of Medical Schools

The ethical obligations of medical schools as societal entities are defined in terms of the constituencies they serve: society, faculty, student body, and patients (Pellegrino, 1976).

Medical schools have been granted a virtual monopoly over the number of students they admit and the number of training places in the various specialties in teaching hospitals. Medical schools are the sole portal into the practice of the profession and, as a result, medical schools incur a responsibility to match the kind and number of physicians they produce with the needs of society. This requires a socially responsive appraisal by medical schools of the way resources are used and curricula are designed, as well as how faculty rewards are distributed. Societal aims sometimes can, and do, conflict with a medical school's pursuit of esteem among its peers, which usually comes not through renown in teaching or the quality of practitioners it produces, but excellence in producing research and academic leaders.

Another important obligation of medical schools is to ensure that graduates are competent to enter postgraduate training and are free of obvious traits of character that would make them dangerous practitioners. Today, most of those admitted to medical school graduate and obtain licenses. Few fail, particularly in the clinical years. This places an obligation on medical schools to evaluate not only a student's knowledge and skill, but some facets of his or her character as well. Close supervision by clinical teachers is mandatory if dubious character traits are to be detected. Educators must balance fairness in their evaluations of students against their obligations to protect future patients from unsafe or dishonest practitioners.

Another societal responsibility of medical schools is to ensure equal opportunity for admission to all qualified students. Despite early progress, there is recent evidence of retrenchment in the support, financial and otherwise, available for minority student recruitment in the United States and in Great Britain (Hanft and White; Esmail and Everington). Subtle forms of discrimination probably still exist in the interview process where it is difficult to detect and prove (Connolly). Gender discrimination and sexism are no longer legally tolerable, but remain a persistent social problem (Hostler and Gressard). Academic administrators and faculty members are morally obliged to ensure equitable treatment of all applicants and must assume collective responsibility for inequities and injustice. In doing so, medical schools must thread their way carefully through an ethical maze of competing claims for preferential treatment and reverse discrimination.

Ethical obligations exist in the relationship between medical schools and faculty members. Faculties are owed freedom of inquiry in research and teaching, justice in hiring, tenure, promotion, compensation, and redress for injury or grievances. Faculty members in turn are morally responsible for the quality of their instruction, for fairness in the evaluation of students, and for properly apportioning their time and effort between teaching and personally remunerative activities such as clinical practice and consultation. Imbalance among these activities compromises the societal responsibilities of a medical faculty.

Faculty and administration are therefore obligated to detect inadequate teachers and to rehabilitate and reassign them or terminate their appointments when necessary. Tenure is among the most privileged benefits of academic life. The obligation to use it responsibly rests squarely on faculty members and administrators.

Incidents of scientific fraud, abuse of consulting and travel privileges, and conflicts of interest are cause for legitimate public concern. While the number is small, such abuses by faculty members invite external limitations and regulation of privileges that can interfere with the educational mission. The ethics of medical academia cannot be a private matter since the moral behavior of academics affects students, patients, the use of public funds, and the quality of fulfillment of the medical school's covenant with society.

Some Ethical Issues Peculiar to Clinical Education

The ethical issues outlined thus far are particular only in part to medical education. What is unique is the medical school's engagement in clinical education, i.e., in providing "hands on" experience for students in the actual care of patients. It is here that serious conflict may arise between patient care and student learning.

Physicians since Hippocrates have taught their students from actual cases. Usually, this was accomplished by preceptorship with a practicing physician or by case demonstrations to entire classes of students. In the mid-nineteenth century, it was a rare school that incorporated more intimate involvement in the care of patients in its teaching (Ludmerer). Toward the end of the same century, William Osler involved students more directly as clinical clerks at the Johns Hopkins Hospital, where they " … lived and worked … as part of its machinery, as an essential part of the work of the wards" (Osler, p. 389). This practice lagged in other schools until the reform of education in 1910 (Ludmerer). Since then, however, it has become standard pedagogic practice.

Today, clinical education centers on practical experience under supervision at every level, from medical school through postgraduate specialty training to lifelong continuing education. Until recently, the merits of this training have been so much taken for granted that the ethical conflicts inherent in the process have been neglected (Fry; Pilowski).

Clinical education by its nature unavoidably puts the aims of caring for patients into potential conflict with the aims of teaching and learning. The involvement of medical students, interns, and residents in patient care slows the process of care, increases its discomforts and fragmentation, and, at times, poses significant danger to the patient. With close supervision by experienced clinical teachers, these potential conflicts are tolerable. The clinical teacher therefore carries a double responsibility for balancing the quality of his or her pedagogy with the quality of patient care.

The moral status of medical students is ambiguous. They are physicians in utero, that is, in a developmental state of competence to provide care. When they enter medical school they are laypersons. When they graduate they are physicians, still in need of further training before they can become safe and competent practitioners. During this process, they take on progressive degrees of responsibility associated with the privilege of caring for patients, although their capacity to fulfill that responsibility is limited.

Patients come to university hospitals primarily to receive optimal treatment, not to be subjects of teaching. They may understand in a general way what being in a teaching hospital means. This in no way suggests, as some assume, that patients give implicit consent to become "teaching material." Patients in teaching hospitals preserve their moral right to know the relative degrees of competence of those caring for them. They have a right to give informed consent to any procedures and to know whether an untrained or partially trained person will perform that procedure. When unskilled students participate in procedures, patients are owed appropriate supervision by someone of significantly greater competence who can protect their safety.

Medical students, therefore, should disclose the fact that they are students to avoid the attributions of knowledge and trust patients still associate with anyone bearing the title "doctor" (Greer; Ganos; Brody; Liepman). They should be introduced as students by their supervisors before procedures like spinal taps and chest taps are performed. For their part, students as well as their supervisors must thoroughly acquaint themselves with the procedures in question and must observe a sufficient number performed by experienced clinicians. Students are under an obligation to refrain from conducting a procedure until these requirements are met and to resist the "see one, do one" philosophy of some clinical teachers. They must also receive instruction on how to obtain a morally and legally valid consent (Johnson et al.).

Students must also be sensitive enough to discontinue even the simplest procedures, such as a venipuncture, if their efforts cause discomfort (Williams and Fost). These injunctions are particularly important in highly personal and sensitive situations such as learning to do vaginal or rectal examinations (Bewley et al.; and Lawton et al.).

Medical students also face problems of personal ethical integrity with respect to abortion, treating patients with acquired immunodeficiency syndrome (AIDS), and attitudes toward the poor (Christakis and Feudtner; Dans; Crandall et al.; Currey et al.; Holleman). They may observe unethical or unacceptable behavior of teachers or colleagues (Morris). The extent of their responsibility and the real possibility of punitive treatment if students "blow the whistle" is a difficult, unresolved, but genuine ethical issue. Students may cheat on exams or see others do so (Rozance; Stimmel). By virtue of their presence at the bedside as members of the "team," they may be drawn prematurely into advising about the ethics of other colleagues. Helping students to deal with these moral dilemmas poses a new challenge to students and to their clinical teachers. This is a crucial part of the ethical maturation of the student (Drew; Andre; Wiesemann).

Two final examples of recently debated ethical dilemmas center on the moral status of dead human bodies and of animals of other species similar to humans. To what extent may recently dead human bodies be used to teach intubation, resuscitation, and tracheostomy? Who can, or should, give permission? May it be presumed? Is it necessary at all (Benfield et al.; Iserson)? Are the moral rights of other animal species to be considered so that they never or rarely should be used in teaching or research? Do computer models or tissue and cell preparations adequately replace animal experimentation?

Conclusion

Despite the sanction society gives to clinical education, there are important ethical obligations that limit this privilege. In no sense can learning by practice be a "right" of medical students or medical schools no matter how high the tuition or the degree of social utility. The privileges of clinical education cannot be bought at any price by the student, or granted even for good purpose by the medical school. Only a social mandate can legitimize the invasions of privacy a medical education entails.

The ethical issues of clinical education have just begun to receive the ethical scrutiny they deserve. Fundamental conceptual issues like the moral status of medical students, dead bodies, and animals are coupled with very practical issues regarding student–faculty and student–patient relationships. Clearer guidelines are needed to deal with the ethical issues characteristic of clinical education. We can expect the literature on this topic to expand in size, sophistication, and importance in the immediate future.

edmund d. pellegrino (1995)

SEE ALSO: Clinical Ethics; Competence; Conflict of Interest; Dentistry; Ethics; Family and Family Medicine; Informed Consent; Nursing Ethics; Profession and Professional Ethics; Race and Racism; Sexism; Virtue and Character; Whistleblowing

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Which of the following are considered main characteristics of the US healthcare system?

What characterizes the US health system?

Which best describes the US healthcare system?

What is one of the best aspects of the US healthcare system?