March 8, 2012

The Art of Bridge Building in Medicine

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From the front porch of a cozy guest house in Oxford’s outskirts, the sunlit banks of the Thames River appear so close together that without further scrutiny, the river between them seems not to be there. Yet to get from one bank to the other, the foot-traveler depends on a bridge, such as the one that I crossed from the railstation to enter town. As I begin my seventh month of living in Europe, bridge-crossing has become symbolic of my work here: I am reconnecting with university life, which is dramatically different from that of the wards at New York Presbyterian Hospital where I spent most of my working hours nine months ago as a third year medical student at Cornell. Now, I have come to Oxford to connect with a former professor after finishing my first semester exams for master’s studies in bioethics, as part of a pan-European program in Belgium, the Netherlands and Italy. My extended course of study in the university setting after having run through the gauntlet of medical education has alerted me to a divide that is in major need of bridging: the academic rift between medicine and the university. In bioethics, exchange between clinical bioethicists and academic bioethicists is limited. Clinicians often mistrust the work of academics while academicians often despise clinicians’ seemingly dogmatic bent towards pragmatism over theory. Not just in bioethics but in many areas of scholarly inquiry today, doctors and traditional professors (i.e. those not oriented with a clinical care institution) often find themselves addressing the same subject with different questions, methods and motives while not collaborating. Take, for instance, the question of resource allocation in healthcare. In graduate school, we discussed the trade-offs between justice, efficiency and care by juxtaposing theoretical models of philosophers like Rawls, Nussbaum and Dworkin, yet we never mentioned what such models mean for basic clinical questions like triaging patients in the Emergency Department. In medical school, however, even in bioethics, we did not even discuss a theory of justice, yet every day we made philosophical decisions based on scarcity of resources when we determined whether or not to send a patient for more invasive, costly tests. Moreover, in medical school our professors presented pragmatism as the only method to resolve clinical ethics dilemmas. However, as I later learned in graduate school, this method does not even comprise one of three main ethical theories that have developed over the centuries — Kantian deontology, virtue ethics and utilitarianism. These examples attest to a deep, pervasive gap in the way that medicine and the university approach knowledge itself. Why does the divide persist? Certainly the economic question looms large, at least in American medicine — a point my friends in socialist Europe never cease to ask me about. Regardless of the changes that President Obama’s 2010 healthcare bill will institute, healthcare providers are still compensated by insurance companies, which are private and pay for performance. Moreover, as the population ages and government budgets for healthcare face pressure, providers will surely feel the squeeze. This translates to more practical responsibilities in medicine and less time for theoretical questions that occupy the time of university academicians. Even in Western Europe, however, where healthcare systems are more insulated from market demands, a strong divide exists between medicine and the university — a fact which attests to internal tensions within each profession’s aims. Medicine is practical. It uses technology to alleviate the pains of illness and disease. The University is theoretical. It betters the world through knowledge and understanding. Thus the aims of one profession may not necessarily line up with those of another. The tenure track professor’s imperative to  “publish or perish” provides differing scholarly incentives than the doctor’s demand to prove clinical efficacy. But are the aims of medicine and the University really that different? Clinical care demands daily answering theoretical questions. As I observed during my rotation in the intensive care unit, the clinical definition of death is often approached as a mere matter of signs and symptoms when such a question involves many rigorous philosophical questions (often poorly attended to, even by ethics consults). Likewise, academia provides insight into practical questions. The notion of patient autonomy, for example, often used in clinical practice to justify a patient’s freedom in decision making on matters ranging from reproductive choices to end-of-life care, originated only several decades ago from academic discussions within the University which challenged healthcare’s traditional authoritarian paradigm. When it comes to medicine and academia, then, theory and pragma are much closer than they seem. The need is now greater than ever for bridge-building between medicine and the University. It will involve the use of skills specific to each profession to find points of contact between their aims. What does this translate to? Interdisciplinary courses exploring the relationship between medicine and theoretical subjects are a start. Medical schools are now supplementing their traditional curricula with courses like “Medicine, Patients and Society” that focus on “humanistic” aspects of patient care, and universities are now offering courses like medical sociology and medical anthropology that explore the relationship between clinical care and traditionally “academic” subjects. Yet more is needed. As any medical student can verify, medical school courses like  “Medicine, Patients and Society” often focus on trite notions like “empathy” and “cultural sensitivity” which fail to impact students’ clinical practices later on. In the same manner, medical sociology and medical anthropology courses can end up decrying medical paternalism and the scientific imprecision of clinical decisions but fail to take into account the realities of clinical practice that obligate doctors to make judgments based on incomplete knowledge or without having discussed every option with a patient. Rather, I propose a more personal change, where doctors take more time to discuss theoretical questions that affect their practice and University professors take care to orient their research aims — however abstract — towards “every day” problems in clinical care. For my part, I must now leave for dinner with my former bioethics professor at the Eagle and Child, an Oxford pub noted as a hub for academic discussions. Having not met with him since my pre-clinical courses, he’s eager to hear about my clinical training and I am equally eager to hear about his book in press. But first, the bridge to get into town awaits my crossing.

Landon Roussel is a fourth-year medical student at Weill Cornell Medical College. He may be reached at [email protected]. What’s Up, Doc? appears alternate Fridays this semester.

Original Author: Landon Roussel