Antecedents and Consequences of Medical Students’ Moral Decision Making during Professionalism Dilemmas

Lynn Monrouxe, Malissa Shaw, and Charlotte Rees
AMA Journal of Ethics. June 2017, Volume 19, Number 6: 568-577.

Abstract

Medical students often experience professionalism dilemmas (which differ from ethical dilemmas) wherein students sometimes witness and/or participate in patient safety, dignity, and consent lapses. When faced with such dilemmas, students make moral decisions. If students’ action (or inaction) runs counter to their perceived moral values—often due to organizational constraints or power hierarchies—they can suffer moral distress, burnout, or a desire to leave the profession. If moral transgressions are rationalized as being for the greater good, moral distress can decrease as dilemmas are experienced more frequently (habituation); if no learner benefit is seen, distress can increase with greater exposure to dilemmas (disturbance). We suggest how medical educators can support students’ understandings of ethical dilemmas and facilitate their habits of enacting professionalism: by modeling appropriate resistance behaviors.

The article is here.

Managing for Academic Integrity in Higher Education: Insights From Behavioral Ethics

Sheldene Simola
Scholarship of Teaching and Learning in Psychology
Vol 3(1), Mar 2017, 43-57.

Despite the plethora of research on factors associated with academic dishonesty and ways of averting it, such dishonesty remains a significant concern. There is a need to identify overarching frameworks through which academic dishonesty might be understood, which might also suggest novel yet research-supported practical insights aimed at prevention. Hence, this article draws upon the burgeoning field of behavioral ethics to highlight a dual processing framework on academic dishonesty and to provide additional and sometimes counterintuitive practical insights into preventing this predicament. Six themes from within behavioral ethics are elaborated. These indicate the roles of reflective, conscious deliberation in academic (dis)honesty, as well as reflexive, nonconscious judgment; the roles of rationality and emotionality; and the ways in which conscious and nonconscious situational cues can cause individual moral identity or moral standards to become more or less salient to, and therefore influential in, decision-making. Practical insights and directions for future research are provided.

The article is here.

Consistent Belief in a Good True Self in Misanthropes and Three Interdependent Cultures.

J. De Freitas, H. Sarkissian, G. E. Newman, I. Grossmann, and others
Cognitive Science, 2017 Jun 6.

Abstract

People sometimes explain behavior by appealing to an essentialist concept of the self, often referred to as the true self. Existing studies suggest that people tend to believe that the true self is morally virtuous; that is deep inside, every person is motivated to behave in morally good ways. Is this belief particular to individuals with optimistic beliefs or people from Western cultures, or does it reflect a widely held cognitive bias in how people understand the self? To address this question, we tested the good true self theory against two potential boundary conditions that are known to elicit different beliefs about the self as a whole. Study 1 tested whether individual differences in misanthropy-the tendency to view humans negatively-predict beliefs about the good true self in an American sample. The results indicate a consistent belief in a good true self, even among individuals who have an explicitly pessimistic view of others. Study 2 compared true self-attributions across cultural groups, by comparing samples from an independent country (USA) and a diverse set of interdependent countries (Russia, Singapore, and Colombia). Results indicated that the direction and magnitude of the effect are comparable across all groups we tested. The belief in a good true self appears robust across groups varying in cultural orientation or misanthropy, suggesting a consistent psychological tendency to view the true self as morally good.

A version of the paper is here.

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents

Martinez W, Lehmann LS, Thomas EJ, et al
BMJ Qual Saf Published Online First: 25 April 2017.

Background Open communication between healthcare professionals about care concerns, also known as ‘speaking up’, is essential to patient safety.

Objective Compare interns' and residents' experiences, attitudes and factors associated with speaking up about traditional versus professionalism-related safety threats.

Design Anonymous, cross-sectional survey.

Setting Six US academic medical centres, 2013–2014.

Participants 1800 medical and surgical interns and residents (47% responded).

Measurements Attitudes about, barriers and facilitators for, and self-reported experience with speaking up. Likelihood of speaking up and the potential for patient harm in two vignettes. Safety Attitude Questionnaire (SAQ) teamwork and safety scales; and Speaking Up Climate for Patient Safety (SUC-Safe) and Speaking Up Climate for Professionalism (SUC-Prof) scales.

Results Respondents more commonly observed unprofessional behaviour (75%, 628/837) than traditional safety threats (49%, 410/837); p<0.001, but reported speaking up about unprofessional behaviour less commonly (46%, 287/628 vs 71%, 291/410; p<0.001). Respondents more commonly reported fear of conflict as a barrier to speaking up about unprofessional behaviour compared with traditional safety threats (58%, 482/837 vs 42%, 348/837; p<0.001). Respondents were also less likely to speak up to an attending physician in the professionalism vignette than the traditional safety vignette, even when they perceived high potential patient harm (20%, 49/251 vs 71%, 179/251; p<0.001). Positive perceptions of SAQ teamwork climate and SUC-Safe were independently associated with speaking up in the traditional safety vignette (OR 1.90, 99% CI 1.36 to 2.66 and 1.46, 1.02 to 2.09, respectively), while only a positive perception of SUC-Prof was associated with speaking up in the professionalism vignette (1.76, 1.23 to 2.50).

Conclusions Interns and residents commonly observed unprofessional behaviour yet were less likely to speak up about it compared with traditional safety threats even when they perceived high potential patient harm. Measuring SUC-Safe, and particularly SUC-Prof, may fill an existing gap in safety culture assessment.

The article is here.

Moral Injury, Posttraumatic Stress Disorder, and Suicidal Behavior Among National Guard Personnel.

Craig Bryan, Anna Belle Bryan, Erika Roberge, Feea Leifker, & David Rozek
Psychological Trauma: Theory, Research, Practice, and Policy 

Abstract

To empirically examine similarities and differences in the signs and symptoms of posttraumatic stress disorder (PTSD) and moral injury and to determine if the combination of these 2 constructs is associated with increased risk for suicidal thoughts and behaviors in a sample of U.S. National Guard personnel. Method: 930 National Guard personnel from the states of Utah and Idaho completed an anonymous online survey. Exploratory structural equation modeling (ESEM) was used to test a measurement model of PTSD and moral injury. A structural model was next constructed to test the interactive effects of PTSD and moral injury on history of suicide ideation and attempts. Results: Results of the ESEM confirmed that PTSD and moral injury were distinct constructs characterized by unique symptoms, although depressed mood loaded onto both PTSD and moral injury. The interaction of PTSD and moral injury was associated with significantly increased risk for suicide ideation and attempts. A sensitivity analysis indicated the interaction remained a statistically significant predictor of suicide attempt even among the subgroup of participants with a history of suicide ideation. Conclusion: PTSD and moral injury represent separate constructs with unique signs and symptoms. The combination of PTSD and moral injury confers increased risk for suicidal thoughts and behaviors, and differentiates between military personnel who have attempted suicide and those who have only thought about suicide.

The article is here.

Is it dangerous for humans to depend on computers?

Rory Cellan-Jones
BBC News
Originally published June 5, 2017

Here is an excerpt:

In Britain, doctors whose computers froze during the recent ransomware attack had to turn patients away. In Ukraine, there were power cuts when hackers attacked the electricity system, and five years ago, millions of Royal Bank of Scotland customers were unable to get at their money for days after problems with a software upgrade.

Already some people have had enough. This week a letter to the Guardian newspaper warned that the modern world was "dangerously exposed by this reliance on the internet and new technology".
The correspondent, quite possibly a retired government employee, continued "there are just enough old-time civil servants left alive to turn back the clock and take away our dangerous dependence on modern technology."

Somehow, though, I don't see this happening. Airlines are not going to scrap the computers and tick passengers off on a paper list before they climb aboard, bank clerks will not be entering transactions in giant ledgers in copperplate writing.

In fact, computers will take over more and more functions once restricted to humans, most of them far more useful than a game of Go. And that means that at home, at work and at play we will have to get used to seeing our lives disrupted when those clever machines suffer the occasional nervous breakdown.

The article is here.

Teaching Humility in an Age of Arrogance

Michael Patrick Lynch
The Chronicle of Higher Education
Originally published June 5, 2017

Here is an excerpt:

Our cultural embrace of epistemic or intellectual arrogance is the result of a toxic mix of technology, psychology, and ideology. To combat it, we have to reconnect with some basic values, including ones that philosophers have long thought were essential both to serious intellectual endeavors and to politics.

One of those ideas, as I just noted, is belief in objective truth. But another, less-noted concept is intellectual humility. By intellectual humility, I refer to a cluster of attitudes that we can take toward ourselves — recognizing your own fallibility, realizing that you don’t really know as much as you think, and owning your limitations and biases.

But being intellectually humble also means taking an active stance. It means seeing your worldview as open to improvement by the evidence and experience of other people. Being open to improvement is more than just being open to change. And it isn’t just a matter of self-improvement — using your genius to know even more. It is a matter of seeing your view as capable of improvement because of what others contribute.

Intellectual humility is not the same as skepticism. Improving your knowledge must start from a basis of rational conviction. That conviction allows you to know when to stop inquiring, when to realize that you know enough — that the earth really is round, the climate is warming, the Holocaust happened, and so on. That, of course, is tricky, and many a mistake in science and politics have been made because someone stopped inquiring before they should have. Hence the emphasis on evidence; being intellectually humble requires being responsive to the actual evidence, not to flights of fancy or conspiracy theories.

The article is here.

The Specialists’ Stranglehold on Medicine

Jamie Koufman
The New York Times - Opinion
Originally posted June 3, 2017

Here is an excerpt:

Neither the Affordable Care Act nor the Republicans’ American Health Care Act addresses the way specialists are corrupting our health care system. What we really need is what I’d call a Health Care Accountability Act.

This law would return primary care to the primary care physician. Every patient should have one trusted doctor who is responsible for his or her overall health. Resources must be allocated to expand those doctors’ education and training. And then we have to pay them more.

There are approximately 860,000 practicing physicians in the United States today, and too few — about a third — deliver primary care. In general, they make less than half as much money as specialists. I advocate a 10 percent to 20 percent reduction in specialist reimbursement, with that money being allocated to primary care doctors.

Those doctors should have to approve specialist referrals — they would be the general contractor in the building metaphor. There is strong evidence that long-term oversight by primary care doctors increases the quality of care and decreases costs.

The bill would mandate the disclosure of procedures’ costs up front. The way it usually works now is that right before a medical procedure, patients are asked to sign multiple documents, including a guarantee that they will pay whatever is not covered by insurance.  But they will have no way of knowing what the procedure actually costs. Their insurance may cover 90 percent, but are they liable for 10 percent of $10,000 or $100,000?

We also need more oversight of those costs. Instead of letting specialists’ lobbyists set costs, payment algorithms should be determined by doctors with no financial stake in the field, or even by non-physicians like economists. An Independent Payment Advisory Board was created by Obamacare; it should be expanded and adequately funded.

The article is here.

The GOP's risky premium pledge

Jennifer Haberkorn
Politico.com
Originally posted June 5, 2017

Senate Republicans may be all over the map on an Obamacare repeal plan, but on one fundamental point — reducing insurance premiums — they are in danger of overpromising and underdelivering.

The reality is they have only a few ways to reduce Americans’ premiums: Offer consumers bigger subsidies. Allow insurers to offer skimpier coverage. Or permit insurers to charge more — usually much more — to those with pre-existing illnesses and who are older and tend to rack up the biggest bills.

Since there’s no appetite within the GOP for throwing more taxpayer money at the problem, Republicans will need to make some hard decisions to hit their goal. But the effort to drive down premium prices will inevitably create a new set of winners and losers and complicate leadership’s path to the 50 votes they need to fulfill their seven-year promise to repeal Obamacare.

“Anyone can figure out how to reduce premiums,” said Sen. Chris Murphy (D-Conn.). “You can reduce premiums by kicking everybody that has a pre-existing condition off insurance or dramatically reducing benefits.”

Republicans say that Obamacare’s insurance regulations are responsible for making coverage prohibitively expensive and contend that premiums would fall if those rules are rolled back. They say they have multiple ideas about how to roll those back while also insulating the most vulnerable but have yet to weave those together into actual legislation.

The article is here.