A Fragile Trust – Reflections on the Dalhousie Controversy

A patient reports to a hospital outpatient procedure unit early one morning for an electively planned, medically necessary surgical procedure.

They divulge personal and sensitive information to a clerk.

They disrobe at the request of a registered nurse.

They allow a phlebotomist to start an intravenous line in their arm.

They allow a resident physician to carry out a physical examination, review test results and reassure them that they are fit to undertake the procedure.

They allow an anesthesiologist to administer medications that will render them insensible, unconscious and unable to breath without assistance.

They allow a surgeon to carry out an invasive procedure that may result in some degree of disfigurement and carries risk of injury or death.

When they awaken, they allow another nurse and a respiratory technician to carry out examinations and measurements, and accept their assurances that they are safe to return home that evening.

Other than the surgeon, they are meeting all these people for the first time.

How does this happen? What allows a person to suspend the usual inhibitions and natural cautions of everyday life to depend so completely on perfect strangers, and for so much?

It happens, I would suggest, because they are able to trust.

That trust is rooted in an assurance that the selection processes, training and regulatory frameworks that govern the activities of these various providers are all robust and vigilantly monitored.  Although our patients can understand and accept that all these providers are people like themselves, subject to human frailty and error, they must believe that, in the context of the services they are providing, those providing care will be highly competent, attentive and focused.  They will be, for that encounter, perfect.

By extension, they must believe that the institutions that train such individuals are focused not only on the acquisition of knowledge and development of technical skills, but also on the identification and development of high levels of integrity, responsibility and concern that ensure that those skills will be applied in the best interests of their patients.

That trust is no mere abstraction or theoretical construct.  It is, in fact, a key component in ensuring patients are willing and able to seek help when needed, and allows them to comply with necessary treatment.  It is a key factor in ensuring effectiveness of the care provided.  It is a core and essential attribute of every health care professional.

Over the past few weeks, the widely-publicized and much-discussed events arising from the Dalhousie Faculty of Dentistry have demonstrated the fragility of that trust.  Without attempting to judge the merits of the charges or question the approach taken by the school officials, it is clear that even the perception of such serious breaches has shaken the confidence of the public in the ability of our schools to ensure our graduates are worthy of those high levels of trust.  Witness the numerous postings from individuals expressing reluctance to seek help from any dental school graduate, requests from regulatory bodies to examine the records of every graduate and withdrawal of financial support from previously loyal school supporters.  Rightly or wrongly, the perceived breach of trust has extended beyond the alleged perpetrators, and threatens to affect a wide array of people and institutions.  To borrow a military term, the “collateral damage” is huge.

These events also bring into sharp focus key issues that professional schools have struggled with for many years.  Because graduates of programs such as Medicine, Nursing, Dentistry and Education will engage positions of public trust and, in fact, are engaging such roles even during their training, they struggle with two key issues:

1. To what extent does the need to preserve the public trust and ensure the safety of people they engage during their training “trump” personal rights, due process and assumption of innocence until proven guilty?  To be more specific, if a student is suspected of a major offense, or even involved peripherally in such activities, can they be allowed to continue in their training or expect anonymity until resolution?

2. To what extent does a university degree confer assurance of public trust?  Our professional schools are largely housed in universities and colleges, institutions that recognize through their degrees and diplomas intellectual mastery of a particular discipline, but not necessarily practice readiness nor assurances of exemplary personal conduct.  Does a student who has demonstrated understanding of content but whose behavior has been deficient merit that degree? Since the final determination of practice readiness resides with the various regulatory agencies, should incidents and issues arising during the educational program be made available to those agencies?  In short, where does the institution’s social accountability over-ride the natural tendency to support their students?

In medical schools, the increasing engagement of competency-based objectives and curricula, although initially somewhat reluctantly engaged, has served to embed social responsibility in the consciousness of both learners and faculty.  It becomes clear to all that medical school is as much about personal and professional development as acquisition of knowledge and skills, and has provided a framework to identify and address behavioural lapses.

If any good is to arise from the “ill wind” of the recent controversy, perhaps it is to engage a wider conversation on these two vital issues and to engage public input on issues that, after all, have the potential to affect them directly.  The public’s trust must be earned, and once earned must be vigorously preserved.

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

10 Responses to A Fragile Trust – Reflections on the Dalhousie Controversy

  1. Sheila Pinchin says:

    Dr. Sanfilippo, I read your blog today with great pride that the leader of our undergraduate medical program has the insight to pinpoint and is able to articulate the real truth at the heart of the problems that Dal is facing. I hadn’t seen the issue in this light, but you are right–it is about trust that patients put in their health care professionals.

    I’ve been working in medical education for over 8 years now, and as someone “on the other end of the stethoscope”, as a patient, I find myself every day impressed by our faculty and our students…and the concern they give to their patients. From first year students’ concerns for patient confidentiality with their “First Patient” to our clerks’ descriptions of the advocacy, professional, and other intrinsic roles they have enacted in their clerkship rotations, from faculty concerned about their students to hearing about the care they give through their patient cases in classes, I see this almost daily.

    But the message from Dal and from other schools is that we have to be vigilant and we have to keep finding ways to make this message of trust a high priority and make it relevant. We also have to take the message to students that this is not only about their future behaviour, or their behaviour with patients. I believe that students demonstrate and reveal their ability to build and maintain the trust of their patients in their relationships they build or don’t build while in medical school. I hope that your blog will lead to a discussion in this school and every medical school about how to bring to the fore the importance of building and maintaining the trust in educational relationships as well as patient/physician relationship, and of taking action when the trust is broken.

  2. Peter O'Neill says:

    Dean Sanfillippo, the questions you raise are good ones. But they are not new ones. At Queen’s, this issue has come up before.

    Dr. Tony Travill wrote of Principal Grant, writing from his death bed at Kingston General Hospital to his medical students: “As to yourselves, for the sake of all that is noble and worthy, take your profession seriously from the outset, quite as seriously as students of divinity take theirs. If you cannot do that, drop it, and seek some honest way of making a living. It is awful to think that men, women and children should be at the mercy of irreverent and half taught young doctors, and for the sake of all humanity, I shall try to let no such student pass our examinations. God help you to lay this work to your hearts.”

    Principal Grant, understood back then in 1902, that patients need doctors who take being a doctor seriously, and demonstrate the justice, humility and duty he saw common to practitioners of both Divinity and Medicine.

    I hear echo’s of Principal Grant in your blog.

    A. A. Travill, Medicine at Queen’s, a Peculiarly Happy Relationship 1854-1920 page 171

  3. Dr. Sanfilippo,

    Thank you for sharing your thoughtful reflections on a topic so relevant and timely. I do agree that upholding the public’s trust is absolutely central to what we do, I unfortunately have no easy answers to the questions you’ve eloquently posed. Instead I have one more question to add into the mix. Is professionalism something medical schools select for or is it something that medical schools teach, or is it a balance of both? Is inspiring trust a competency that we expect medical students to achieve by day one or do they learn about it one patient at a time with the help of good mentorship, as they do other lessons about becoming a doctor? If we expect it from day one, then how do we ensure our admissions processes select for it? If it is something that we learn along the way, are we permitted to fail and to what degree?

    All hard questions and agree we need public inform our policies. How do we get them involved in the discussion? A Travill Debate topic next year perhaps….

    Eve

    • Thanks Eve. You raise a critical point, as usual. My own view is that medical schools must define and demonstrate professional behaviour for our students, but if it isn’t already part of their values and moral make-up, it can’t be manufactured. Selection processes therefore become key and, although perfection is always elusive, I’m pleased to say I believe we’re doing a great job.

  4. David Walker says:

    As usual, Tony, you have perceptively and eloquently identified the fundamental issue; your questions frame it well. Their answers challenge us, but they must be answered, continually. Perhaps we need a forum where we can talk about this, all together.

  5. David Walker says:

    I think the forum rather depends on the desired outcome. While challenging, perhaps an open town hall discussion might bring to light the views of a very eclectic audience. It might be interesting to have our students and our practitioners hear what the public thinks, and vice versa. Alternatively it might in be a more closed environment such as Faculty Board (or whatever we now call it) – might improve attendance.

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