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)
Undergraduate Medical Education