Medicine 90Q : Weekly assignment overview
Fall Quarter, 1999

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Week 1: Radical changes in medicine - economics, ethics, and the physician

  1. Definitions: Define and understand the following:
  2. Status Panic
    Does the medical profession follow Weber's conceptualization of the consequences of bureacracy and social change? If so, is this inevitable? If not, are there unique characteristics of this profession which make it different than other professions?
    What are the basic elements of the profession which provide a source of stability during a time of rapid change?
  3. Capitation, integration, and managed care
    What are the author's conclusions about the history to date of capitation and managed care? Is the current expansion of for-profit managed care the expected historical outcome? If so why, if not why?
  4. Physicians, cost control, and ethics
    Can a physician serve both patient and the health plan bottom line?
    Is gatekeeping ethical? Is fee-for-service ethical?
  5. The future of health care systems?
    What challenges does the advent of internet-based information exchange concerning health information present to the patient and to the doctor?
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Week 2: Advancing the art and science of medicine


Definitions: Dementia
The focus of the reading and discussion this week is to compare and contrast two different ways in which one can learn the art and science of medicine. The first is through the critical reading of the medical literature (evidence-based medicine) and the second is through reading and writing about medicine in literature.
We will approach the review of this area in class through two exercises.
The first in-class exercise will be to compare and contrast the two areas as they pertain to the acquisition of medical knowledge regarding the patient-experience, the doctor-patient relationship, and the work of the doctor.
Therefore, we will construct a table as described below, emphasizing what each approach offers in a unique or complementary nature to our understanding of medical knowledge (which for discussion purposes, I have divided into three areas: knowledge about the patient experience, knowledge about the doctor-patient relationship, and knowledge about the work of the doctor).
In the second in-class exercise, we will discuss the two examples of these approaches : literature in medicine (The Double Corner) and evidenced-based review of medicine (Behavioral Complications of Dementia). Please consider the following questions in your preparation for discussion:
  1. What does each article teach us about the patient experience?
  2. What do we learn about the doctor-patient relationship from these articles?
  3. What do we learn about the work of the doctor in these articles?
  4. Does reading these two articles teach you everything you need to know about taking care of a patient with dementia? If not, what else would help in your understanding?
The case report article should be reviewed and as time allows, compared and contrasted with the two other approaches for understanding the art and science of medicine. We will utilize case reports later in the course.
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Week 3: Defining the profession of medicine

The Study of Occupations
  1. Define guilty knowledge and how it relates to the professions. Can a profession survive the free exchange of this knowledge?
  2. Where does the authority for license and mandates for the professions arise? What is the nature of the relationship between those who give and receive such privilege?
  3. Do professionals view their profession in the same manner as the non-professional? If so, what are the commonalities, if not, where are the differences?
  4. What is the role of differentiation of function in the formation of the professions? (E Durkheim)
  5. What defines individual progress in a career like medicine?


Social Transformation of American Medicine
  1. How did power effect the dream of reason?
  2. Does protection of autonomy and authority by a profession compromise the moral community?
  3. Can the profession resist the current economic and social forces without disintegration?


Medicine as a moral community
  1. What benefits and negative consequences to the profession and to society are evident in the historic eras of the medical community?
  2. What impact does the subsumption of the medical profession into a for-profit business have on the 'internal morality' of medicine with respect to the following?
  3. What conflicts arise for progessional integrity when the focus becomes unquestionably the served?


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Week 4: The patient experience

Duck Season
  1. How has the illness affected Gracie and her relationships with her children and her husband?
The tyranny of health
  1. Define health? Are most people in your close-community of family and friends healthy? If not, why? If so, what makes them healthy?
  2. Briefly contrast the health status of the two people in the following examples.
    21 year old competitive nationally ranked track and field athlete. Dropped out of college to focus on athletics after grades dropped below 2.5. Currently taking medications for stress and insomnia.
    51 year old woman who recently underwent bone marrow transplant for a immunological disorder. She also has rheumatoid arthritis, her kidney function is only 25% normal, and has had multiple skin cancers removed over the last four years. She has 4-8 doctor appointments per month.
  3. Should society-sponsored health car pay for the following care?
    Repeat cardiac bypass surgery for a 65 year old man who continues to smoke 2 packs per day which has resulted in premature blockage of his bypass vessels only 4 years after his intial surgery.
    Valve replacement in a 23 year old with history of infection on his heart valves due to bacteria introduced during repeated self-administration of heroin. He also has chronic hepatitis from sharing needles, his HIV tests are pending.
    45 year old executive with liver failure has only one option - liver transplantation. She is an excellent candidate except for her alcohol abuse which has caused her liver to fail. There is an extreme shortage of organs for transplant and in your hospital, 10 people have died in the last six months waiting for a transplant.
The last-well person
  1. Does engaging in the latest preventive medicine recommendations enhance well-being? If beneficial, is the effect immediately or only after a long time in the future?
  2. Is this person healthy? Would you recommend this approach to others or follow it yourself?
Finch the spastic speaks
  1. Describe Finch's description of his body and its deterioration.
  2. What do others in his circle of friends and family see and experience?
  3. Could Finch ever be considered healthy? If no, why not? If yes, what would his definition of health entail?
  4. How has this disease changed his experience of life?
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WEEK 5: What is healing? Who is the healer?

Case of AJ
A.J. is a 23 year old man brought to you by his family after experiencing several episodes which are frightening to them and to A.J. Over the last several weeks he has had several episodes in which he develops a blank stare lasting for several minutes, then begins smacking his lips and rises, walking about with no visible purpose. Sometimes the episode stops here and he returns to his normal self, but other times he begins to have jerking motions of his arms and legs, followed by a loss of control of urination and seems to fall on the ground in a deep sleep. This sleep can last for several minutes, then he awakens with no memory of the attack and often falls back asleep, to then sleep for 8-12 hours, awakening normally. The young man says that before he loses his normal consciousness, the visible world seems to become smaller and smaller and he feels t hat this has happened to him before, but has no subsequent control of the episodes to follow.
He has no prior known physical or emotional problems. His mother remembers that he fell off the roof of the house about a year ago and had a bad pain in his head for several weeks but this pain seems to have faded and had been forgotten.
He does not eat unusual plants or other dangerous substances and can be found working normally. He involves himself with this family and community in a customary fashion. His family is healthy, both parents are well, and his two sisters are older than he and are healthy.
On exam he is healthy looking and you find no physical evidence of any abnormality.

In the context of your healing tradition, please answer the following questions:
  1. What additional history (if any) would you need to understand this case?
  2. Are there any other examinations you would like to perform?
  3. What do you think is the cause of this young man's problems?
  4. What healing approach would you utilize and how would you go about healing?
  5. How would you involve this patient and his community in the healing?
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WEEK 6: When the physician fails


Case 1
A 38 year old man with a history of insulin-dependent diabetes is admitted for intravenous antibiotic treatment of an infection on his leg which began after a cycling injury several weeks prior to admission. On the morning of discharge, the intern writes an order to resume his regular dose of insulin and writes the dose as 46 units of insulin. The nurse reads the order and prepares to give the insulin, but is challenged by the patient who relates that his usual dose is four to six units in the morning, not 46. The nurse checks with the doctor who confirms that she read from the attending doctor's typed notes that the patient usually gets 46 units of insulin and over the patient's objections, the entire 46 units of insulin are administered.
Two hours later, the patient becomes sweaty and the blood glucose is measured at 40 mg/dl (normal is over 80 mg/dl). The patient requires an additional eight hours of hospitalization with continuous administration of IV glucose to correct his low glucose. He is discharged to home without any permanent sequelae.
Review of the attending physician's dictated note discloses a typographical error in which the number "46" is typed instead of "4-6".
  1. What are the errors which occured in this case? What contributed to these errors?
  2. Where does blame lie for this error which occurred? Nurse? Intern? Attending? Patient?
  3. Should the patient be compensated for this incident? If so, how much? If not, why?
  4. What changes could be made to prevent these errors in the future


Case 2
A 26 year old woman in labor with her first child is admitted to labor and delivery after the rupture of her membranes and increased frequency of contractions. After twelve hours, she undergoes emergency cesarean section, but during the closure of the uterus, the right ureter is unknowingly sutured closed. A week after this, she experiences worsening pain in her side, the problem is identified, and she undergoes an emergency surgical procedure to repair the ureter.
....Assuming the kidney function returns to normal:
  1. Should the patient be compensated for this surgical error? How much?
  2. Where does the problem lie in this instance?
  3. Could this have been prevented? If so, how? If not, why?
....If her kidney function does not return to normal:
  1. Should the patient be compensated for this surgical error? How much?
  2. What are the factors which predict whether she will file a lawsuit and win such a lawsuit?


Case 3
Your are called by your mother now living in Boston because your father is scheduled for urgent coronary artery bypass surgery. He was referred to a nearby hospital on the basis of a recommendation by his cardiologist. On the suggestion of friends, she has searched the on-line Massachusetts database of doctors and finds that your father's surgeon has had several malpractice cases filed against him in the past. Your father is scheduled for surgery in two days and his cardiologist recommends that he not delay the surgery.
  1. What further recommendation would you need to determine the significance of this information?
  2. How would you counsel your mother?
  3. Are on-line malpractice records helpful to patients? to other patients?


Case 4
You are asked by your hospital's physician organization to review a case of a colleague which prompted a recent patient complaint.
The patient was treated for breast cancer and then underwent breast reconstruction surgery by the colleague now the target of your review. The patient experienced a severe infection at the site of the reconstruction which required repeat operation. She is left with a cosmetically unsatisfactory result. The patient believes that she experienced an adverse reaction and when she discussed this with her surgeon, the surgeon becomes defensive and told her that she was fully informed that early failure was a possibility. She has tried to discuss this further with the doctor, but when calling the office, is told by the doctor's nurse that the doctor does not want to provide further care and recommends she follows up with another physician.
  1. How would you determine whether an adverse event occurred?
  2. What recommendation would you make to this physician in-line with the readings to decrease
  3. his risk of malpractice lawsuit?

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WEEK 7: Elements of the patient-physician relationship: Compassion

Pellegrino, ED, Thomasma, DC. Compassion
Define and contrast:
Is compassion learned or a basic part of an individual's personality?
If compassion is innate, at what level of development might compassion develop?
If compassion is learned, what are the ways in which such learning might be promoted?
Should applicants to medical school be assessed for their compassion potential? If so, how?
Maclean, N. Young Men and Fire.
On August 4, 1949, a group of fifteen US Forest Service airborne firefighters, the Smokejumpers, were dropped above a remote forest fire in the Montana wilderness. Less than an hour after their jump, all but three of these men were dead or mortally burned. Norman Maclean reconstructs the tragedy in this book.
The selections were chosen as an example of looking at this tragedy through the compassionate pen of the author. After reviewing these selections, consider what this author teaches us about compassion.
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