PreparingPre-healthProfessionalStudents&AdvisorsfortheMul8pleMini-Interviews:AdvancedIssues
RobertKlitzman,MDProfessor of Psychiatry Director, Bioethics Masters & Online Certificate & Course Programs ColumbiaUniversity
BioethicsMasters&OnlineCoursePrograms
MMIBasics• MedicalschoolsareincreasinglyusingMul8pleMini-Interviews(MMIs)• Studentsgotoaseriesofsta8ons,ateachofwhichtheyreceiveapromptofascenarioorques8on• Studentsthenhave2minutestogathertheirthoughtsbeforeenteringtheroom,anddiscussing.
MMIscenariosmayexplore:– Ethics and Judgment – Problem-solving capacities – Integrity – Communication skills – Ability to work as part of a team
Source:NewYorkUniversitySchoolofMedicine.Mul8pleMini-Interview(MMI)FAQ
Prac8ceandprepcanhelp– Identifying nervous habits – Understanding the basic structure, time limit and
number of stations – Doing mock interviews through advisors’ office,
friends or others – Practicing addressing ethical questions
Source:NewYorkUniversitySchoolofMedicine.Mul8pleMini-Interview(MMI)FAQ
MMIBasics
Manystudentsencounterchallenges
• Havingto“thinkontheirfeet”• Organizingtheirthoughts• Ques8onsoWenhavenosingle“right”answer• Workingwith8melimits–planningappropriately• Problemsexacerbatedbyanxiety
Hereisasampleques8on
Youareafirst-yearmedicalstudent.Afriendinyourclasstellsyouthathermotherwasrecentlydiagnosedwithbreastcancer.Shefeelsoverwhelmedandisthinkingaboutdroppingouttospendmore8mewithhermother.– What would you say?
Source:Astroff'sPrepforMul8pleMiniInterview
StepsintheEthicalDecision-MakingProcess1. Gatherthefacts2. Definetheethicalissues3. Iden8fytheaffectedpar8es(e.g.,stakeholders)4. Iden8fytheconsequences5. Iden8fytheobliga8ons(principles,rights,jus8ce)6. Consideryourcharacterandintegrity7. Thinkcrea8velyaboutpoten8alac8ons8. Checkyourgut9. Decideontheproperethicalac8onandbepreparedtodeal
withopposingarguments
Source:MayDR.StepsoftheEthicalDecisionMakingProcess
GathertheFacts
• Whatques8onsdoyouhave?• Whatelsedo/wouldyouneedtoknow?• Whatis“thestory”?• Who,what,when,where,why?
BioethicalPrinciplesProvideausefulframework
• Autonomy/Respectforindividuals– Informed consent?
• Beneficence(responsibili8estohelpothers)• Non-maleficence(“Donoharm”)• Jus8ce– Social, distributive and procedural justice
Autonomy/RespectforindividualsWhoaretherelevant“stakeholders”?
HerMotherHowdoeshermotherfeelaboutit?– What is her medical condition? • Howacuteisit?Doesshehavesymptoms?– Perhapsthecancerwaslocatedandsurgicallyremovedwithoutproblemorspread
– How is she coping? What does she need? • Maybesheliveswithherhusbandandotherchildren/caregivers
Whoaretherelevant“stakeholders”?
TheStudentHowdoesthestudentfeelaboutit?– How long has she felt overwhelmed? – Has it affected her school performance?
Beneficence:1. Whatresponsibili8esdothestakeholders
havetohelpothers–to“dogood”?2. Whatwouldthestudentdoexactlyifshe
droppedout?3. Howmightithelphermother?
Non-Maleficence/Risks
1. Whatmightbethepossiblerisks/harmsthatmightensue?
2. Whatarethedisadvantagesofdroppingout?a) School performance? b) Having to “redo” the year? c) Would that cost more money?
Jus8ce(Social,distribu8veandproceduralJus8ce):Ifthemotherhasneeds,whichfamilymembersmightandshouldbeinvolved?Whatis“fair”withinthefamily?– How are decisions made?
Otherconsidera8ons
Relevantlaws?Moralintui8ons/gutfeelings– Be aware of your gut feelings – May or may not be optional approach to follow – Any biases? – Important to know
Brainstorm:Possibleac8ons/solu8ons
• Aretherealterna8vesolu8ons/op8onsotherthantheonesthatarecurrentlyassumed?
• Canasolu8onbemediated?• Hasthestudenttalkedtohermother?Otherfamilymembers?
• Couldshetalktothedeanaboutpossiblytaking8meoff?
• Ifsheisdistressed,wouldpsychotherapyhelp?
Decidingonacourseofac8on
Weighingcompe8ngprinciplesYoumightconsider:– Distinguishing primary vs. secondary stakeholders – Short- vs. long-term consequences (risks and benefits) – Magnitude vs. probability of consequences • Whichargumentsarethemostcompelling?
Overallapproachestoweighingcompe8ngprinciplesConsequentalist(“u8litarian”)approaches– e.g., though her mother would welcome her company, she feels
that the student dropping out would jeopardize the student’s career too much.
vs.Rights-based(“deontological”approaches)– If her mother has had a long history of chronic medical problems,
including alcoholism which has hampered the student’s own life and career for years, and other family members are currently meeting the mother’s needs, the student might feel that she has a right to pursue her own life and career
Processconsidera8ons• Involveallrelevantstakeholders/considertheirposi8ons- Consulting with others - Experts? - Supervisors?
• Transparency:Afairprocessmaybemoreprac8cablethanauniversally-agreedfairoutcome
• Possibleobjec8onstoyourapproach?• Howmightsomeonechallengeyou?
Remember:
• Theremaynotbeasingle“right”answer• Whatisimportantis:thinkingthroughtherelevantconsidera8ons
• Drawonunderlyingprinciples• Considerpossiblecoursesofac8on– Weigh relevant principles • E.g.,prosandconsofeach
• Drawingonpersonalexperiencescanalsobehelpful,butshouldnotreplacelogicalthinkingthataddressestheques8onasked.
SampleQues8on#2
Youaretrea8ngapa8entwithbreastcancer.Alumpwassurgicallyremoved,butshedoesnotwanttoundergochemotherapyandradia8ontherapyasfollow-upandinsteadwantstotrycomplementaryandalterna8vemedicine(CAM).– How should you address the issue with her?
Autonomy/Whoarethestakeholders?
Thepa8ent:– Has the right to decide her own treatment
Thephysician:– Has responsibilities to help her
Otherethicalprinciples
Benefits:- Radiation and chemotherapy might help her • CAMmaynotbeproventowork,butmightofferpsychological
benefits-makeherfeelshehassomecontroloverherfate
Risks:- What would happen if she does not pursue radiation
or chemotherapy? - What are the odds that her cancer will return?
Jus8ce:- Is she refusing because she lacks insurance? • Fairprocess:Explainissuestoher
Gatherthefacts:– Assuming that risks exist in refusing treatment, why
does she not want to pursue it? – Does she understand the risks of not pursing treatment? – Does she have the cognitive capacity to make this
decision (vs. has Alzheimers or depression)? Brainstormsolu8ons:– Are there family members whom you might speak to? – Spouse? Offspring? Siblings? Otherpointsofview?
Otherethicalprinciples
SampleQues8on#3
Yourecommendan8-depressantsforadepressedpa8ent,butshesaysthattheyarenoteffec8veandsodoesnotwanttotakethem.Hermothercommimedsuicideseveralyearsago.– What would you do?
Summary
• Thinkcri8cally• Thinklogically– Can use bioethical principles
• Bioethicalcourses,educa8oncanhelp
Otherresourcesavailable
ColumbiaUniversity“BioethicsforPremeds”site:sps.columbia.edu/bioethics/premed– Provides free materials – video and print
Otherresourcesavailable
Bioethicscoursesatyourins8tu8onorelsewhere.Online&face-to-faceBioethicscourses,cer8ficate,andmastersdegree– At Columbia or elsewhere • Manypremedstudentsobtainabioethicscer8ficateormastersdegree:– Duringtheirgaporglideyear,– Tohelpwithmedicalschooladmissions,
– Tohelpmakethemselvesbemerdoctors.
Ques8ons?
RobertKlitzman,MDProfessor of Psychiatry Director, Bioethics Masters and On-line Certificate and Course Programs ColumbiaUniversityPhone:(646)774-6912E-mail:[email protected]