Education: Student Programs: Human Context in Health Care

Human Context in Health Care- Introduction

We expect too much of the student, and we try to teach him too much. Give him good methods and a proper point of view and all other things will be added as his experience grows.
Sir William Osler
 
Spoon feeding in the long run teaches us nothing but the shape of the spoon.
E.M. Forster
 
We do not see what we want to see, we see what we expect to see.
Anonymous, MS-I
 
In order to avoid imposing my own belief structures on patients, I need to understand my own perceptual mechanism which almost unconsciously filters everything I experience and places a distinguishing name or judgment on it.
Anonymous, MS-I
 
You are the only reliable instrument you have, so learn to calibrate yourself well.

This course will provide an opportunity for the student to identify the personal perspective they* bring to a clinical situation and the implications of this perspective for the medical care they provide. This personal perspective, a synthesis of life experience, beliefs and values, determines the individual's reactions§ to the events of daily life; it determines what that person sees and how that person reacts to what they are looking at, and significantly influences how that person ultimately responds to an event. No less than in daily life, the physician's personal perspective determines that physician's reactions in the clinical encounter; it determines what that physician sees and significantly influences how that physician responds to the patient with whom that physician is engaged. That reaction, although it is affective in nature, may as readily be experienced as specific thoughts as it may be experienced as inchoately emotional, and it is as intrinsic to the encounter with a patient as it is to any human encounter. Whichever form it takes, and this is entirely personal to the individual, even when taking the form of specific thoughts, it is antecedent to, and largely determines the direction taken by the subsequent "rational" analysis; these affective reactions are most clearly manifest in "first impressions", often ignored, even unrecognized, but nonetheless there and exercising an influence on what follows.

*Because of the awkwardness of using "he or she", "hers or his", or similar inclusive constructions, in those contexts where they might be used, the British convention of using "they" or "their" with a singular subject will be applied throughout the course. §For the purpose of precision, "reaction" will be used in reference to those thoughts and feelings that arise when initially confronted with a situation. "Response" will be used to describe the comments and actions ultimately taken in that situation. In a clinical encounter, it will refer to the comments and actions taken with the patient. Students are requested to follow this convention in their response papers.

As might be expected, the influence of one's perspective and initial reactions on their ultimate response in a situation will vary with the situation. In making most purchases, one's views about appropriate conduct of salespersons and one's reactions to a particular sales situation are much less likely to significantly determine their responses than are the specifics of the situation, convenience, quality, price, etc. In contrast, situations involving health care, by their very nature, elicit strong reactions. This is as true for the physician providing care as it is for the patient seeking it. Whether it is something as pervasive as uncertainty, as personal as sexuality, as ineffable as death, or as troubling as child abuse, both patient and physician almost reflexively react to these human issues apart from their subsequent more thoughtful analysis of the situation. And in addition to the separate, and often different, reactions of the physician and patient to the particular circumstances of the situation, in the clinical encounter, the reaction can as readily be to the patient personally or to the physician personally.
 
The significance of the physician's perspective and the reaction that accompanies it, is that the physician's reaction to a clinical encounter, whether to the issues it raises or to the patient who is raising it, is a manifestation of the attitude that physician brings to that encounter, and in turn, how that physician thinks about that patient. The physician's initial reaction in the encounter forms the lens through which intellectual knowledge is focused on the individual patient. If the lens is clear and free of distortion-if the physician is comfortable with that reaction, whatever it is, and appreciates and can correct for the possible effects of idiosyncratic personal experience-then the analysis of the patient's condition will be caring in the clarity of its focus on the individual patient's situation. If the lens is cloudy and replete with astigmatic distortions-if the physician cannot acknowledge that reaction, whether because it is frightening or otherwise unacceptable, and fails to recognize the existence or the possible consequences of idiosyncratic personal experience-then however precise the analysis may be in the abstract, it cannot clearly focus on the needs of the particular patient.
 
The goal of the course is to prepare the student to deal effectively with those human reactions of both physician and patient that transcend diagnosis and medical specialty and can facilitate or impede the process of health care. Those reactions are significant as components of what is customarily described as "the clinical approach" to medical care-a systematic, analytic approach to familiar, human phenomena-the way day-to-day medicine is optimally practiced. The clinical approach requires the synchronous functioning of affect and cognition, of emotion and intellect, to enable the physician to provide the most effective care.
 
I. CONTENT
 
A technician can be identified as someone who knows every aspect of his job-except its ultimate purpose and social consequences.
Sir Richard Livingston
 
Guerir quelquefois, soulanger souvent, consoler toujours. (To cure sometimes, to relieve often, to comfort always)
French aphorism, 15th century
 
People don't want medical treatment; they want medical care. Comment by a physician, now malpractice attorney, following the hospitalization of his wife after a cardiac arrest.

To accomplish the above goal, the course addresses selected aspects of the human elements significant in the health care context. It is divided into four segments:
 
(1). The first segment opens with a structured exercise in which students are given the opportunity to interact with others from an unfamiliar culture and encouraged to observe their reactions-thoughts and feelings-to the experience, and identify the role of those reactions in determining their subsequent responses to the situation. They are then asked to examine how their own cultural contexts and their personal values and attitudes about "differentness", developed out of their unique life experiences, structured those initial reactions and subsequent responses, and to consider how these elements might play a role in their responses to patients, both those overtly "different", from a different cultural background, and those who may seem "like them", as well, given the recognized existence of a "doctor culture" and a "patient culture".
 
This examination and the analysis it entails is the first step in the analytic process students are expected to follow with each of the topics addressed in the course: First, observe their reactions to the material presented; then, analyze these reactions for what they indicate is the student's perspective and underlying attitudes about various aspects of the issue being considered and identify the possible sources of that perspective and attitude in their life experiences, beliefs and values; and finally, consider the possible consequences of those attitudes for patient care and what might be done to minimize potentially harmful ones.
 
Following this exercise, four topics are more formally examined.
 
1. Confidentiality in military medicine; because of concerns frequently expressed by students about limitations on the confidentiality in the military of their personal medical information, this issue is addressed first.
2. Uncertainty as a pervasive phenomenon in medicine.
3. "Contextual thinking" as applied in medicine, the hallmark of the clinical approach.
4. The nature of the physician-patient relationship.
 
(2). The second segment of the course explores three areas of the physician's personal experience in the healing relationship:
 
1. Medical malpractice. Itself no more than a description of an unfortunate event, in most physicians and medical students, the phrase evokes both dread and anger.
2. Sexuality.
3. The death of a patient.
 
The focus of these sessions is the physician's experience in providing care. The objective of these sessions is to enable the student to identify the features of the health care situation that elicit personal concerns likely to affect the care of patients, and to recognize the crucial role of self-awareness in effectively dealing with these issues. This objective is to be achieved by identifying those personal reactions to each of the issues raised, analyzing those reactions for the attitudes that evoke them and the sources of these attitudes, recognizing the potential consequences, both salutary and detrimental, of these attitudes for patient care, and finally, what might be done to facilitate the salutary consequences and prevent the detrimental ones.
 
(3) The third segment is concerned with the experience of the patient as a person in the health care situation. Three aspects are examined:
 
1. The variety of initial responses to becoming ill, to the dis-ease of disease, the reminder of mortality.
2. Living with the limitations of chronic disability and handicapping conditions.
3. Bereavement as experienced by the family of a loved one.
 
In contrast with the second segment of the course, in which the experience is examined from the perspective of the physician, each of these areas will be examined from the viewpoint of the patient. The objective of this segment is twofold. First, it is to enable the student to appreciate the widely varying, individually unique reactions to these human experiences of illness, limitation and loss, to realize how these reactions occur whatever the particular illness, the specific limitation or the nature of the loss, and to recognize the universal concerns which underlie them. Second, it is to enable the student to recognize how their personal perspective on these universal concerns of mortality, disability and loss can affect their response to their patients. The course readings and class sessions will provide some insight into the first of these objectives. As with the earlier segments of the course, the second objective is to be achieved by identifying the perspective the individual student brings to these issues through observing and analyzing their reactions to the material presented, then recognizing how this perspective may influence their response when these events occur in the lives of their patients.
 
(4) The final segment of the course examines the human environment in health care, the socially determined attitudes, expectations and behaviors of both patient and physician which influence health care. Four areas are explored:
 
1. The subtle health care consequences of attitudes toward alcohol use.
2. Unidentified gender-associated bias in medicine and its impact on health care.
3. Unrecognized racial stereotyping and its manifestations in the provision of care.
4. The effects on health care of culturally determined perspectives on family violence.
 
The objective of these sessions is to enable the student to identify the factors in each of these aspects of the environment which influence health care, to recognize their personal perspective regarding these factors and to appreciate the potential consequences of this perspective for patient care. Achieving this objective, as in the earlier segments of the course, begins with the self-reflection and identification and analysis of personal reactions and how they are determined by experience, beliefs, and values.
 
Concurrent with these last two segments of the course, in Introduction to Clinical Medicine-I, students will begin observing and conducting patient interviews. These interviews will focus on the patient's symptoms and experience of the illness. Through the reactions they evoke in the student during the interview, they will provide an opportunity to experience a sampling of the range of reactions physicians have to patients. This will enable the student first, to appreciate the relevance of the issues being raised in the first three segments of the course, and second, to begin to understand how their reactions will shape their responses to patients in the future.
 
The student who has not yet had any clinical experience or exposure to the clinical approach may initially find it more difficult to appreciate the significant distinctions among these related topics. If the features distinguishing any topic from others remain unclear after reading the handout, the course director should be consulted for clarification.
 
II FORMAT
 
Do not waste the hours of daylight in listening to that which you may read by night.
Sir William Osler
 
If you would be a real seeker after truth, it is necessary that at least once in your life you doubt, as far as possible, all things.
René Descartes
 
What you see when you look depends on where you're standing when you're looking.

Before the beginning of each term, reading material relevant to each of the topics considered will be distributed. Classes will alternate between general sessions, consisting of panel presentations at which participants will discuss personal experiences relevant to the topic, and small group discussions where students will have the opportunity to interact with one another and with a faculty member. Following the panel presentation on each topic, students will write response papers analyzing their reactions to the readings and panel. These will then be read and evaluated by the faculty member who will meet with the group the following week.
 
(a) Handouts
 
Course reading material will consist of an introductory essay and several short articles or excerpts for each topic. The essay is intended to provide a general conceptual background to the topic. Each essay defines the area being addressed and draws from the scientific literature for an overview and analysis of relevant aspects of the topic (Half the essays are referenced; references to material in the others will be provided on request). The essays are accompanied by a selection of articles or excerpts included because each highlights some aspect of the issue being examined. The articles were selected to provoke thought, not simply to inform. Typically, the articles will address, often by implication, infrequently examined aspects of the topic being considered; in some cases, the articles may be presented as primary data. The essay will place the articles in context and indicate why they were selected, and draw your attention to important questions or issues they may raise.
 
A week before each panel, a cover note providing background information for the presentation will be distributed. It will identify the speakers and the issues they were asked to address. It will identify the salient elements to observe in the presentation and will include an outline of how the response paper might be approached.
 
(b) Panels
 
Consistent with Osler's advice quoted above, the general sessions have been designed to provide material for the student to apply the clinical approach, the panels representing clinical presentations for observation and analysis, rather than informational briefings for storage and retrieval. They are not intended to directly address the content of the readings or to provide further substantive information about the topic, although they may incidentally do so. They are intended to provide neither a "correct" understanding of the issues addressed (as if there was one!), nor a model of "correct" behavior (as if there was one!). Rather, they are designed to provide primary data and an experience that can be thought about analytically.
 
The panelists will be speaking as colleagues recounting an experience in patient care, or as patients recounting their medical history. They see their statements as opening a discussion with the class, and all have indicated a willingness to respond to questions, however personal they may seem. In the classes on the introductory sequence of topics and in those sessions addressing the physician as a person, the panelists' statements-which may seem to be no more than "war stories"-are being presented to reflect ways of thinking about problems or ways of dealing with difficult situations (the true value of "war stories" in any context). Similarly, in the sequence addressing the patient as a person, although the panelists may be familiar faculty members or fellow students, they are there as patients, describing how they have experienced and reacted to their conditions-patients presenting their medical histories. Embedded in those histories and in the way they are presented, will be their unspoken concerns, their values, their preoccupations, their way of looking at what they are experiencing. The ability of the physician to recognize these unspoken issues and factor them into a treatment plan may be the sole determinant of the successful outcome of a clinical encounter.
 
(c) Response Paper
 
Following the general session, students will prepare a brief (ca. 1500 words), response to the reading and panel presentation. This is to be a paper reflecting thought, not a research paper; the intent is for the student to concisely, and in an organized manner, present their analysis of their reactions to the readings and to the panelists in class, not merely a description of those reactions.
 
The goal of this activity is the development of the student's ability to systematically analyze issues arising in the clinical context. This includes refinement of observation and listening skills, and the application of these skills in a systematic manner. Inasmuch as reasoning is directed by the expectations (which include values), experience and emotional reactions that structure thought, systematic analysis of any situation begins with recognizing relevant personal expectations, experience and emotional reactions, to identify one's perspective on the situation. Factoring these elements into the reasoning that leads to the choice of approach to a clinical problem may be particularly difficult, insofar as it may require the translation of what is experienced in emotional terms into the cognitive terms necessary for them to be used in any rational analysis. These steps are critically important to the clinical approach because the failure of physicians to appreciate how their personal attitudes and expectations affect their thinking and judgment has been found to be at the root of their poor performance in the evaluation and treatment of conditions as diverse as chronic pain, child abuse, sexual issues and alcohol abuse.
 
This process of analysis follows several well-defined steps:


Observing the situation to be analyzed.
 
In this situation, the object of observation consists of the material in the handout and the panel presentations-what the panelists had to say and how they said it. Essential here is the meticulous observation and attentiveness to precisely what is being said-or not being said (or written or not written)-and how it is being said (or written) that is central to the work of the physician and is the first step in the ongoing process of analyzing and integrating what the physician sees and hears into what the physician already knows about this person, about the human condition, and about themselves-their expectations, their experience, their emotional reactions. The paper must be specific about what was observed that elicited the reaction.
 
Identifying personal reactions to each of the issues raised in the situation.
 
This entails identifying feelings and thoughts elicited by the issue generally and by the points made in the essays and by the panelists (Some find it useful to jot down these reactions as they occur). It may sound easy, but it isn't. It isn't, because in many situations, a person's "gut" reactions aren't exactly what they would like them to be. Those reactions are often less kindly, meaner, more selfish, even vindictive and punitive, than would be expected of the pure, caring, generous, altruistic-even virtuous-individuals that people like to think they are. The incongruity of such reactions with the "take charge" and "in control" self-image individuals feel is appropriate for them to have as physicians often leads to the reactions going unrecognized, despite their demonstrated value in assessing the patient's situation, no less than their influence on physician's decisions and actions.
 
It is in this component of identifying personal reactions and their significance that observation in the clinical context is a profoundly different process than observation in the biological sciences as it is commonly understood. Observation in the clinical situation includes self-observation as an integral element, as important as detailed observation of the patient and the patient's environment. With rare exceptions, the fully successful clinical encounter depends on the effective integration of the data from this self-observation with what is seen and heard from the patient and with what is known of the pathophysiology of disease. This process can lead to a questioning of one's understanding, even one's perceptions; this opportunity to reevaluate one's understanding is most clearly presented when the patient is reacting to their situation in a manner other than how the physician might react if in a similar situation. As the quotation from Descartes opening this section suggests, this self-questioning and self-doubt that may go to the root of how a person sees the world, is not at all something people are practiced in doing in their daily lives.
 
Analyzing those reactions for the attitudes that evoke them. This consists of:
 
Identifying the sources of these attitudes in experience, beliefs, and values-in the perspective brought to the situation. Distinguishing among the sources those originating in scientifically validated data and those originating in individual experience, beliefs, and values.
 
The next step is to analyze those reactions for the attitudes and expectations-for the perspective-that induced them, and identify their sources. Distinguishing among these sources for attitudes that may be based on scientifically validated data, and attitudes based on personal experience, beliefs and values is important because the conduct of the physician's personal life is appropriately dictated by those beliefs and values developed over the course of their lives, and may be entirely independent of the data of science. In the physician's professional life, however, it is inappropriate to introduce personal beliefs and values in making recommendations to patients; the physician's license is to practice allopathic medicine, requiring the physician to base recommendations on scientifically validated data. In the absence of this analysis, the physician is at serious risk of innocently assuming their perspective on an issue for a patient to be based on accepted scientific data, when it is, in fact, personal bias. The sources of the physician's perspective become particularly important when the physician experiences unexpected reactions to situations or to patients, or when the physician's reactions indicate an attitude inconsistent with positions expressed in the scientific literature or inconsistent with the reactions of a patient. In those situations, an examination of personal experience and its attendant beliefs and values may reveal the source of the inconsistency. Here, it is important to recognize that relevant experiences are not only those clearly related to the issue being considered, but can also be the absence of clearly related experiences.
 
Recognizing the potential consequences, both salutary and detrimental, of these attitudes for patient care.
 
The next step is to identify the implications of those reactions for patient care. This consists of "stepping outside of oneself" and recognizing how those reactions-both positive and negative-may affect how clinical situations are perceived, and consequently, the judgments the clinician will make in those situations. The operative word here (and elsewhere in this Introduction), is "may"; these reactions merely represent risks that can be reduced and become less likely to be realized when adequately addressed. It may feel awkward and embarrassing, even painful to acknowledge it in specific situations, but in the abstract, it can easily be appreciated how reactions such as disliking a patient or being particularly repelled by their condition or disturbed by their reaction to it, or feeling particularly helpless in dealing with it, places the physician at risk for thinking of good reasons for not doing what may be clinically indicated for patients and providing less than optimal care. While less apparent, a patient simply reacting differently to a situation than the physician might react in a similar situation, can also place the physician at risk for providing less than optimal care. Even more difficult to recognize, may be how liking a patient, or feeling particularly moved by their situation, entails equivalent risks; the physician will go the "extra mile" for the patient they like without even thinking about it, but that can also lead to justifying inappropriate, and even futile interventions.
 
Considering how to prevent the detrimental consequences and how to facilitate the salubrious ones, based on your understanding of their sources. The final step in this analysis, is to consider what might be done about those reactions when taking care of patients, if anything seems warranted. This is the most critical step because it's not the reactions themselves that are important, it's what the physician does about them. It doesn't matter whether the reaction to a patient is compassion, anger, or even erotic stirrings, whether the reaction is of wanting to care for them, to kill them or to make love to them-all, and everything in-between, reactions that experienced, outstanding physicians have described. What matters is how the physician deals with that reaction so that patient care is facilitated, rather than impeded.
 
While as noted, this is the most critical step in the process, because students have not yet had any clinical experience, it is understood that whatever they might say about this would necessarily be highly speculative. When questioned, students not infrequently dismiss the value of what they have said or written for this reason. Since such speculation, when a product of the analysis described above, represents a first effort at thinking through a clinical problem likely to be encountered in practice, they are dismissed only imprudently.
 
It is also useful to recognize early-and to avoid being perceived as shallow-that "objectivity", often introduced to resolve difficulties in this arena, is a phantom concept. It certainly doesn't exist in the clinical situation. Since precise language to describe a perspective that might be agreed upon as being "objective" is lacking, close attention to situations in which it is commonly used, reveals it to be indistinguishable from indifference-which carries its own risk of overlooking a patient's unique situation.
 
Equally likely to be perceived as shallow are statements about what the student anticipates thinking or believes they should think after becoming a physician, or what they perceive their obligations will be as a physician. The student wanting to be recognized as grasping the issues being addressed will always write in the first person and will avoid writing about "The physician"; expressions such as, "The physician should . . .", or "The doctor must . . ." are indicators of misunderstanding the assignment.
 
(d) Discussion Groups
 
The discussion groups will meet two weeks after the lecture, before the next panel presentation. Discussion leaders are drawn from all clinical departments of the school. They will provide a more complete picture of the physician's experience, demonstrating what experienced physicians of diverse specialties feel and think about these issues, and how they deal with them.
 
The discussions will provide opportunities to:
 
Explore the possible significance in the clinical situation of reactions to the issues raised by the readings and the panel;
 
Determine where and how the crucial factors of personal experience and values play a role in these reactions through comparing the differing reactions among group members to a common experience-the panel presentation.
 
Examine issues raised by the discussion leader about points made in individual papers.
 
The goal of these discussions is to enable the student, first, to consider and appreciate the diversity of views that exist about medical issues, and second, to recognize the origins of these views in the different values and attitudes represented in the class and among the faculty.
 
III LOGISTICS
 
The schedule of general sessions and discussion groups is shown in Appendix II. Discussion group and room assignments are shown in Appendix III. Unfortunately, the rooms are not all equally pleasant; assignments were made by lot. To provide a balance between continuity and diversity, discussion groups will be reconstituted midyear. Faculty for the discussion groups will rotate through the groups so that each student may be exposed to the variety of perspectives to be found in the faculty. Should no faculty member be present for a discussion group by 0740, a representative of the group should go to Room A-1038 for instructions about where to go to join another group for the discussion.
 
Student papers should be identified by name and group number. They are to be submitted to the Department of Family Medicine, Room A-1038, by 1300 on the Thursday of the week following the lecture. There is a basket of hanging folders, each identified by group number, in the Department reception area; papers should be placed in the appropriate numbered file. The papers will be distributed to the faculty members assigned to each group for review and comment in advance of the class. They will be returned at the beginning of the discussion group with the faculty member's comments and will serve as the basis for the discussion. Papers must be typewritten, double-spaced, with 1.5 inch margins, to allow room for interlinear and marginal comments by faculty.
 
Papers will be collected at the end of the discussion group for grading. Evaluation of the paper and participation for each session will be by the faculty member for that session and will be based on the thoughtfulness and clarity of the analysis expressed in the papers and in the discussion. The criterion for the evaluation of the paper is the rigor of the student's analysis about how, based on their reactions to the course material and on personal experience, they may perceive, react, and respond to patients. Whether the faculty member agrees, disagrees, or is concerned about a student's anticipated reactions and responses, is irrelevant to the evaluation. Papers that described anticipated reactions and responses that caused the faculty member serious concern have been evaluated as thoughtful on the basis of being well reasoned. In such situations, the faculty could only hope that under the cumulative pressure of directly witnessed human suffering, greater compassion or better judgment might be shown than was described.
 
An "Outstanding" paper will be one showing exceptional perceptiveness or analysis applied to the issue addressed in the session. A "Thoughtful" paper will follow the analytic steps outlined in the cover note, examining the student's reactions to the readings and presentation, reflecting on their sources in personal experience, and considering their possible implications for patient care. A paper that addresses only individual steps in the analysis, or merely summarizes or reiterates the material in the readings or the general session, demonstrates "Insufficient Analysis", as defined earlier. A "Poor" paper is one that either is irrelevant to the topic, merely makes a statement of unsupported opinion (which is no more than an emotional reaction stated in cognitive terms), or is seriously flawed in thinking and analysis; the mere fact of disagreement does not warrant a poor evaluation. The guidelines provided to the faculty are in Appendix IV. A paper that simply recounts a personal experience and its consequences for the student, however compelling and profound, without considering its possible consequences for patient care, may be returned without a formal evaluation entered. For calculation of final grades, these assessments are converted to numerical values: "Outstanding"=+2; "Thoughtful"=+1; "Insufficient Analysis"=0; and "Poor"=-1. Graded papers will be returned at the discussion session following the one for which the papers were prepared. Students whose papers are considered to warrant further discussion will be asked to meet with the course director; no grade will be entered in the record for that class until after the meeting. The course director should be promptly consulted any time a paper is returned without a grade.
 
Should a paper receive a lower than expected evaluation, whatever its basis, the student has the option of requesting a re-evaluation. Such papers may be reviewed-with the student's name and original faculty member's comments removed-by several additional faculty members. Should there be concurrence with the initial evaluation, the student has the option of appending a clarification, or even rewriting the paper and having the rewritten paper evaluated on its own merits.
 
The faculty member assigned to the group will evaluate student participation in the discussion. A "+1" represents thoughtful participation through comments examining the student's response to the panelists and readings and the factors contributing to it, comments that promote exploration of the sources and significance of differences among the students; a "0" represents unremarkable, or no participation. The faculty recognizes that learning is not a matter of participation; one can learn quite well as an entirely silent bystander. Contributing, however, does require participation, and it is for their contribution that students are evaluated. That is why a student may speak in group a great deal, yet receive a "0" for participation; the discussion leader's perception was that the student's speaking did not significantly contribute to the discussion. An unexcused absence is recorded as a "-1".
 
Appendix V is a questionnaire seeking an anonymous response, about the experience of the discussion group. Copies of this are provided to discussion leaders to use at their discretion at the end of the discussion group. When used, individual responses will be tallied by the Assistant to the Course Director, and the results of the tally returned to the group members within 3 days after the questionnaires are delivered to the Department of Family Medicine. Each question requests an assessment of the student's own experience, as well as the impression obtained of the experiences of the others in the group. The latter question is asked, insofar as much of a physician's career, particularly in the uniformed services, is spent working collaboratively in groups, and one's effectiveness in those groups is largely determined by how accurately one is able to "read" the group. For each student, comparing the numbers in the tally with their impressions at the end of the session will provide them with a measure of the accuracy of their assessments of others in a work group.
 
The final grade for the course is determined by the evaluation of student papers and participation in the group discussions. As the course is more closely related to the clinical, rather than the basic science component of medical education, both in the direct focus of its concerns and in the subjectivity of grading, final grades are based on the average distribution of grades in the clinical years in a 3 year sample-27% "A", 57% "B", 14% "C". An evaluation of "Insufficient analysis" for a paper will preclude a grade of "A". Two unexcused absences will result in a lowering of the student's final grade by one grade. More than two unexcused absences will require some remediation, to be negotiated with the course director. A final grade will not be submitted at the usual time when: (a) No evaluation has been recorded for a paper; (b) There is no record of the student responding to a request to discuss a paper; (c) There have been more than two unexcused absences at the discussion groups and remediation has not been arranged. Students will be notified at the end of each term if any of these conditions are noted. Should existing conditions not be resolved by 30 September of the next academic year, a grade of "F" will be submitted.
 
Since the goal of the course is the demonstrated mastery of the objectives described above, as applied to the unique circumstances of the individual student/physician and the particular patient, students who feel that their evaluations do not accurately reflect their abilities can negotiate with the course director an exercise that will provide them with an opportunity to demonstrate the necessary enhanced level of mastery.
 
There will be no examinations in the course.
 
Responses to 10 frequently asked questions about the course will be found in Appendix VI.
 
Simon L. Auster, M.D., J.D.


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