I recently return from a very interesting ethics panel at the pre-departure HEARTT Symposium, this year organized by University of Chicago’s Section of Emergency Medicine.
Health Education and Relief Through Teaching (HEARTT) is a non-profit organization that helps facilitate the provision of care in at JFK Memorial Hospital in Monrovia, Liberia. Its main program partners with a collaboration of US academic medical centers to provide emergency, pediatric, surgical, mental health, and OB services. (see full EM description here) Residents and faculty convene annually at the pre-departure HEARTT symposium.
The panel was created to help prepare resident for elective at JFK hospital. turned out to be one of the more successful sessions of the 2 day event according to the HEARTT faculty. The ethics panel moderated by Michelle
Niescierenko aimed to present 4 real clinical cases to discuss challenging ethical situations. Drs. Nathan Allen, Emilie Calvello, James Sirleaf, and Donna Staton were panel members and shared a wide breadth of honest and insightful perspectives.
The case presentation format is similar to Iverson et al’s recent Academic Emergency Medicine article, but it takes the next steps in three unique ways.
1) Integrating this important issue into pre-departure training
2) Creating an interactive environment, where participants are able to exchange ideas and engage in focused discussions about a specific global EM context.
3) Approach this challenging topic from the “ground up” with interactive discussions. Where new and experienced physicians share multifaceted approaches to handling difficult clinical situations. The skinny statement here is– let’s talk about ethical challenges and move beyond a meta-level toward a discussion of what it may look like when “you’re in the thick of it”. A “what would you do at that moment” approach, and what are some lessons learned that you could lean upon?
Residents and faculty, some new and others experienced discussed two difficult cases scenarios specific to the JFK hospital context. .
During a motor vehicle accident where a car hits a group of people sitting under a tree, all seriously injured, how would you prioritize acute trauma care with an already full room?
The proposed solutions shared by both residents and faculty in the panel session surfaced ethical challenges related to
– limited resources; in particular human capacity and skill sets
– understanding expectations of patients and families in a post-conflict environment.
Experienced EM faculty and residents shared their perspective with honest, and personal recollections of similar experiences, while focusing on imparting kernels of advice and tempered words of caution.
“know your limitations” “you are the primary resource” “your US triage skills may fail you” “you are integrating into their healthcare system” “people understand that there are limitations to the system” “do not offer an intervention unless you are 100% confident it can be achieved- because even if there is a surgeon there for the operation if the electricity goes out there will be no operation”
The different approaches and perspectives represents the richness of views and organic interactions that evolve in this type of learning environment. One comment that I found quite memorable and powerful was
“There is no one answer to this”
It was the way it was imparted to the audience, discussing how there could be ….and have been different approaches. And learning that the “right” answer is not always clear and recognizing the existence of grey can be very difficult and often emotional. But the fact that uncertainty exists in this manner is a very valuable lesson that is often hard to see in passive learning environments.
So what were some of the guiding themes from this panel? I’ll leave those answer to be discussed and shared by the audience members and panelists. But as one audience member, here are a few kernals that I walked away with.
The importance of empathy. While this sounds obvious, enacting this and maintaining this in difficult scenarios can be quite difficult. The challenges of making ethical decisions when resources are limited, payment for services may be part of the norm, and ways of working may be markedly different from what you are used to -imparting empathy to patients, families and other colleagues around you were echoed from experience members of the audience.
“remember the endpoint of what you are doing”
“keep an eye on the bigger picture”