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:rlk2@columbia.edu