By: Dr. Kaif Pardhan (@kaifpardhan)
The last few years have been a tumultuous time in Canadian healthcare and an interesting time to begin a career as a medical educator. Controversial topics and conversations seem to crop up more and more frequently and I often find myself wondering what my role is as an educator in discussing these issues with the trainees I work with each day. This post is my initial reflection on our collective role as educators in discussing controversial topics in medicine with trainees. It strives to set out some basic principles to help guide our discussions of difficult issues with our trainees.
Simply to put this discussion in context, the following are a sampling of issues that have swept Canada in the last decade:
- Life sustaining treatment in cases where ongoing intervention was felt to be futile1,2
- Cuts to refugee healthcare benefits3
- Medical aid in dying4
- Changes to physician compensation5
- Changes to taxation for Canadian Controlled Private Corporations (CCPC)6
- Legalisation of cannabis7
- National pharmacare
- Non-physician health care professionals, providing “traditionally” physician services
- Private healthcare clinics8
- Resident Hours of Work, Fatigue Risk Management9
Along with teaching the CanMEDS competencies, a core part of the medical educator role is to facilitate the professional identity formation of our trainees. One could posit that part of forming this professional identity includes learning skills enabling one to form opinions, rationally research, and respectfully discuss topics that may be more controversial in medicine. Unfortunately, it is rare that explicit time for this is built into formal curricula although, perhaps, this is because we have not had a discussion of what this professional identity looks like as it relates to controversy. This may be further compounded by trainees arriving to medicine, or their core discipline, with specific political views or views based on their ethnic, cultural, religious or social background.
How, then, do we effectively engage in controversial discussions with our trainees in a manner that fosters a free exchange of ideas in a non-threatening environment? There are certainly challenges: time and space to have a nuanced discussion, a busy training environment in which many trainees and supervisors are already suffering from symptoms of burnout, an increasingly polarized political environment both within and outside of medicine, and, on some of the issues identified above, an ongoing emotionally charged social discussion.
These challenges can be overcome and, as educators, we have a responsibility to our trainees and society to ensure that physicians can have nuanced discussions about issues where there often is no one best answer. The following are six principles that may help guide our discussions with our trainees on these topics.
- Make it a priority. By incorporating time into the curriculum to have these discussions, it helps to normalize having the conversation. The time might be built into the protected academic teaching time or it might be time set aside in a clinic or ward day and it should allow as many trainees as are interested to participate.
- Be open to other perspectives. Moral absolutism or positional statements will likely lead to an abbreviated discussion. Even if your position is set, be open to hearing your trainee’s perspective and, more importantly, how and why they may have arrived there. This will sometimes mean setting aside your own opinions in order to listen to the opinions of others within the group and/or ensuring that those with minority opinions have the opportunity to be heard in a non-judgemental environment. By doing this, you not only teach, but also role-model skills in dialogue and acceptance of other viewpoints
- Be evidence informed. Many of these discussions are highly emotionally charged. It is incumbent upon us as educators, that push high quality evidence when it comes to the medical expert competencies, to be similarly rigorous when considering the controversial issues in our profession and our society. Much of this evidence may come from outside of the healthcare environment: economists, social scientists, anthropologists, legal scholars and experts in all areas of the human experience may have more evidence to offer, and for us to take advantage of, than we do ourselves
- Recognize expertise in your trainees. Medical student and resident organizations are highly active in medical education, wellness, resiliency, social determinants of health and many other areas. Their leaders are articulate, intelligent and, in many cases, may know more about a particular area of controversy than we do. Medical trainees also come from a variety of backgrounds and, as such, may have experiences and knowledge beyond that of their teachers. Embrace this knowledge and learn from your trainees. Their experiences in training and personal growth in an increasingly digital and information rich environment will continue to diverge from that of their educators. Our responsibility will be to enable them to use those experiences to help shape their own and their successors’ education
- Be aware of the pitfalls of social media. Our personal social media feeds tend to be populated by those we agree with and create an echo chamber in which we feel comfortable expressing our views10,11. How we use those public platforms will model for our trainees what acceptable use of social media looks like and they will emulate it. The character limits, particularly on Twitter, limit our ability to build nuance and context into our discussions. Using social media to reach out to your trainees and colleagues is important and we should all strive to use it effectively and responsibly
- Discussions are formative. Trainees are acutely aware of the power differential between their educators and themselves. Threats to future career prospects both explicit and implicit have, unfortunately, coloured the discussions of many of the topics listed12. It is incumbent upon us as educators to ensure that the spaces we create to have these discussions are clearly a safe space for a free, open and collegial exchange of ideas. Further, it is also our responsibility to ensure that our fellow educators are living up to this ideal, both during in person and online debates. This is how we can create environments that allow for rich discussion and that are safe for learning.
Controversies, both large and small, are a reality in medicine. Educators should not shy away from these controversies as they impact our patients, our trainees, our society and ourselves. Engaging respectfully and thoughtfully in these discussions and teaching our trainees how to do the same as healthcare professionals is a key part of our role. Perhaps, as we move forward, the medical education community can begin to discuss what professional identity formation looks like and how we can be more deliberate in its formation, both among ourselves and those we teach.
- Cuthbertson v. Rasouli, 2013 SCC 53  3 S.C.R. 341 https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/13290/index.do
- Golubchuk v. The Salvation Army Grace Hospital, 2008 MBQB 49, 227 Man. R. https://www.canlii.org/en/mb/mbqb/doc/2008/2008mbqb49/2008mbqb49.html
- Government of Canada (2012) Order respecting the interim federal health program http://laws-lois.justice.gc.ca/eng/regulations/SI-2012-26/FullText.html
- Carter v. Canada 2015 SCC 5,  1 S.C.R. 331 https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do
- Picard A (2016) Ontario doctors’ dispute lays bare deep divisions within medical profession. The Globe and Mail. https://beta.theglobeandmail.com/news/national/doctors-contract-dispute-has-exposed-deep-divisions-in-medical-profession/article31388272/?ref=http://www.theglobeandmail.com& Retrieved October 4 2017
- Department of Finance Canada (2017) Tax planning using private corporations https://www.fin.gc.ca/activty/consult/tppc-pfsp-eng.asp
- Allard v Canada 2016 FC 236 http://cas-cdc-www02.cas-satj.gc.ca/rss/T-2030-13%20reasons%2024-02-2016%20(ENG).pdf
- Brend Y (2017) Epic court battle over private health care rages in B.C. court. Canadian Broadcasting Corporation. http://www.cbc.ca/news/canada/british-columbia/cambie-surgeries-healthcare-canada-public-vs-private-system-bc-dr-brian-day-1.3977566
- National Steering Committee on Resident Duty Hours (2013) A pan-Canadian consensus on resident duty hours. http://www.residentdutyhours.ca/
- Halberstam Y, Knight B (2016) Homophily, group size, and the diffusion of political information in social networks: evidence from Twitter. Journal of Public Economics. 143 pp 73-88
- Brady WJ, Wills JA, Jost JT, Tucker JA, Van Bavel J (2017) Emotion shapes the diffusion of moralized content on social networks. Proceedings of the National Academy of Science 114
- Broca T (2017) Bullying is like a ‘chronic disease’ in medicine and we can’t just move on: panel. The Medical Post (Gated) http://www.canadianhealthcarenetwork.ca/physicians/news/professional/bullying-is-like-a-chronic-disease-in-medicine-and-we-cant-just-move-on-panel-50778 Retrieved October 4 2017