Confidentiality and Ethical Policies in Gross Anatomy

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Confidentiality and Ethical Policies in Gross
Anatomy

• James J. Walker, Ph.D.
• IUSM-Lafayette at Purdue University
• Ernest F. Talarico, Ph.D.
• IUSM-Northwest at Indiana University Northwest

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QUESTIONS

• How do you view the following issues in the
• class/laboratory with respect to the use of
• human cadavers or cadaveric materials?
• (1) confidentiality
• (2) respect
• (3) professionalism
• (4) human dignity
• (5) safety
• What are your thoughts with how these skills and
  values were emphasized in your educational
  process, and with what was done for "remediation"
  (i.e., consequences, if a student did not act
  appropriately with respect to any of the above)?
• What are your recommendations for change, if
  any?

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• We verbally state the following and include it in
  our course guide as part of the 1st lab day
  procedureI.        Respect and Compassion for
  the Donated Body (Donor)        A.  Call your
  first patient "donor."  This individual was once
  a living human being, and should be treated
  with as much respect and compassion as a
  living patient.     B.  You will be provided
  with the first name (only) of your donor Please
  always refer  to your donor by his/her given
  name.       C.  Note significant and
  interesting variations, anomalies and evidence
  for disease.  Discuss these findings among your
  lab partners and with the instructors.  Your
  lab group (table) must complete a polished
  Donor Report that describes your donor's
  anatomical variations, anomalies, and evidence
  of disease.  In essence, the Donor Report
  will be your first "Autopsy Report".        D. 
   Discuss your feelings about the dissection
  experience with your classmates.We've only
  had one instance in past history where
  individuals were not acting professionally (and
  it was with respect to their name for their
  donor) - we called the group into our office,
  told them they were being unprofessional and
  disrespectful, and they should change the name
  and their behavior.  They apologized and did so
  immediately, and we had no further problems with
  that group. Valerie Dean O'Loughlin, Ph.D.
  (IUSM-Bloomington)

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• I give a half-hour presentation where I
  provide a brief introduction to our gross anatomy
  course and spend the bulk of my time talking
  about professionalism and the IUSM Anatomical
  Education Program (AEP), including details about
  our body donation process. Some of the material I
  use was produced by you two a few years ago for
  use with your students. At the end of my
  presentation I announce a self-reflective writing
  assignment that is due one week after the start
  of class. Much of this information is repeated
  and expanded on during our first class lecture
  for the benefit of first-year doctor of physical
  therapy students who join our combined course.
• Students are reminded that it is a privilege to
  be allowed to dissect and participate in this
  unique learning experience. I tell the students
  that the dissection lab introduces many to the
  reality of death, to the donor as their first
  patient, to the language of medicine, to social
  bonding, collaboration, and communication skills,
  and to the need for them to understand and
  develop professionalism and professional
  attitudes. We remind them of the respect and
  gratitude they owe the donor and the trust the
  donors have placed in them. 
• The medical students are required to complete
  and submit a reflective writing exercise in
  partial fulfillment of Competency V-Self
  Awareness, Self Care and Personal Growth on one
  of the following items (1) Reflect on your
  thoughts about the dissection experience in
  anticipation of the first day of gross anatomy
  class. Describe your fears or concerns, if any,
  prior to class and how these changed over the
  course of the first week of class. (2) What
  thoughts do you have toward the donor in the
  context of learning anatomy, your medical
  education, and the future care of patients? How
  do you think their decision will impact these
  areas of your life?
• The students are not given the donors name,
  though a few give them one. We post the cause of
  death and age for each donor and each table is
  responsible for completing the donor reports. We
  stress the importance of the doctor-patient
  relationship and the associated confidentiality
  that it demands, and therefore do not allow
  non-student visitors in the lab.
• We have not experienced any overt acts of
  disrespect or unprofessional behavior toward the
  donors. It is my impression that student
  awareness, sensitivity, and sense of respect,
  gratitude, and responsibility in the lab has
  increased since the commencement of my freshmen
  orientation talks about 3 or 4 years ago and
  adoption of the self-reflective writing exercise.
  Often during laboratory dissection at individual
  tables we remind students of their donors
  sacrifice.  Because we have not instituted a
  formal mechanism for addressing lapses in student
  behaviors, remediation would likely involve
  talking to the student and determining what
  corrective measure is most appropriate, if
  any. Mark Seifert
  (IUSM-Indianapolis)

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On the first day of class the students are given
rules about proper behavior in the gross lab and
told that violation of the rules (e.g., removing
human material from lab) will result in severe
disciplinary action.  I also tell them that it is
a privilege to dissect a cadaver.  We do our
best to preserve human dignity and we have a
"burial" service at the end of the semester with
candles and music in which the students
symbolically place the cadavers into body bags. 
I tell them that part of the purpose of this
ceremony is to restore the cadaver's humanity
after dissection.I really don't see where there
are issues of confidentiality b/c we don't know
names.I've never had a student that showed
disrespect.  I guess if one did I would talk to
him/her first.  Theoretically I grade
professionalism in the course but I'm not sure I
would use that. Joel Vilensky, Ph.D. (Fort
Wayne)
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During the first lecture in gross anatomy I take
about 20 minutes and address each of these
topics. Much of what I talk about is in the
context of Competency IX (professionalism) for
which I am the local point-person.  Time is spent
educating the students on the value of the
dissection experience, how cadavers are acquired,
and the need to respect the gift that has been
given by that individual and/or their family to
the students educational experience.  There is
also some time spent on discussing how cadaveric
material is to be handled and how acting in a
professional manner in the lab and on through
their careers as physicians is an important
aspect of their personal development. Examples of
unprofessional behavior in the lab are presented
as a way to elevate the students awareness of
how actions no matter how innocuous they might
seem at the time can be considered offensive and
unprofessional and that care in considering ones
actions regarding cadaveric material is extremely
important. Re Remediation
Consequences. Such behavior is considered on a
case by case basis.  In general a reported
behavior would most likely fall in the category
of Unprofessional activity and hence be
referred to the local Competency director for
Competency IX.  In the past this would
precipitate a one on one conversation with the
student regarding the behavior and how their
actions have impacted others and why such
behavior can have lasting negative consequences
(competency evaluations) for them if it is not
modified.  Dale Saxon (IUSM-Evansville)
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RESPECT

• esteem for or a sense of the worth or excellence
  of a person, a personal quality or ability, or
  something considered as a manifestation of a
  personal quality or ability I have great respect
  for her judgment.
• deference to a right, privilege, privileged
  position, or someone or something considered to
  have certain rights or privileges proper
  acceptance or courtesy acknowledgment respect
  for a suspect's right to counsel to show respect
  for the flag respect for the elderly.
• the condition of being esteemed or honored to be
  held in respect.

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HUMAN DIGNITY

• Dignity is a term used in moral, ethical, and
  political discussions to signify that a being has
  an innate right to respect and ethical treatment.
  It is an extension of enlightenment-era beliefs
  that individuals have God-given, inviolable
  rights, and thus is closely related to concepts
  like virtue, respect, self-respect, autonomy,
  human rights, and enlightened reason.
• In more colloquial settings it is used to suggest
  that someone is not receiving a proper degree of
  respect, or even that they are failing to treat
  themselves with proper self-respect.

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TABLE 1. Description of PROFESSIONALISM Leading
Medical Organizations Organization Specific
knowledge, skills, and attitudes
required ACGME1 Keyword Demonstrate Demonstrat
e respect, compassion, and integrity
a responsiveness to the needs of patients and
society that supercedes self-interest
accountability to patients, society, and the
profession commitment to excellence and
on-going professional development Demonstrate
a commitment to ethical principles pertaining
to provision or forfeiture of clinical
care confidentiality of patient
information informed consent
business practices Demonstrate sensitivity
and responsiveness patients culture, age,
gender, and disabilities ABIM2 Keyword
Commitment Commitment to professional
competence honesty with patients patient
confidentiality maintaining appropriate
relations with patients improved quality
of care improved access to care a
just distribution of finite resources
scientific knowledge maintaining trust
by managing conflicts of interest professional
responsibilities AAMC NBME3 Keyword
Behavior Altruism Responsibility and
accountability Honor and integrity Excellence
and scholarship Care and compassion Leadershi
p Respect McGill University4 Key word
Core attributes Competence Autonomy
Self-regulation Commitment Responsibility to
society Integrity and honesty Responsibility
to the profession Morality and ethics
Teamwork Altruism 1Accreditation
Council for Graduate Medical Education (1999)
2ABIM Foundation et al. (2002) 3NBME (2003)
42005Workshop on Teaching Professionalism with
Department Chairs Steinert et al. (2005).
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CONFIDENTIALITY

• Confidentiality has been defined by the
  International Organization for Standardization
  (ISO) as "ensuring that information is accessible
  only to those authorized to have access" and is
  one of the cornerstones of information security.
• Confidentiality also refers to an ethical
  principle associated with several professions
  (e.g., medicine, law, religion, professional
  psychology, and journalism).
• Confidentiality can restrict information flow,
  with both positive and negative consequences.

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• Patient confidentiality means that personal and
  medical information given to a health care
  provider will not be disclosed to others unless
  the individual has given specific permission for
  such release.

• Confidentiality is the right of an individual to
  have personal, identifiable medical information
  kept private. Such information should be
  available only to the physician of record and
  other health care and insurance personnel as
  necessary.
• As of 2003, patient confidentiality was protected
  by federal statute.

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• The concept of "doctor-patient confidentiality"
  derives from English COMMON LAW and is codified
  in many states' statutes. It is based on ethics,
  not law, and goes at least as far back as the
  Roman Hippocratic Oath taken by physicians.
• The duty of confidentiality continues even after
  patients stop seeing or being treated by their
  doctors. Once doctors are under a duty of
  confidentiality, they cannot divulge any medical
  information about their patients to third persons
  without patient consent. There are, however,
  exceptions to this rule.

Physician must not disclose his or her patient's
information without lawful authorization even
after the patient dies A physician must not
disclose without lawful authorization the medical
records of another physician's patients
regardless of the information source. (Tzu Chi
Med J 2006 18241-243)
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• Respect for patient confidentiality is one of the
  core concepts of professionalism and should have
  high priority in medical education.
  Confidentiality should be introduced early in the
  curriculum so that students understand their
  ethical, professional, and legal obligations
  throughout their medical studies and later
  professional career.

Anatomists have important opportunities for
teaching professional values including
confidentiality and should be major contributors
to a multidisciplinary teaching on professionalism
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In the Anatomy Lab

• One of the earliest opportunities for students to
  explore confidentiality is in anatomy lab where
  educators are well placed to introduce concepts
  of confidentiality within the boundaries of
  professional behavior in the dissecting room
  (Pawlina and Lachman, 2004).
• Students may think of their cadaver as their
  first patient (Levin, 1998) and develop a respect
  for the donor that enables them to make links
  with their future patients (Lempp, 2005).
• Against this background, the moral and ethical
  dimensions confronted in the dissection room can
  be applied to professional clinical practice.
• It is important at introductory briefings to
  emphasize that students have an ethical
  obligation and a duty of confidentiality to the
  deceased and their relatives (GMC, 2004) and a
  requirement to keep confidential all information
  in the deceaseds medical record including
  information entered postmortem (AMA, 2005).
• Students should understand that they must not
  discuss details of cadaver dissection in public
  or with family and friends. Casual chatter may
  unwittingly breach confidentiality.

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Small Group Session

• 6 Case (i.e. 6 groups)
• 20 minutes small group discussion
• 15 20 minutes (each group will present their
  case/thoughts)

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Scenario No. 1 - Ms. Mercedes

• Jamie Somers is dissecting her donor, an elderly
  female identified as Donor No. 6872, with 3 of
  her team mates. You approach their table and ask
  them to present their dissection of the thorax
  and mediastinum. Student Doctor Somers begins
  and refers to her donor as Mercedes. None of
  her table mates seem concerned by this, and you
  ask Student Doctor Somers why she refers to her
  donor in this way. She answers, Thats the name
  that I gave her because she is going to enable me
  to own a bunch of Mercedes.

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Scenario No. 2 Eating at Dennys Feels So Good!

• As medical students are preparing in the lab for
  dissection, you overhear 5 - 6 of them speaking
  about their lunch at Dennys following the last
  lab period. Apparently, they went to the
  restaurant directly after lab and dressed in
  their scrubs. During lunch they discussed the
  course, their dissections/findings and their
  donors using the donors first names. The
  restaurant was bustling with the lunchtime crowd.

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Scenario No. 3 Pin Cushions, Probes and
Sandwiches

• During open lab time, you observe Dr. Ham, your
  fellow lab instructor and full-professor,
  lecturing to a group of 1st - year medical
  students around a cadaver donor. He has a ham
  sandwich in one hand, and a probe in the other.
  He is using a probe on the cadaver as he talks to
  the students, occasionally taking a bite out of
  his sandwich. The students seem unconcerned and
  are mesmerized by his knowledge of anatomy. From
  where you are standing, you also observe that at
  least a half-dozen instruments have been stuck
  into the intercostal muscles holding the
  instruments like a pin cushion. In fact, you
  observe Dr. Ham and a student both removing and
  placing instruments between the intercostal
  muscles. You are the new guy on the block, an
  assistant professor, 2 years on tenure track.

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Scenario No. 4 Clinical Grapefruits

• Student Doctor Sanders is a 26-year-old, married
  male, and is attending medical school on a U.S.
  Army scholarship. While dissecting in the lab,
  after regularly scheduled lab time, he finds two
  grapefruit-sized lymph nodes in his donor. He is
  excited by this finding and excises both nodes.
  Then, while dressed in his scrubs, lab coat and
  gloves, he carries the lymph nodes in his hands
  walking down the hallway (half the length of the
  building) and to your office to show you this
  exciting find. Your office is located inside of
  the outpatient clinic. Student Doctor Sanders
  opens the door to the clinic and proceeds through
  the waiting room to your office. Your door is
  open, and you are having lunch at your desk (an
  ice tea and Chicken Cesar Salad). He approaches
  your desk with excitement and shows you the nodes
  as he speaks of his fascinating discovery.

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Scenario No. 5 - Expecting the Unexpected

• Part 1 Your undergraduate lab assistant is
  helping prepare cadaver donors for the incoming
  medical class. He enters the lab to assist you
  and two other helpers in storing a female donor.
  The donor is naked and in supine position, having
  just been removed from her body bag. When he
  sees the donor he exclaims, My God, what did
  they do to him? They cut his thing off. Your
  assistant is Muslim, and a junior pre-med major.
  Your other helpers smile and laugh Discuss Part
  1 before proceeding to Part 2.

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Scenario No. 5 Expecting the Unexpected
- continued

• Part 2 Two weeks pass after this incident, and
  after you spoke to him about his reaction. You
  now understand from talking with him that because
  of the sect and strictness of his religion, he
  has never seen a naked woman not even a
  photograph in a magazine, a book or a painting.
  He has told you that his career goal is to
  become a surgeon and return to the Middle East to
  help his people.
• Now during lunch, he is asked in front of a group
  of approximately 15 people why he desires to help
  in the lab and dissect/prepare cadaver donors.
  You are the only person in the room that has
  knowledge of this prior incident. He replies, I
  want to know what it feels like to cut on a human
  body. This occurs approximately 30 days after
  the 9/11 attack in New York.

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Case No. 6 Interactions with the Donors, Fellow
Students and Faculty

• You are a faculty member, and have been observing
  the interactions of a 1st - year, female medical
  student in the gross anatomy lab. Frequently,
  she appears with a blank expression, seems
  disinterested and distant, and she will never
  look at anyone in the eye when they talk with
  her. Her interactions with members of her
  dissection team are poor. She stands beside her
  donor and does not dissect, frequently walking
  about the lab looking disoriented, but at the
  same time appearing to observe dissections
  completed by other students. Occasionally, she
  holds a probe or scissor and destroys tissues and
  structures when she is asked (by faculty) to
  dissect. Her classmates ignore this. When
  students are asked to contribute
  comments/thoughts to be included to letters to
  the donors families, she is the only student
  that does not contribute. Now your
  co-instructors notice that this same student
  leaves the lab whenever you enter/arrive and
  returns to the lab when you exit. Lab attendance
  is mandatory, and dissection is a required part
  of the course. Students must be able to work as
  a team to accomplish dissection goals, thus
  building skills and behaviors that they will use
  throughout their careers.