David J Doukas

M.D.
William Ray Moore Professor of Family Medicine and Medical Humanism, Director, Division of Medical Humanism and Ethics

Publications

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    ABSTRACT: Effectively developing professionalism requires a programmatic view on how medical ethics and humanities should be incorporated into an educational continuum that begins in premedical studies, stretches across medical school and residency, and is sustained throughout one's practice. The Project to Rebalance and Integrate Medical Education National Conference on Medical Ethics and Humanities in Medical Education (May 2012) invited representatives from the three major medical education and accreditation organizations to engage with an expert panel of nationally known medical educators in ethics, history, literature, and the visual arts. This article, based on the views of these representatives and their respondents, offers a future-tense account of how professionalism can be incorporated into medical education.The themes that are emphasized herein include the need to respond to four issues. The first theme highlights how ethics and humanities can provide a response to the dissonance that occurs in current health care delivery. The second theme focuses on how to facilitate preprofessional readiness for applicants through reform of the medical school admission process. The third theme emphasizes the importance of integrating ethics and humanities into the medical school administrative structure. The fourth theme underscores how outcomes-based assessment should reflect developmental milestones for professional attributes and conduct. The participants emphasized that ethics and humanities-based knowledge, skills, and conduct that promote professionalism should be taught with accountability, flexibility, and the premise that all these traits are essential to the formation of a modern professional physician.
    Academic medicine: journal of the Association of American Medical Colleges 12/2014; DOI:10.1097/ACM.0000000000000616 · 2.34 Impact Factor
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    Howard Brody, David Doukas
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    ABSTRACT: ContextDespite considerable advances in the incorporation of professionalism into the formal curriculum, medical students and residents are too often presented with a mechanical, unreflective version of the topic that fails to convey deeper ethical and humanistic aspirations. Some misunderstandings of professionalism are exacerbated by commonly used assessment tools that focus only on superficially observable behaviour and not on moral values and attitudes.Methods Following a selective literature review, we engaged in philosophical ethical analysis to identify the key precepts associated with professionalism that could best guide the development of an appropriately reflective curriculum.ResultsThe key precepts needed for a robust presentation of professionalism can be grouped under two headings: ‘Professionalism as a trust-generating promise’ (representing commitment to patients’ interests, more than a mere business, a social contract, a public and collective promise, and hard work), and ‘Professionalism as application of virtue to practice’ (based on virtue, deeper attitudes rather than mere behaviour, and requiring of practical wisdom).Conclusions These key precepts help students to avoid many common, unreflective misunderstandings of professionalism, and guide faculty staff and students jointly to address the deeper issues required for successful professional identity formation.
    Medical Education 10/2014; 48(10). DOI:10.1111/medu.12520 · 3.62 Impact Factor
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    David J Doukas, John Hardwig
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    David J Doukas, John Hardwig
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    ABSTRACT: Respect for persons protects patients regarding their own healthcare decisions. Patient informed choice for altruism (PICA) is a proposed means for a fully autonomous patient with decisionmaking capacity to limit his or her own treatment for altruistic reasons. An altruistic decision could bond the patient with others at the end of life. We contend that PICA can also be an advance directive option. The proxy, family, and physicians must be reminded that a patient's altruistic treatment refusal should be respected.
    Cambridge Quarterly of Healthcare Ethics 07/2014; 23(4):1-6. DOI:10.1017/S0963180114000073 · 0.58 Impact Factor
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    ABSTRACT: Background/Objective:Apolipoprotein E (APOE) genetic testing is used to assist in the diagnosis of Alzheimer's Disease (AD). Whenever genetic testing is performed, an informed consent process should occur.Methods:In this case, a patient with memory loss presented to the neurologist. The neurologist ordered a lumbar puncture (LP). The LP was performed by a neuroradiologist who also ordered APOE genetic testing. The patient received no genetic counseling, nor was an informed consent document offered.Results:After the testing was completed, the neurologist faced an ethical dilemma. His solution was to offer the genetic testing to the patient in order to have an informed consent process. It was clear that the patient and her adult children did not want the genetic testing and that they would have been burdened with the results. The neurologist opted not to disclose the results.Conclusion:Genetic counseling and a signed informed consent document are required prior to any genetic testing. In this case, neither occurred and it led to an ethical dilemma that was ultimately resolved by the neurologist. As the population ages and AD becomes more prevalent, there is a need to expand the workforce of genetic counselors and educate physicians who commonly treat AD about genetic testing.
    American Journal of Alzheimer s Disease and Other Dementias 03/2014; 29(7). DOI:10.1177/1533317514525829 · 1.52 Impact Factor
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    ABSTRACT: To measure trainees' exposure to negative and positive role-modeling for responding to medical errors and to examine the association between that exposure and trainees' attitudes and behaviors regarding error disclosure. Between May 2011 and June 2012, 435 residents at two large academic medical centers and 1,187 medical students from seven U.S. medical schools received anonymous, electronic questionnaires. The questionnaire asked respondents about (1) experiences with errors, (2) training for responding to errors, (3) behaviors related to error disclosure, (4) exposure to role-modeling for responding to errors, and (5) attitudes regarding disclosure. Using multivariate regression, the authors analyzed whether frequency of exposure to negative and positive role-modeling independently predicted two primary outcomes: (1) attitudes regarding disclosure and (2) nontransparent behavior in response to a harmful error. The response rate was 55% (884/1,622). Training on how to respond to errors had the largest independent, positive effect on attitudes (standardized effect estimate, 0.32, P < .001); negative role-modeling had the largest independent, negative effect (standardized effect estimate, -0.26, P < .001). Positive role-modeling had a positive effect on attitudes (standardized effect estimate, 0.26, P < .001). Exposure to negative role-modeling was independently associated with an increased likelihood of trainees' nontransparent behavior in response to an error (OR 1.37, 95% CI 1.15-1.64; P < .001). Exposure to role-modeling predicts trainees' attitudes and behavior regarding the disclosure of harmful errors. Negative role models may be a significant impediment to disclosure among trainees.
    Academic medicine: journal of the Association of American Medical Colleges 01/2014; DOI:10.1097/ACM.0000000000000156 · 2.34 Impact Factor
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    David J Doukas
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    ABSTRACT: Given recent emphasis on professionalism training in medical schools by accrediting organizations, medical ethics and humanities educators need to develop a comprehensive understanding of this emphasis. To achieve this, the Project to Rebalance and Integrate Medical Education (PRIME) II Workshop (May 2011) enlisted representatives of the three major accreditation organizations to join with a national expert panel of medical educators in ethics, history, literature, and the visual arts. PRIME II faculty engaged in a dialogue on the future of professionalism in medical education. The authors present three overarching themes that resulted from the PRIME II discussions: transformation, question everything, and unity of vision and purpose.The first theme highlights that education toward professionalism requires transformational change, whereby medical ethics and humanities educators would make explicit the centrality of professionalism to the formation of physicians. The second theme emphasizes that the flourishing of professionalism must be based on first addressing the dysfunctional aspects of the current system of health care delivery and financing that undermine the goals of medical education. The third theme focuses on how ethics and humanities educators must have unity of vision and purpose in order to collaborate and identify how their disciplines advance professionalism. These themes should help shape discussions of the future of medical ethics and humanities teaching.The authors argue that improvement of the ethics and humanities-based knowledge, skills, and conduct that fosters professionalism should enhance patient care and be evaluated for its distinctive contributions to educational processes aimed at producing this outcome.
    Academic medicine: journal of the Association of American Medical Colleges 09/2013; 88(11). DOI:10.1097/ACM.0b013e3182a7f8e3 · 2.34 Impact Factor
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    David J Doukas
    Mayo Clinic Proceedings 09/2013; 88(9):1035-1037. DOI:10.1016/j.mayocp.2013.07.006 · 5.81 Impact Factor
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    Joseph J Fins, Barbara Pohl, David J Doukas
    Cambridge Quarterly of Healthcare Ethics 08/2013; DOI:10.1017/S0963180113000200 · 0.85 Impact Factor
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    Gregory W Ruhnke, David J Doukas
    Mayo Clinic Proceedings 05/2013; 88(5):438-41. DOI:10.1016/j.mayocp.2013.02.003 · 5.79 Impact Factor
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    David J Doukas
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    Academic medicine: journal of the Association of American Medical Colleges 09/2012; 87(9):1153. DOI:10.1097/ACM.0b013e3182637e3b · 2.34 Impact Factor
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    ABSTRACT: Medical education accreditation organizations require medical ethics and humanities education to develop professionalism in medical learners, yet there has never been a comprehensive critical appraisal of medical education in ethics and humanities. The Project to Rebalance and Integrate Medical Education (PRIME) I Workshop, convened in May 2010, undertook the first critical appraisal of the definitions, goals, and objectives of medical ethics and humanities teaching. The authors describe assembling a national expert panel of educators representing the disciplines of ethics, history, literature, and the visual arts. This panel was tasked with describing the major pedagogical goals of art, ethics, history, and literature in medical education, how these disciplines should be integrated with one another in medical education, and how they could be best integrated into undergraduate and graduate medical education. The authors present the recommendations resulting from the PRIME I discussion, centered on three main themes. The major goal of medical education in ethics and humanities is to promote humanistic skills and professional conduct in physicians. Patient-centered skills enable learners to become medical professionals, whereas critical thinking skills assist learners to critically appraise the concept and implementation of medical professionalism. Implementation of a comprehensive medical ethics and humanities curriculum in medical school and residency requires clear direction and academic support and should be based on clear goals and objectives that can be reliably assessed. The PRIME expert panel concurred that medical ethics and humanities education is essential for professional development in medicine.
    Academic medicine: journal of the Association of American Medical Colleges 03/2012; 87(3):334-41. DOI:10.1097/ACM.0b013e318244728c · 2.34 Impact Factor
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    Article: The Abyss
    David J Doukas
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    The American journal of medicine 10/2010; 123(12):1155-6. DOI:10.1016/j.amjmed.2010.05.027 · 5.30 Impact Factor
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    ABSTRACT: Abraham Flexner was commissioned by the Carnegie Foundation for the Advancement of Teaching to conduct the 1910 survey of all U.S. and Canadian medical schools because medical education was perceived to lack rigor and strong learning environments. Existing proprietary schools were shown to have inadequate student scholarship and substandard faculty and teaching venues. Flexner's efforts and those of the American Medical Association resulted in scores of inadequate medical schools being closed and the curricula of the survivors being radically changed. Flexner presumed that medical students would already be schooled in the humanities in college. He viewed the humanities as essential to physician development but did not explicitly incorporate this position into his 1910 report, although he emphasized this point in later writings. Medical ethics and humanities education since 1970 has sought integration with the sciences in medical school. Most programs, however, are not well integrated with the scientific/clinical curriculum, comprehensive across four years of training, or cohesive with nationally formulated goals and objectives. The authors propose a reformation of medical humanities teaching in medical schools inspired by Flexner's writings on premedical education in the context of contemporary educational requirements. College and university education in the humanities is committed to a broad education, consistent with long-standing tenets of liberal arts education. As a consequence, premedical students do not study clinically oriented science or humanities. The medical school curriculum already provides teaching of clinically relevant sciences. The proposed four-year curriculum should likewise provide clinically relevant humanities teaching to train medical students and residents comprehensively in humane, professional patient care.
    Academic medicine: journal of the Association of American Medical Colleges 02/2010; 85(2):318-23. DOI:10.1097/ACM.0b013e3181c85932 · 2.34 Impact Factor
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    ABSTRACT: The traditional view of standard hospice (SH) care is that once begun, the doorway toward curative and other forms of nonpalliative treatment is irrevocably locked. We will argue that such a traditional view needs to be reassessed in light of new arguments and data regarding access to these avenues of treatment. We will argue that patients should be supported in their transition from SH to open access hospice (OAH). Open access hospice should be available to all patients because of ethical arguments, patient satisfaction arguments, and costs of care arguments. More randomized controlled research trials need to be performed to study the impact of OAH versus SH. This research should focus on patient satisfaction, cost, and survival.
    The American journal of hospice & palliative care 02/2010; 27(1):86-90. DOI:10.1177/1049909109338388
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    David J Doukas
    The American Journal of Bioethics 05/2009; 9(4):19-21. DOI:10.1080/15265160902718873 · 4.00 Impact Factor
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    David J. Doukas
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    ABSTRACT: Recent accreditation standards have changed for all US and Canadian medical schools and residency programs. Newly mandated knowledge, skills, behavior, and attitudes required of the learner to become a medical professional are permeated with professionalism and associated curricular themes. The art of medicine now emphasizes humanistic skills, ethical precepts, and principle-based values. To this end, this chapter calls for enhanced learner collaboration with educators, as well as a required longitudinal ethics curriculum and medical apprenticeship for all phases of medical education. These efforts can thereby result in greater moral reflection on professionalism and its successful assimilation into clinical practice.
    10/2006; 10:185-209. DOI:10.1016/S1479-3709(06)10009-6

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