Interesting article, and points to fundamental flaws in the US medical system, from medical school through residency and then in practice.
Free speech as a patient advocate is a critical part of good medical practice. A physician who does not communicate a complete and fearless truth to patients can never be acting completely in the patient's best interest.
However, this kind of communication is discouraged in physicians from the medical school onward.
- A critical part of the medical community (a "brotherhood" in the best and worst senses of the term) is an unwillingness to criticize another physician or their decisions. This is inculcated in medical students from their first clinical rotations, and the expectation continues to be present through one's career. It is only when a physician makes egregious errors in judgment that any public commentary or censure is permitted; even then, one will _never_ see public criticism coming straight out of the mouth of a physician's peers, only from those in regulatory roles.
- Medical students can only disclose to patients what their attending physician wishes them to say (I recall caring for a cancer patient whose resection margins were not clear, and his attending physician did not wish him aware of this critical information).
- Physicians employed by religious institutions - and even by our own government, with its abstinence-only policies - are often not permitted to discuss contraception, abortion and other "hot-button" items, even when doing so might be critical to the patient's interests. (That said, many physicians in these situations have private discussions with patients that range further than those charted - but some don't.)
Thus, our medical system is critically flawed in more ways than in those relating to access to health care; the medical "community" and its expectations of its members needs to be re-defined so that _parrhesia_ is not only tolerated, but encouraged, if we are ever to become healthy, and be able to fully work as advocates for our patients' health.
Competing interests
None
Foucault's
Charles Huffine, Charles Huffine, MD Private practice of psychiatry
22 April 2008
I read over the article: Foucault's "fearless speech" and the transformation and mentoring of medical students. I have to say that mostly I did not like it. I found it narrow and naive in its application of what could be a laudable quality in a mentor and in a student. But to bravely speak out, though admirable at times, is not a universal good. The concept of parrhesia, a term evidently borrowed by Foucault from a grossly different era came across to me as contrived and it seemed "forced" into relevance in this article. In effect the authors stated quite correctly that an ethical person will speak up against hypocracy that hides certain evils. They erred by implying by "speaking the "truth" good things will come. As one who lived through the 60's and its aftermath in the 70's and 80's I watched the grossly unskilled and politically naive members of my generation deteriorate in their failures into the most crass apologists for the compounding evils of our system, including the medical system. Those who stuck to their guns (often got guns actually) became marginalized bitter and ineffectual people fit for sitting on bar stools in pathetic taverns.
I would much rather have read an article that dealt with the actual ethical imperatives of todays health care system and its co-opting qualities. The one example of medical students standing up to forswear drug company money was charming but not news. (Have the authors heard of "no free lunch?" Go to their desk at the APA meeting first of May) It seemed a rather inadequate example that didn't really prove the point. I even have trouble with those brave souls who agitate for a single payer plan. I want to see leadership who can do the politically wise thing and make real change and deliver such a plan. Grandstanding doesn't cut it for getting results.
Perhaps I am missing some fine points in philosophy here, and maybe my comment is totally ineffectual. I guess maybe the article inspired me to practice parrhesia after all.
Competing interests
No competing interest
How can we always tell the “truth”?
Adamson Sinjani Muula, Department of Community Health, University of Malawi and Department of Epidemiology, University of North Carolina at Chapel Hill
26 April 2008
The paper by Papadimos and Murray [1] certainly adds to the ongoing debate as to how medical education can be changed or remodeled to respond effectively to modern day health care. They have presented perspectives that are held by many, both within the medical profession and without, but which, like almost all things, can be contested. My reservation, however, is that it appears to me that the authors lean towards absolutist principles. "Truth-telling" is an ideal that I believe we should all strive to; assuming we know the truth. In some instances, the situation is clear cut. Oftentimes however, I have found that I have doubts in diagnosis, treatment and follow-up care as I attend to patients. I do not know whether patients would benefit from being appraised of all the thoughts that I am considering as I take care of them. I know this sounds rather paternalistic and I can understand that patients deserve better than what they are given credit for.
There was concern that junior physicians are sometimes compelled to tell patients information that the attending thinks should be transmitted. An opposite but possibly disastrous situation could be an instance where the junior physician thinks that a patient has a life-threatening condition and goes ahead and informs the patient only to be told by the attending that things aren't so. I doubt if there would be many patients who would appreciate that as an attempt at "truth-telling." An equally compelling situation occurs when potentially lifesaving information - or information that if known would change the patient's outlook of her or his life - were withheld because the attending did not think that the patient needed to be told.
Perhaps the moral of my writing is: Tell the truth always if you know the truth. Many a times we think we have the truth when we have a semblance of truth. Secondly, take all the paternalism out of medical practice and let us see what we have. I do not think we will have a good product but others can disagree.
Reference
Papadimos TJ, Murray SJ: Foucault's "fearless speech" and the transformation and mentoring of medical students. Philos Ethics Humanit Med. 2008;3(1):12
US Medical Community Virulently Anti-Parrhesia
21 April 2008
Interesting article, and points to fundamental flaws in the US medical system, from medical school through residency and then in practice.
Free speech as a patient advocate is a critical part of good medical practice. A physician who does not communicate a complete and fearless truth to patients can never be acting completely in the patient's best interest.
However, this kind of communication is discouraged in physicians from the medical school onward.
- A critical part of the medical community (a "brotherhood" in the best and worst senses of the term) is an unwillingness to criticize another physician or their decisions. This is inculcated in medical students from their first clinical rotations, and the expectation continues to be present through one's career. It is only when a physician makes egregious errors in judgment that any public commentary or censure is permitted; even then, one will _never_ see public criticism coming straight out of the mouth of a physician's peers, only from those in regulatory roles.
- Medical students can only disclose to patients what their attending physician wishes them to say (I recall caring for a cancer patient whose resection margins were not clear, and his attending physician did not wish him aware of this critical information).
- Physicians employed by religious institutions - and even by our own government, with its abstinence-only policies - are often not permitted to discuss contraception, abortion and other "hot-button" items, even when doing so might be critical to the patient's interests. (That said, many physicians in these situations have private discussions with patients that range further than those charted - but some don't.)
Thus, our medical system is critically flawed in more ways than in those relating to access to health care; the medical "community" and its expectations of its members needs to be re-defined so that _parrhesia_ is not only tolerated, but encouraged, if we are ever to become healthy, and be able to fully work as advocates for our patients' health.
Competing interests
None
Foucault's
22 April 2008
I read over the article: Foucault's "fearless speech" and the transformation and mentoring of medical students. I have to say that mostly I did not like it. I found it narrow and naive in its application of what could be a laudable quality in a mentor and in a student. But to bravely speak out, though admirable at times, is not a universal good. The concept of parrhesia, a term evidently borrowed by Foucault from a grossly different era came across to me as contrived and it seemed "forced" into relevance in this article. In effect the authors stated quite correctly that an ethical person will speak up against hypocracy that hides certain evils. They erred by implying by "speaking the "truth" good things will come. As one who lived through the 60's and its aftermath in the 70's and 80's I watched the grossly unskilled and politically naive members of my generation deteriorate in their failures into the most crass apologists for the compounding evils of our system, including the medical system. Those who stuck to their guns (often got guns actually) became marginalized bitter and ineffectual people fit for sitting on bar stools in pathetic taverns.
I would much rather have read an article that dealt with the actual ethical imperatives of todays health care system and its co-opting qualities. The one example of medical students standing up to forswear drug company money was charming but not news. (Have the authors heard of "no free lunch?" Go to their desk at the APA meeting first of May) It seemed a rather inadequate example that didn't really prove the point. I even have trouble with those brave souls who agitate for a single payer plan. I want to see leadership who can do the politically wise thing and make real change and deliver such a plan. Grandstanding doesn't cut it for getting results.
Perhaps I am missing some fine points in philosophy here, and maybe my comment is totally ineffectual. I guess maybe the article inspired me to practice parrhesia after all.
Competing interests
No competing interest
How can we always tell the “truth”?
26 April 2008
The paper by Papadimos and Murray [1] certainly adds to the ongoing debate as to how medical education can be changed or remodeled to respond effectively to modern day health care. They have presented perspectives that are held by many, both within the medical profession and without, but which, like almost all things, can be contested. My reservation, however, is that it appears to me that the authors lean towards absolutist principles. "Truth-telling" is an ideal that I believe we should all strive to; assuming we know the truth. In some instances, the situation is clear cut. Oftentimes however, I have found that I have doubts in diagnosis, treatment and follow-up care as I attend to patients. I do not know whether patients would benefit from being appraised of all the thoughts that I am considering as I take care of them. I know this sounds rather paternalistic and I can understand that patients deserve better than what they are given credit for.
There was concern that junior physicians are sometimes compelled to tell patients information that the attending thinks should be transmitted. An opposite but possibly disastrous situation could be an instance where the junior physician thinks that a patient has a life-threatening condition and goes ahead and informs the patient only to be told by the attending that things aren't so. I doubt if there would be many patients who would appreciate that as an attempt at "truth-telling." An equally compelling situation occurs when potentially lifesaving information - or information that if known would change the patient's outlook of her or his life - were withheld because the attending did not think that the patient needed to be told.
Perhaps the moral of my writing is: Tell the truth always if you know the truth. Many a times we think we have the truth when we have a semblance of truth. Secondly, take all the paternalism out of medical practice and let us see what we have. I do not think we will have a good product but others can disagree.
Reference
Papadimos TJ, Murray SJ: Foucault's "fearless speech" and the transformation and mentoring of medical students. Philos Ethics Humanit Med. 2008;3(1):12
Competing interests
None declared