"The Inner Conflicts – Interactions between physicians' emotional
dilemmas and professional conflicts
of interest" Marc Zaffran, M.D.
CREUM (Université de Montréal)St Mary’s Grand Rounds, Dec.
14, 2011
Whence came this guy ? Family Physician, from 1982 to 2008. Trained in France, practiced medicine in French countryside and public hospital settings (Women’s health center)
Professional Writer : Fiction, non fiction (healthcare, patient-doctor relationship), cultural criticism
Guest researcher, Centre de Recherches en Ethique de l’U de M (CREUM) 2009 2012 – « Transmission of Ethical Values in Medical Training », « Conscientious objection in healthcare » and « Representation of medical dilemmas in television Drama »
Résident permanent since Dec 7, 2011 (Thank you, Canada !)
Latest publication : « Profession Médecin de famille », Presses de l’Université de Montréal, 2011
Conflicts of interests
Nonewhich would be relevant to this
presentationand that I’m aware of.
But I intend to show it’s not that simple…
Previously…. Doctors are the targets of moral
manipulation
« We should always ask ourselves :
Which ones of my buttons are they
trying to push ? »
Every man is mortalSocrates is a man Therefore, Socrates is mortal
Every human being is conflicted A physician is a human beingTherefore, a physician is conflicted
Conflict : con·flict (n.)
1. A state of open, often prolonged fighting; a battle or war.
2. A state of disharmony between incompatible or antithetical persons, ideas, or interests; a clash.
3. Psychology A psychic struggle, often unconscious, resulting from the opposition or simultaneous functioning of mutually exclusive impulses, desires, or tendencies.
4. Opposition between characters or forces in a work of drama or fiction, especially opposition that motivates or shapes the action of the plot.(From: The Free Dictionary - http://www.thefreedictionary.com/)
1° impulses = innate instinctive Mechanisms, acquired through evolution and shared by all great apes – including humans. They include (even for physicians) :
-Seeking food and shelter for survival-Competing for resources-Mating & Reproduction (sex drive)-Fitness display, conspicuous consumption (peacock’s tail), competing for sexual selection -Care for offspring -Kin support and exclusion of non kin/free riders-Social skills : cooperation/conformity and altruism
Intensity/importance are different for each individual
Workman, L. Evolutionary psychology : an introduction Cambridge University Press, 2008
2° Desires are conscious (and rationalized) Expressions Of impulses. As far as Doctors are concerned, they Include :
In the interest of self : - Acquire skills and knowledge/understand illness -Become a respected professional (leadership, status)-Marry a nice person to have sex and raise children with -Live long and prosper -Extend one’s own influence
In the interest of kin :-Care for/protect parents, spouse, children, siblings-Be a source of pride (extended status)-Make money (acquire security, resources)
In the interest of non-kin (altruistic) : -Contribute to common well-being/social life -Contribute to social order (reward and sometimes punish/control) -Increase common knowledge, contribute to medical progress-« Make a difference » (social/global involvement in care)
Conflicts arise when IMPULSES CLASH WITH PROFESSIONAL STANDARDS/OBLIGATIONS
- Attraction to/dating patient (sexual selection)
- Scientific fraud (status or resource-seeking)
- Nepotism (kin support)
- Racial or ethnic or social bias (exclusion of non-kin)
- Conformity to debatable peer views (against personal or social moral standards and public interest)
Can you think of other examples ?
Conflicts can also come from unseen/untold sources :
- Psychological traits (Five Factors Model/OCEAN)
- Personal unpleasant experience and/or trauma (illness, handicap, being bullied, being rejected, abused, etc.)
-Influence of teachers and mentors (I see and I do it the way I was taught.)
-Family history (ethnicity, war, persecution, poverty)
-Political tendencies (liberal vs conservative)
-Religious beliefs (euthanasia, abortion)
-Pressure from spouse and/or family and/or friends
A few inner conflicts illustrated by imaginary characters.
Physician # 1I am a 45-year old ob-gyn.
I have specialized in cervical cancer screening and diagnosis and I am a lead researcher in the field.
Based on my expertise, the Province’s ministry of health has asked me to be the spokesperson for its HPV immunization campaign.
I have received money and retribution (directly or indirectly). from the company which markets the vaccine.
How many inner conflicts might be at work here (not including the blatant conflict of interests ?)
I am another 45-year old ob-gyn, working in an inner-city hospital.
Cervical cancer screening is one of my many daily activities which include : Diagnosing and treating common gynaecological problems, pregnancy follow-up, delivering babies and some surgical practice.
A friend of mine has asked me to come to a PTA meeting andbive my professional opinion on HPV immunization of 9 to 12 year old girls in order for parents to make an informed cecision.
I have not received any money and/or retribution (directly or indirectly) from the company which markets the vaccine.
How many inner conflicts might be at work here ?
Physician # 2
(Physician # 2, continued) ‘I’m slightly obsessive and an overachiever.’
‘Several of my patients have been diagnosed with cervical cancer. Some have died, including one I had a strong connection with.’
‘My mother was diagnosed with cervical cancer when I was in Med School.’
‘I haven’t had a Pap test for some time (can’t find the time to get an appointment and don’t really feel quite comfortable stripping down in front of a colleague)’
‘I have two daughters, one of them is sixteen and since the divorce she stays a lot at her father’s where she is not properly monitored because he’s an unreliable immature sonof (expletive deleted)…’
Now, How many sources of conflict/bias are there in this picture ?
An assignment (optional)
Think of one (just one) inner conflict that you feel might have impaired your judgment, recently or in the past.
Write it down as a single sentence.
Think of and write down another one every day, until you run dry. Don’t read the earlier entries.
In one month, count your entries.
Can I really avoid being biased ?
If I can’t avoid being biased, what can I do to avoid being (unknowingly) manipulated through my (undisclosed/secret/untold) biases ?
Two questions
And remember, regardless of gender, there are always…
…Two sides to our inner physician….
