AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

2016 Conley Ethics Essay Contest for Medical Students

Instructions for Submission of Essays

Currently enrolled US medical students are eligible to submit essays (1,800 word maximum, excluding references) for consideration. Essays must be typed, double-spaced, and include the author’s name, address, telephone number, email address, medical school, and class on a cover sheet. (Do not place names on the essay pages; essays including authors’ names will not be reviewed.) Essays must be submitted as one Word file (whose filename is the author’s last name only) attached to an email (with the cover page as the first page of the document) by 5 pm central time on Monday, September 19, 2016 to Mr. Kelly Shaw at kelly.shaw@ama-assn.org. Authors of winning essay(s) must be willing to revise their essay(s) at the request of AMA Journal of Ethics editorial staff in order to have their work published in the journal. Please visit Conley Contest for more information.

Case: Responding to Pain in a So-Called "Difficult" Patient

John is a third-year medical student on his first day with a new service during his surgery rotation. On this particular morning, John is going on rounds with the chief resident, Dr. M, and an intern, Dr. S. As the team walks down the hall to the next room, John quickly glances over his rounding sheet for a 48-year-old man, Mr. C. Mr. C had a toe amputation three days ago and suffers from chronic pain and diabetes mellitus type I. He also has a history of using opioids, and his pain medications are being carefully controlled in the hospital.

Before they enter the room, the intern Dr. S softly says to Dr. M, “Hey, just as a heads up, I heard this one was feisty last night. Apparently, the attending came down hard on his request for more analgesia. The patient was not happy with the refusal and gave the nursing staff a lot of trouble.” Dr. M responded, “I heard about that. But he’s always been difficult; I saw him in clinic last month.” The team then enters the room.

As Dr. M begins questioning Mr. C, “How are you doing this morning?” Mr. C starts to moan in pain and offers short responses. Dr. M concludes his questions, “Now we’re going to take a look at the toe.” Mr. C begins shouting in pain as John and Dr. S remove the bandage. “Please stop!” he moans. Dr. M tries to soothe him, “I promise we’ll give you more for the pain; I’ll talk to your nurse when we leave. But right now, we need to get this off and take a look at the surgical site.” Mr. C retorts, “You’ve never taken care of my pain! I’ve been asking for help every day, but you don’t listen!”

When John rips open the packet of gauze to apply a new dressing, Mr. C angrily states, “I don’t want to be touched, poked, or prodded anymore.” John and Dr. S pause, bandage in hand, waiting for instructions from Dr. M.

Dr. M responds, “We’re trying to help you, but we need you to work with us.” Mr. C flatly refuses and shouts, “Nobody cares about my pain—you have no idea what I’ve been through.”

Dr. M silently stares for a few seconds at Mr. C who whimpers quietly. Dr. M turns his gaze from Mr. C to Dr. S, mutters “Let’s go—don’t worry about the bandage,” and walks out of the room. John wonders what to do with the bandage he’s holding and how to respond to Mr. C.

Essay Prompt

Is repairing a damaged patient-physician relationship an equally shared responsibility for a physician and patient or does one person bear more responsibility? Consider some of the following concepts and questions in your response: Which clinically or ethically relevant circumstances might change how we think about this responsibility? Which intentions, emotions, perceptions, or other moral psychological factors might be influencing Dr. M’s actions in this case? How should these factors be considered when evaluating Dr. M’s role in his relationship with Mr. C? Should John try to mediate between Mr. C and Dr. M even though he did not contribute to the tension between them?