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Grand Rounds

Growing ethically

By Joseph F. O'Donnell, M.D.

In 1987, I assembled a group of Dartmouth medical students to meet with Dr. Robert Coles. Dr. Coles—a noted author and child psychiatrist, a professor of medicine and humanities at Harvard, and the recipient of a Pulitzer Prize for his work documenting the experiences of children involved in the integration of schools in the South—was in town to give Dartmouth College's fall convocation address.

He and I lingered after the meeting and talked about our dreams for and worries about medical education. We developed a friendship, a lasting bond, and he became my mentor. I grew convinced that his approach—combining participation in direct community service with the use of literature to provoke reflection—was a useful strategy for education, especially the education of medical students. Dr. Coles's important works—including The Call of Stories: Teaching and the Moral Imagination and The Call of Service: AWitness to Idealism—became my guidebooks, and his approach of "doing as a part of learning" became my mantra.

Over the years, I witnessed how Dr. Coles's stories could light a fire in students (and probably even more so in me). One story I'll never forget is one that he tells about his mentor, Erik Erikson, a psychoanalyst known for his theory on social development and for coining the phrase "identity crisis."When Erikson was teaching at Harvard, a student once asked him what he thought the value of a Harvard education should be. After a thoughtful pause, Erikson answered: "I hope this is a place where we can all grow ethically—where we become kinder and more thoughtful toward others." He paused again and added: "All the knowledge in the world is but a prelude to the moral challenges of our everyday life."

Glib: This same type of question could quite rightfully be asked regarding medical education. The glib answer might be "to produce the types of doctors that society wants and needs, ones who can attend to our health and advocate for better health care." But is this what we are, in fact, producing?

Idealism is an early casualty in medical education. Students often experience a jumble of mixed messages during their

This ethical growth happens wherever relationships are forged, values are fostered by example, and community develops.

training. Medical school has been described as a test-strewn, competitive, judgmental, and lonely educational environment that inhibits idealism and is full of instances of shame and humiliation. The standard breakdown of medical school into two preclinical and two clinical years has been facetiously called the "precynical" and "cynical" years.

My own view is that "it's different at Dartmouth." I believe we have some parts of the vision that Erikson espoused, that we strive to be a place where students can "grow ethically" and "become kinder and more thoughtful toward others." The main place this growth is happening is in the informal curriculum—all of the activities outside (plus a few inside) the classroom and clinic.

These are places where relationships are forged, values are fostered by example, and community develops. It happens in hockey games on Occom Pond, in art classes or yoga classes, in spontaneous karaoke nights. It happens in enrichment electives, where students learn about such diverse topics as anthropology, the life of a neurosurgeon, or how to really present medical cases on rounds. It happens in research labs, where students

toil side by side with faculty and see firsthand how much they love what they do.

Empowered: It happens at community service sites, where students shoulder real responsibilities, feel empowered by trying to make a difference, and learn about the social determinants of illness in a tangible, compelling way that makes their classroom lessons come alive. It happens in international settings, where students see our faculty perform plastic surgery on a patient with a severe burn, remove a cataract so someone can see again, or teach local caregivers how to use an ultrasound machine that will save many lives. It happens on springbreak trips to work in a clinic in New Orleans or with the Frontier Nursing Service in Appalachia. It happens in student government and other organizations where students try to, as the saying goes, "leave the campground better than they found it."

We have a wonderful, contemporary, ever-evolving, and rigorous formal curriculum of which we are very proud. All these informal curricular experiences complement the formal curriculum and help our students live their values and become the kind of physicians that society needs. There are so many opportunities outside the classroom. I think of these like the "thousand points of light"—organizations that influence society and thatmake a difference—which the elder George Bush celebrated during his presidency. The trouble with having so many lights here at DMS is that if students partake of too many, they may get burned. But if they choose a few, these lights might counteract that precynical-cynical trend, the same way that light therapy counteracts seasonal affective disorder.

Fabric: I consider myself the informal dean of this informal curriculum. One of my tasks in that role is to get positive stories about these experiences out there and weave them into the fabric of the institution, so students can learn from them as well as from one another. My hope is for Dartmouth Medical School to be a place where we all—faculty and administrators, as well as students—can grow ethically as we become ever kinder and more thoughtful toward others.

The Grand Rounds essay covers a topic of interest to the Dartmouth medical faculty. O'Donnell, a 1971 Dartmouth Medical School graduate, is a professor of medicine and of psychiatry, senior advising dean, and director of community programs at DMS.

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