Gap Year Learning in the Culture of Medicine

MCL Profile

By Lorraine Pereira

"The Host is inviting you to join Breakout Room: 3.” I noticed my hands had tensed up as I moused over to click “Join” and start my next Multiple Mini Interview. Medical schools use the MMI to interview applicants; each mini-interview lasts 6-8 minutes, and in each short segment a new interviewer asks a question or presents a puzzle. In Breakout Room 3, the interviewer presented me with a scenario that involved navigating one of the most challenging ethical dilemmas in medicine. The scenario began, “Speak with the adult daughter of your patient – who is dying of a terminal illness and in a coma – about her mother’s treatment options.”

As I read on, the tension in my hands dissipated. I’d spent hours reading about bioethics topics in medicine and pestering my friends to quiz me on them. That helped. But what really relaxed me was my experience navigating the real world of end-of-life care in my work as a clinical research coordinator at UCSF.

At UCSF, I joined the team of Liz Dzeng, an MD hospitalist and PhD sociologist whose work examines the norms, policies, and practices – or “cultures” – that shape end-of-life care. Dr. Dzeng is particularly focused on addressing the prevalence of non-beneficial life-sustaining treatments near the end of life for older adults with dementia.

In the United States, it is very common for older adults nearing the end of their lives to receive treatments that extend life without improving its quality. The problem has been well-recognized for decades, but our healthcare system has struggled to grapple with it. Dr. Dzeng has approached this as a challenge in the culture of medicine. Discerning culture through those who experience it, she has spent the last few years conducting in-depth, ethnographic interviews with clinicians who provide end-of-life care to dementia patients. My role on the team has been to qualitatively analyze these interviews and to work with the team that is puzzling over what we could do to make non-beneficial care a thing of the past.

Non-beneficial care is an unintended consequence of the incredible life-saving technologies that, thankfully, can be found in any hospital or ambulance. Emergency medical services and intensive care units have an astounding ability to keep people alive – ventilators to assist with breathing, continuous dialysis to remove toxic substances from the blood and maintain blood volume, and tubes to feed and hydrate those who can no longer eat. These life-sustaining treatments showcase an important distinction between being alive and living: though they keep older adults alive inside the hospital, they do not restore these patients’ abilities to do what brings them joy and purpose both within and beyond hospital walls.

As was the case for the patient described in the MMI scenario, many dementia patients lack the decisional capacity to engage in conversations about their care at the end of life. We can’t ask patients how much or what kinds of care they want. Families typically bear the responsibility for deciding which of these treatments are appropriate for their loved one. 

In Dr. Dzeng’s interviews, clinicians recount the challenge of caring not only for patients who are unable to share their treatment preferences but also for their families. ED and ICU clinicians have the clinical knowledge to know when care is non-beneficial, but many do not feel empowered to engage families – the surrogate decision-makers -- in conversations around withdrawing care. For family members who are placed in this position, ending their loved one’s suffering is essentially synonymous with ending their life, making it emotionally difficult to withdraw even care that bears no benefit. This places clinicians in the difficult situations of either having to continue providing care that they don’t believe is beneficial or having a series of conversations with family members about withdrawing or withholding care. This is the type of situation I was asked to reflect upon in Breakout Room 3.

In their interviews, clinicians also discussed the emotional burden of providing, withdrawing, or withholding non-beneficial life-sustaining treatments for irreversible conditions. All three pathways create ethical conflicts between clinicians’ obligations to save lives and do no harm. Issues of moral distress and burnout frequently came up in the interviews.

Because I am interested in pursuing palliative and end-of-life care, I foresee these challenges as some of the greatest I will experience in my medical career. I hope that being in academic medicine will allow me protected time to reflect on the challenges I experience as a clinician and use them to inform research questions in the pursuit of bettering the medical system. I believe that the ability to reflect on and transform my world as a physician will allow me to combat the feelings of helplessness that are at the root of moral distress and burnout, and help me be a better physician.

Dr. Dzeng’s semi-structured interview style lends itself to clinicians sharing vivid patient stories, their critiques and praises of the structuring of healthcare, their distress around non-beneficial, life-sustaining care, the ways that different clinicians’ skillsets intertwine, and the ways that all of these intermesh to create the clinical world. Indeed, I have gained an understanding of the complex intricacies of practicing medicine in a way only an ethnography can impart.

My deepened understanding of medicine – in its best and worst lights alike – helped me relax during that MMI. I thought about those interviews with palliative care clinicians as I discussed how I would navigate Breakout Room 3. A few weeks after the interview, I received my first medical school acceptance. I’m grateful that my work with Dr. Dzeng helped me during that interview, but I’m even more grateful for how the experience working with her has prepared me for what is to come as I embark on a career in medicine. I am entering the field with more realistic expectations about the challenges physicians encounter in daily clinical practice, and I will enter medical school with a deeper understanding of my own values as they relate to the profession.