That's the Spirit

Lacey Brennan, MD, MBE '18 is set to question the letter and spirit of hierarchy in medicine
Lacey Brennen, MD, MBE, recieves her master's hood at graduation.
Photo: Lipofsky.com

by PHOEBE KNOX

Questions with no clear answers don’t deter Lacey Brennan, they inspire her. From an early age, she was drawn to explore the mysteries of science, earning a bachelor’s degree in pathophysiology and toxicology from the University of Western Ontario, and later a medical degree from the University of Calgary. It was during her training as a physician, that she developed an interest in the philosophical questions involved in clinical care.

“I discovered I was as interested in ethical dilemmas as in medicine,” said Brennan. In medical school, the single ethics course in the curriculum left her craving more information and a formal structure to help integrate the fundamental concepts of bioethics into her clinical practice.

Brennan faced her first bioethical dilemma on a pediatric gynecology rotation in medical school. Her ten-year-old patient, Patient A, was a severely developmentally disabled girl who was cognitively impaired, nonambulatory, and non-verbal. Patient A experienced vaginal bleeding severe enough to require multiple hospitalizations and blood transfusions. The patient’s parents had tried many different treatments: birth control, dietary changes, and other methods to stop the bleeding. They wanted something more to be done. Doctors gave Patient A an IUD to help slow the uterine bleeding, but it did not help. Patient A’s parents suggested a hysterectomy, but she could not consent to the surgery due to her young age and disabilities, so her doctors never seriously considered it as a treatment option. Patient A continued to be hospitalized repeatedly due to blood loss.

“We have such a complicated history when it comes to taking advantage of disabled people and performing surgeries on them,” said Brennan. “But the doctors were so focused on the rules around consent and sterilization, they may have missed the spirit of those rules: doing what is best for the patient.”

The absolute focus on patient autonomy, according to Brennan, is one of the shortcomings of modern medicine. “Sometimes we end up doing questionable things just to follow rules that were set up to be challenged in the first place. That is what bioethics is, challenging the rules for the benefit of the patient,” she said.

Her experience with Patient A, says Brennan, was the beginning of her passion for reproductive ethics, informed consent, and improving medical care for women with intellectual disabilities. “This patient’s parents wanted to do what was best for their daughter, but it was also my job to advocate for the patient,” said Brennan. “At the time, I didn’t have the skills to do that.”

Some Rules Are Meant to be Broken

Training physicians and clinicians is, in many ways like an apprenticeship, with more seasoned physicians sharing their knowledge, experience, and ensuring each patient recieves appropriate care. However, says Brennan, because medical culture emphasizes experience and authority students and residents at the bottom of the structure may not have an outlet to voice concerns, suggest alternatives treatments or ways of thinking. Though Brennan, who holds both an MD and MBE, believes that the hierarchical culture in medicine is there for an important reason, her experience with Patient A revealed this part of medical culture, which was particularly troubling to her.

“Someone needs to be in charge, but in the rush to make decisions and treat patients quickly, we can lose the ability to think more deeply,” said Brennan. “There is little time to breathe and completely understand what the patient wants, or if they really know the difference between multiple treatment options.”

Brennan’s experiences as a physician-in-training and clinician, inspired her to delve more deeply into ethics to better serve her patients. She was drawn to the master of bioethics program at the Center for Bioethics at Harvard Medical School because of the dual emphasis on clinical care and bioethical theory. She also saw respect for individual thinking and opportunities for close relationships with the faculty.

Working with professors who took a personal interest in her—faculty members knew her name, interests, and the activities she liked to do outside of the classroom—was new to Brennan. “The faculty really took an interest in getting to know me, which is not something that I was used to as a student,” she said. Brennan says she appreciated the networking opportunities they gave her, as well as career advice.

Brennan says she is most grateful for the personal relationships she made at the Center. In particular, “Friday's at 4,” a weekly gathering that brings bioethics faculty, students, and thought leaders together to discuss and share ideas about the field helped Brennen to be in touch with professors, mentors, and colleagues outside of the classroom, says Brennan.

A Personal Touch

A month before she received her master's degree, Brennan presented her year-end field experience project advised by Dr. Louise King, assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School. “The capstone project was very big and Lacey did an incredible job of pushing forward. She is incredibly kind and skilled at expressing her own opinions in a way that is not confrontational and that leaves room for disagreement, which is difficult to do,” said King, who also directs reproductive ethics at the Center.

Brennan holds a high level of maturity with that type of discourse, and that maturity shows through in her academics, professional work, and socially. “I am always available to be engaged with my student mentees, but Lacey really seized the opportunity," said King. "I was very happy to collaborate closely with her. We have been so productive as a team and I credit that to the strength of our communication.”

The capstone project King and Brennan collaborated on examined surgical outcomes in gynecology at Beth Israel Deaconess Medical Center. The project, “An Ethical Basis for Reforming Gynecologic Surgical Practice,” examined two factors: surgical volume and how the surgery was performed. The literature they examined suggested that outcomes were superior for high-volume surgeons and for laparoscopic versus abdominal hysterectomies.

Their research will likely be passed along to another master’s student in the coming year. Brennan and King have a paper in progress and three abstracts pending, which they will jointly present over the next year.

“The connection we built is something I value highly now and will for the rest of my career. I consider Dr. King a lifelong mentor and a dear friend,” said Brennan.

The Next Adventure

Brennan says she will miss her academic work at the Center, particularly the clinical ethics consortia, a montly meeting of Harvard-affiliated clinicians who examine difficult ethics cases.  “It is rare to be in a room of experts in medicine who have made significant contributions to a speicalized field that I'm interested in. For me, the consortia are a real strength of the program, said Brennan.

But her fellow graduates are planning to stay connected via a social media group they established as students. The group served as a hub for instant communication on coursework questions, getting together around Boston, and even about keeping each other informed about where there would be free food at events on the HMS campus.

In addition to their social connections, Brennan says that many of her classmates share research interests, and it is likely they will co-author papers in the future.

Brennan values the career advice that some of the more senior master's students give. She says, “Some students are practicing staff physicians and surgeons who are late into their careers. Having those peer relationships with people who already went through what I'm about to go through is great. Their advice is invaluable.”

The former water skiing instructor, turned doctor, will begin her residency in July at the Royal University Hospital, affiliated closely with the University of Saskatchewan. The native Canadian will rotate in the three hospitals affiliated with the university. Brennan is interested in continuing ethics research and wants to keep ethics a focus in all the work she does.

"Integrating a knowledge of bioethics into obstetrics and women’s health—into all medicine—can only bring about positive change," said Brennan. "I can't wait to bring the ideas I have explored in the master's program to my profession, my new job, and most of all to my patients."

by PHOEBE KNOX