Health care professionals’ and trainees’ conceptions of their responsibilities to patients can change over time for a number of reasons: evolving career goals, desires to serve different patient populations, and changing family obligations, for example. Some changes in conceptions of responsibility are healthy, but others express moral damage. Clinicians’ changes in their conceptions of what they are responsible for express moral damage when their responses to others express a meager, rather than robust, sense of what they owe others. At least (...) two important expressions of moral damage in the context of health care are these: callousness and divestiture. Callousness describes the poor condition of a clinician's capacity for moral perception; when her capacity to accurately appreciate features of moral relevance that configure others’ needs, vulnerabilities, and desert of care diminishes, such that she fails to respond with care to those for whom she has duties to care, she is callous. Callousness has been explored in detail elsewhere,1 and so the focus of this paper is divestiture. A clinician divests when the value of responding with care to others becomes less centrally and importantly constitutive of his personal and professional identity. Divestiture has important consequences for patients and health professions education, which I will explore here. (shrink)

Developing residents’ communication skills has been a goal of residency training programmes since the Accreditation Council for Graduate Medical Education codified it as a core competency. In this article, a case that features problematic communication between a generalist and specialist physician is drawn upon, and it is suggested how their communication might become open and effective through a practice of reason exchange. This is a practice of giving reasons, listening to reasons given by others, evaluating reasons and deciding which particulars (...) of situations constitute reasons to act and reasons how to act. Drawing on recent literature in teaching communication to radiology residents, it is proposed that practices of reason exchange are part of the skill set generally referred to as “negotiation skills” that should be cultivated in all residents. Particularly, in cases in which generalist and specialist physicians disagree about the reasons to do something, not do something or do something this way or that way, how well physicians are trained to practice reason exchange depends on whether they can communicate effectively and negotiate disagreement collegially. (shrink)