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Wicaksono RB, Ferine M, Lestari DWD, Hidayah AN, Muhaimin A. Experience of Indonesian medical students of ethical issues during their clinical clerkship in a rural setting. J Med Ethics Hist Med 2022; 14:6. [PMID: 35035794 PMCID: PMC8696554 DOI: 10.18502/jmehm.v14i6.6750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 06/01/2021] [Indexed: 11/29/2022] Open
Abstract
Although ethics is an essential part of medical education, little attention has been paid to ethics education during the clerkship phase, where medical students observe how physicians make decisions regarding various ethical problems. Specific nuances and cultural contexts such as working in a rural setting can determine ethical issues raised. This phenomenology study aimed to explore ethical issues experienced by Indonesian students during clinical clerkship in a rural setting. In-depth interviews were used to explore students’ experiences. Participants were ten students, selected on gender and clerkship year variations. Data saturation was reached after eight interviews, followed by two additional interviews. Thematic analysis was used in this study, and trustworthiness was ensured through data and investigator triangulation, member checking, and audit trail. Three main themes found in this study were limited facilities and resources, healthcare financing and consent issues, as well as unprofessional behavior of healthcare providers. Many ethical issues related to substandard care were associated to limited resources and complexities within the healthcare system in the rural setting. Early exposure to recurrent ethical problems in healthcare can help students prepare for their future career as a physician in a rural setting.
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Affiliation(s)
- Raditya Bagas Wicaksono
- Lecturer, Department of Bioethics and Humanities, Faculty of Medicine, Universitas Jenderal Soedirman, Purwokerto, Indonesia
| | - Miko Ferine
- Lecturer, Department of Bioethics and Humanities, Faculty of Medicine, Universitas Jenderal Soedirman, Purwokerto, Indonesia
| | - Diyah Woro Dwi Lestari
- Lecturer, Department of Bioethics and Humanities, Faculty of Medicine, Universitas Jenderal Soedirman, Purwokerto, Indonesia
| | - Arfi Nurul Hidayah
- Lecturer, Department of Bioethics and Humanities, Faculty of Medicine, Universitas Jenderal Soedirman, Purwokerto, Indonesia
| | - Amalia Muhaimin
- Lecturer, Department of Bioethics and Humanities, Faculty of Medicine, Universitas Jenderal Soedirman, Purwokerto, Indonesia; Researcher, Department of Ethics, Law, and Humanities, Amsterdam University Medical Centres, University of Amsterdam, The Netherlands
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deSante-Bertkau J, Herbst LA. Ethics of Pediatric and Young Adult Medical Decision-Making: Case-Based Discussions Exploring Consent, Capacity, and Surrogate Decision-Making. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2021; 17:11094. [PMID: 33598537 PMCID: PMC7880251 DOI: 10.15766/mep_2374-8265.11094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 11/02/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Most medical decisions in pediatrics involve surrogate decision-makers. Because of this, pediatricians are even more likely to encounter ethical conflicts and dilemmas surrounding medical decision-making. Pediatricians continue to report a lack of preparedness to manage situations when conflicts and dilemmas arise, suggesting a gap in education. In response to this gap, we developed a module on the ethics of medical decision-making focused on pediatrics. METHODS The Ethics of Pediatric and Young Adult Medical Decision-Making module included three case-based, small-group sessions on decision-making capacity and advance directives, parental decision-making, and informed consent and adolescent assent. Session materials were developed based on expert opinion and previously published content. Sessions were developed for pediatric residents; however, medical students rotating on pediatrics also participated in most sessions. Trainees completed pre- and postsession assessments of comfort and understanding. RESULTS An average of 19 learners completed each session. Understanding of ethical principles increased after each session. Seventy-nine percent of trainees reported increased understanding of ethical principles related to decision-making capacity, and 88% reported increased understanding of standards of surrogate decision-making. Following the session on obtaining consent and assent, 71% of trainees reported comfort obtaining consent compared to 57% reporting comfort obtaining assent. DISCUSSION This module successfully increased trainee comfort with many ethical issues related to pediatric medical decision-making. Areas where trainee comfort was still low postsession-specifically, obtaining consent or assent-are content areas where actual practice of these psychomotor skills is likely necessary.
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Affiliation(s)
- Jennifer deSante-Bertkau
- Assistant Professor, Department of Pediatrics, Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine
| | - Lori A. Herbst
- Assistant Professor, Department of Pediatrics, Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine; Volunteer Assistant Professor, Department of Family & Community Medicine, Palliative Care Team, University of Cincinnati Medical Center and University of Cincinnati College of Medicine
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Tillman S. Consent in Pelvic Care. J Midwifery Womens Health 2020; 65:749-758. [PMID: 33283429 DOI: 10.1111/jmwh.13189] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 09/28/2020] [Accepted: 09/28/2020] [Indexed: 11/26/2022]
Abstract
Consent is a clear dialogue between individuals to engage in a specific activity. Expectations for consent to intimate examinations in health care should be equal to, if not exceed, expectations for intimate interactions in society. In reality, current definitions of consent in health care vary. These blurry definitions lead to individualized interpretation, incomplete fulfillment, and opportunities for misunderstanding by both patient and health care provider. If a patient does not believe they have consented to an examination or procedure, they are likely to rightfully identify with one of consent's antonyms, assault. Within the field of gynecology, a history of misogyny, racism, and classism illuminates abhorrent contexts of assault disguised as care. Similar practices persist in the modern application of pelvic care, ranging from overt sexual assault to coercion disguised as guidance. Health care providers and students who seek to improve consent practices can look to evidence-based frameworks such as trauma-informed care and shared decision making, both of which are embraced widely by professional organizations. These approaches often take precedence during the first pelvic examination; care for people who are lesbian, bisexual, queer, transgender, or nonbinary; and care for anyone with a known history of sexual assault; they can be easily extrapolated to all intimate examinations. Beyond obtaining consent for the examination itself, health care providers must also intentionally obtain consent to include students in care and openly discuss new universal recommendations for chaperone presence. Scripting for common procedures, such as bimanual examinations for pelvic care or cervical examinations in labor, allows health care providers to practice trauma-informed language, include evidence-based guidance, and avoid unintentional bias. Contemporary providers of intimate pelvic care must work to understand and strengthen the definition of consent and ensure its realization in practice.
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Hawking M, Kim J, Jih M, Hu C, Yoon JD. "Can virtue be taught?": a content analysis of medical students' opinions of the professional and ethical challenges to their professional identity formation. BMC MEDICAL EDUCATION 2020; 20:380. [PMID: 33092593 PMCID: PMC7584068 DOI: 10.1186/s12909-020-02313-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/16/2020] [Indexed: 05/21/2023]
Abstract
BACKGROUND Efforts have begun to characterize the ethical and professional issues encountered by medical students in their clinical years. By applying previously identified taxonomies to a national sample of medical students, this study seeks to develop generalizable insights that can inform professional identity formation across various clerkships and medical institutions. METHODS In a national survey of medical students, participants answered an open-ended survey item that asked them to describe a clinical experience involving an ethical or professional issue. We conducted a content analysis with these responses using the Kaldjian taxonomy of ethical and professionalism themes in medical education through an iterative, consensus-building process. Noting the emerging virtues-based approach to ethics and professionalism, we also reexamined the data using a taxonomy of virtues. RESULTS The response rate to this survey item was 144 out of 499 eligible respondents (28.9%). All 144 responses were successfully coded under one or more themes in the original taxonomy of ethical and professional issues, resulting in a total of 173 coded responses. Professional duties was the most frequently coded theme (29.2%), followed by Communication (26.4%), Quality of care (18.8%), Student-specific issues of moral distress (16.7%), Decisions regarding treatment (16.0%), and Justice (13.2%). In the virtues taxonomy, 180 total responses were coded from the 144 original responses, and the most frequent virtue coded was Wisdom (23.6%), followed by Respectfulness (20.1%) and Compassion or Empathy (13.9%). CONCLUSIONS Originally developed from students' clinical experiences in one institution, the Kaldjian taxonomy appears to serve as a useful analytical framework for categorizing a variety of clinical experiences faced by a national sample of medical students. This study also supports the development of virtue-based programs that focus on cultivating the virtue of wisdom in the practice of medicine.
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Affiliation(s)
- Michael Hawking
- Hematology and Oncology, The University of Chicago, Chicago, IL, USA
| | - Jenny Kim
- Department of Biological Sciences, The University of Chicago, Chicago, IL, USA
| | - Melody Jih
- Department of Economics, The University of Chicago, Chicago, IL, USA
| | - Chelsea Hu
- Department of Economics and the Department of Political Science, The University of Chicago, Chicago, IL, USA
| | - John D Yoon
- MacLean Center for Clinical Medical Ethics, Department of Medicine, The University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA.
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Han JJ, Luc JGY, Pak E. Ethical Dilemmas Associated With the COVID-19 Pandemic: Dealing With the Unknowns and Unanswerables During Training. J Am Coll Cardiol 2020; 76:1266-1269. [PMID: 32883420 PMCID: PMC7458529 DOI: 10.1016/j.jacc.2020.07.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Jason J Han
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jessica G Y Luc
- Division of Cardiovascular Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Esther Pak
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Chervenak FA, McCullough LB, Hale RW. Guild interests: an insidious threat to professionalism in obstetrics and gynecology. Am J Obstet Gynecol 2018; 219:581-584. [PMID: 30240659 DOI: 10.1016/j.ajog.2018.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 09/10/2018] [Indexed: 11/29/2022]
Abstract
Powerful incentives now exist that could subordinate professionalism to guild self-interest. How obstetrician-gynecologists respond to these insidious incentives will determine whether guild self-interests will define our specialty. We provide ethically justified, practical guidance to obstetrician-gynecologists to prevent this ethically unacceptable outcome. We describe and illustrate 2 major incentives to subordinating professionalism to guild self-interest: demands for productivity; and compliance and regulatory pressures. We then set out the professional responsibility model of ethics in obstetrics and gynecology to guide obstetrician-gynecologists in responding to these incentives so that they preserve professionalism. Obstetrician-gynecologists should identify guild interests affecting their group practices, set ethically justified limits on self-sacrifice, and prevent incremental drift toward dominance of guild self-interests over professionalism. Guild self-interests could succeed in undermining professionalism, but only if obstetrician-gynecologists allow this to happen. When guild self-interest becomes the deciding factor in patient care, professionalism withers and insidious incentives flourish.
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Affiliation(s)
- Frank A Chervenak
- Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, New York, NY
| | - Laurence B McCullough
- Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, New York, NY.
| | - Ralph W Hale
- International Federation of Gynecologists and Obstetricians, London, United Kingdom; American College of Obstetricians and Gynecologists, Washington, DC
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Rees CA, Keating EM, Lukolyo H, Swamy P, Turner TL, Marton S, Sanders J, Mohapi EQ, Kazembe PN, Schutze GE. Host clinical preceptors' perceptions of professionalism among learners completing global health electives. INTERNATIONAL JOURNAL OF MEDICAL EDUCATION 2018; 9:206-212. [PMID: 30055101 PMCID: PMC6129158 DOI: 10.5116/ijme.5b40.6e4b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 07/07/2018] [Indexed: 05/04/2023]
Abstract
OBJECTIVES This study aims to gain an understanding of the perceptions of host clinical preceptors in Malawi and Lesotho of the professionalism exhibited by short-term learners from the United States and Canada during short-term global health electives. METHODS Focus group discussions were conducted with 11 host clinical preceptors at two outpatient pediatric HIV clinics in sub-Saharan Africa (Malawi and Lesotho). These clinics host approximately 50 short-term global health learners from the United States and Canada each year. Focus group moderators used open-ended discussion guides to explore host clinical preceptors' perceptions of the professionalism of short-term global health learners. Thematic analysis with an inductive approach was used to identify salient themes from these focus group discussions. RESULTS Eleven of the 18 possible respondents participated in two focus group discussions. Adaptability, eagerness to learn, active listening, gratitude, initiative, and punctuality was cited as professional behaviors among short-term global health learners. Cited unprofessional behaviors included disregard of local clinicians' expertise and unresponsiveness to feedback. Host clinical preceptors described difficulty providing feedback to short-term global health learners and discrepancies between what may be considered professional in their home setting versus in the study settings. Respondents requested pre-departure orientation for learners and their own orientation before hosting learners. CONCLUSIONS Both host clinical preceptors and short-term global health learners should be aware that behaviors that may be considered best practice in one clinical setting may be perceived as unprofessional in another. Future studies to develop a common definition of professionalism during short-term global health electives are merited.
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Affiliation(s)
- Chris A. Rees
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, USA
| | - Elizabeth M. Keating
- University of Utah, Department of Pediatric Emergency Medicine, Salt Lake City, UT, USA
| | - Heather Lukolyo
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Padma Swamy
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Teri L. Turner
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Stephanie Marton
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Jill Sanders
- Baylor College of Medicine Children's Foundation Lesotho, Maseru, Lesotho
| | - Edith Q. Mohapi
- Baylor College of Medicine Children's Foundation Lesotho, Maseru, Lesotho
| | - Peter N. Kazembe
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Gordon E. Schutze
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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