Young physicians' recall about pediatric training in ethics and professionalism and its practical utility

Perceptions of pediatric residents and pediatricians about ethical dilemmas: The case of Turkey

BACKGROUND

This study determined the knowledge, attitudes, and behaviors of pediatricians and pediatric residents regarding issues of ethics, professional education, clinical ethical principles, and consent they encounter in health service delivery.

METHODS

Participants in the study were 134 pediatricians and pediatric residents from three hospitals in Ankara, Turkey. Participants were asked questions regarding their sociodemographic characteristics, their knowledge and views of ethics and ethical education, whether they had ever encountered an ethical problem, their beliefs about obtaining consent from pediatric patients and their families, and case-based questions. All data were collected and evaluated.

RESULTS

Of the participants in the study, 82 (61.2%) were residents, 41 (30.6%) were pediatricians, and 11 (8.2%) were faculty lecturers. The data revealed that 10% of the pediatricians and pediatric residents received ethical education, apart from medical ethics/deontology education at medical school, and 90.3% required further education on children and ethical problems. It was determined that 89% of residents and 78% of pediatricians needed help with the ethical problems they encountered during the diagnostic and treatment processes. Overall, 65.7% of the participants stated that the ethical problems they encountered affected the efficiency of health service delivery. It was observed that residents were more affected by ethical issues than pediatricians were. The present study revealed that pediatric residents and pediatricians need ethics education and there is a need to establish ethics counseling centers in hospitals. There is also a need for further studies in pediatrics and ethics.

Ethics education in pediatrics: Implementation and evaluation of an interactive online course for medical students

INTRODUCTION

The COVID-19 pandemic has catalyzed the development of online learning formats in virtually all areas of medical education. In pediatric ethics, online learning may not only substitute but also offer specific advantages over traditional classroom teaching. Many pediatricians rate their ethics education as poor and medical ethics education lacks evaluation, especially regarding the students' needs. The aim of this project was to implement and evaluate a novel interactive distance learning approach to engage medical students in pediatric ethics education.

METHODS

An online ethics course was designed and delivered between May and June 2020. Core item of this course was a moderated, written forum discussion spanning several days. Evaluation was mixed methods. We evaluated the effectiveness of the course in terms of quality of the learning environment with a particular focus on relevance to students as well as interactive learning and reflective thinking. The Constructivist On-Line Learning Environment Survey (COLLES) was used to evaluate six different domains of the course. Data are presented as mean (standard deviation [SD]). The respective score range is 1-5, whereby a score of 4 or 5 means that the participants indicated the corresponding item as frequently or almost always present.

RESULTS

Responses were available from 104 (78.3%) of the 133 participating students. "Relevance" yielded a score of 4.17 (0.83), "reflective thinking" a score of 4.22 (0.83). "Interactivity" was scored 3.76 (0.99) and "tutor support" 4.72 (0.53). "Peer support" and "interpretation" scored 3.87 (0.98) and 4.49 (0.60), respectively. In qualitative analysis, students particularly valued the structure of the course, the relevance for their professional practice, their active participation and the incentive to reflective thinking. Students also indicated that this was an innovative and exciting format, which fills a current educational gap and should hence be continued beyond the pandemic.

CONCLUSION

In conclusion, students actively engaged in online learning and perceived this ethics course as highly relevant for their professional practice.

Appealing to Tacit Knowledge and Axiology to Enhance Medical Practice in the COVID-19 Pandemic: A Systematic Review and Hermeneutic Bioethical Analysis

Background: The pressure of coronavirus disease 2019 (COVID-19) pandemic, epidemiological and demographic changes, personnel-patient relationship in healthcare, and the development of biotechnologies do not go unnoticed by the healthcare professional. Changes are so wide and at a high rate that guidelines and mere scientific knowledge, which are represented by evidence-based medicine, are not sufficient to lead actions, thus the experiential aspects in the configuration of an ethos present as a fundamental part of the resources to deal with critical scenarios, such as a pandemic. In this regard, the recognition of tacit knowledge as a way of teaching and learning skills related to ethical aspects such as principles, virtues, and values, revealed as a fundamental part of the clinical field. The challenge is to strengthen binomial evidence-based medicine and values-based in order to achieve excellence in the health care of the patients and the well-being of the clinical personnel.

Method: A 2-fold analysis was conducted taking pediatric endocrinology as an example. First, a systematic review was carried out in electronic databases BIREME, PubMed, and PhilPapers following PEO and PRISMA approaches. A total of 132 articles were garnered. After reading their title and abstract, 30 articles were obtained. Quantitative information was arranged in an Excel database according to three themes: ethics, axiology, and tacit knowledge. A quality criterion that meets our research question was assigned to each article and those which had a quality criterion of 3 (9) were taken to carry out the hermeneutic bioethical analysis, which consisted of three stages, namely naïve reading, codification, and interpretation. The results were analyzed in Atlas.ti. to elucidate the relations between the three main themes in accordance with the objective.

Results: Although there was no difference in the frequency of tacit knowledge skills, including cognitive, social, and technical, for medical practice, there is an intrinsic relationship between epistemic and ethical values with cognitive skills, this means that professionals who practice honesty, authenticity and self-control are capable of seeing patients as persons and thus respect their dignity. This suggested that there is a strong partnership between evidence-based medicine and value-based medicine, which reinforced this binomial as the two feet on which medical practice decisions rested. With regard to tacit knowledge in terms of the context of the COVID-19 pandemic, the challenges refer to (1) adapting and learning a new way of establishing trust with the patient and (2) how to capitalize on the new knowledge that new experiences have posed.

Discussion: The analysis of ethical-tacit knowledge in medicine is a recent phenomenon and is in full development. Although no references were found that dealt with any of the main topics in pediatric endocrinology, there is an interest in pediatrics to explore and discuss educational strategies in ethics related to its tacit dimension as a vector of enhancement in the clinical practice. Educational strategies ought to take into consideration the development of skills that promote reflection and discussion of experiences, even more vigorously in the context of the COVID-19 pandemic.

Postgraduate ethics training programs: a systematic scoping review

BACKGROUND

Molding competent clinicians capable of applying ethics principles in their practice is a challenging task, compounded by wide variations in the teaching and assessment of ethics in the postgraduate setting. Despite these differences, ethics training programs should recognise that the transition from medical students to healthcare professionals entails a longitudinal process where ethics knowledge, skills and identity continue to build and deepen over time with clinical exposure. A systematic scoping review is proposed to analyse current postgraduate medical ethics training and assessment programs in peer-reviewed literature to guide the development of a local physician training curriculum.

METHODS

With a constructivist perspective and relativist lens, this systematic scoping review on postgraduate medical ethics training and assessment will adopt the Systematic Evidence Based Approach (SEBA) to create a transparent and reproducible review.

RESULTS

The first search involving the teaching of ethics yielded 7669 abstracts with 573 full text articles evaluated and 66 articles included. The second search involving the assessment of ethics identified 9919 abstracts with 333 full text articles reviewed and 29 articles included. The themes identified from the two searches were the goals and objectives, content, pedagogy, enabling and limiting factors of teaching ethics and assessment modalities used. Despite inherent disparities in ethics training programs, they provide a platform for learners to apply knowledge, translating it to skill and eventually becoming part of the identity of the learner. Illustrating the longitudinal nature of ethics training, the spiral curriculum seamlessly integrates and fortifies prevailing ethical knowledge acquired in medical school with the layering of new specialty, clinical and research specific content in professional practice. Various assessment methods are employed with special mention of portfolios as a longitudinal assessment modality that showcase the impact of ethics training on the development of professional identity formation (PIF).

CONCLUSIONS

Our systematic scoping review has elicited key learning points in the teaching and assessment of ethics in the postgraduate setting. However, more research needs to be done on establishing Entrustable Professional Activities (EPA)s in ethics, with further exploration of the use of portfolios and key factors influencing its design, implementation and assessment of PIF and micro-credentialling in ethics practice.

Ethics of Pediatric and Young Adult Medical Decision-Making: Case-Based Discussions Exploring Consent, Capacity, and Surrogate Decision-Making

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.

Why Are There So Few Ethics Consults in Children's Hospitals?

In most children's hospitals, there are very few ethics consultations, even though there are many ethically complex cases. We hypothesize that the reason for this may be that hospitals develop different mechanisms to address ethical issues and that many of these mechanisms are closer in spirit to the goals of the pioneers of clinical ethics than is the mechanism of a formal ethics consultation. To show how this is true, we first review the history of collaboration between philosophers and physicians about clinical dilemmas. Then, as a case-study, we describe the different venues that have developed at one children's hospital to address ethical issues. At our hospital, there are nine different venues in which ethical issues are regularly and explicitly addressed. They are (1) ethics committee meetings, (2) Nursing Ethics Forum, (3) ethics Brown Bag workshops, (4) PICU ethics rounds, (5) Grand Rounds, (6) NICU Comprehensive Care Rounds, (7) Palliative Care Team (PaCT) case conferences, (8) multidisciplinary consults in Fetal Health Center, and (9) ethics consultations. In our hospital, ethics consults account for only a tiny percentage of ethics discussions. We suspect that most hospitals have multiple and varied venues for ethics discussions. We hope this case study will stimulate research in other hospitals analyzing the various ways in which ethicists and ethics committees can build an ethical environment in hospitals. Such research might suggest that ethicists need to develop a different set of "core competencies" than the ones that are needed to do ethics consultations. Instead, they should focus on their skills in creating multiple "moral spaces" in which regular and ongoing discussion of ethical issues would take place. A successful ethicist would empower everyone in the hospital to speak up about the values that they believe are central to respectful, collaborative practice and patient care. Such a role is closer to what the first hospital philosophers set out to do than in the role of the typical hospital ethics consultant today.

Pediatricians' Experience with Clinical Ethics Consultation: A National Survey

OBJECTIVE

To conduct a national survey of pediatricians' access to and experience with clinical ethics consultation.

STUDY DESIGN

We surveyed a randomly selected sample of 3687 physician members of the American Academy of Pediatrics. We asked about their experiences with ethics consultation, the helpfulness of and barriers to consultation, and ethics education. Using a discrete choice experiment with maximum difference scaling, we evaluated which traits of ethics consultants were most valuable.

RESULTS

Of the total sample of 3687 physicians, 659 (18%) responded to the survey. One-third of the respondents had no experience with clinical ethics consultation, and 16% reported no access to consultation. General pediatricians were less likely to have access. The vast majority (90%) who had experience with consultation had found it helpful. Those with fewer years in practice were more likely to have training in ethics. The most frequently reported issues leading to consultation concerned end-of-life care and conflicts with patients/families or among the team. Intensive care unit physicians were more likely to have requested consultation. Mediation skills and ethics knowledge were the most highly valued consultant characteristics, and representing the official position of the hospital was the least-valued characteristic.

CONCLUSION

There is variability in pediatricians' access to ethics consultation. Most respondents reported that consultation had been helpful in the past. Determining ethically appropriate end-of-life care and mediation of disagreements are common reasons that pediatricians request consultation.