Deception, discrimination, and fear of reprisal: lessons in ethics from third-year medical students

Revisiting Moral Courage as an Educational Objective

In a 2005 paper about the variety of ethical conflicts third-year medical students observed, and their responses to those conflicts, a reluctance to speak up for fear of reprisal emerged as a salient finding. Based on that finding, the authors proposed that moral courage falls within the realm of professional expectations for medical students and that its cultivation is an appropriate formal objective for medical education. Since then, one of those authors has engaged in remediating trainees and practicing clinicians who have committed professional misdeeds, including failures in professionalism, ethics, and maintaining professional boundaries. The perspective gained from working with these individuals and hearing their stories, as well as concepts from behavioral science, have broadened that author's understanding of how poor professional judgments are made and misdeeds committed and expanded her appreciation for the role of moral courage. Most individuals arrive at their remedial course knowing on some level that what they did was wrong, but are incredulous at how they became capable of acting so improperly. They must learn that every student and practitioner, without exception, is at risk for committing a professional misdeed. Moral courage is required to participate in the kind of reflection and self-assessment necessary to examine one's own professional wrongdoing and practice safely and competently at all times, just as it is required to speak truth to power and risk negative consequences. The author concludes that medical educators can and should assist trainees to mitigate their risks through regularly-and courageously-assessing themselves and their circumstances with honesty and clarity to develop a mature professional identity, safeguard patients, and ultimately cherish the privilege of licensure.

Investigating Medical Students' Navigation of Ethical Dilemmas: Understanding the Breakdown and How to Solve It

PURPOSE

Medical students receive a varying amount of training in medical ethics and are expected to navigate clinical ethical dilemmas innately. There is little literature on attempts to navigate ethical dilemmas experienced during early clinical experiences and whether current curricula prepare students for these dilemmas. This study explores the different ethical dilemmas experienced by medical students on their third-year clerkships and analyzes the factors, sources, and resolutions proposed by them.

METHODS

From 2016 to 2018, third-year medical students completed a written assignment to describe, analyze, and reflect on a clinical situation in which they experienced an ethical dilemma. They identified specific ethical dilemmas present, potential preventative and aftermath solutions, and reflected on their professional development from their experience. The research team utilized applied thematic analysis to identify themes and patterns in the data. A thematic matrix was utilized to examine similarities and differences across medical students.

RESULTS

Of the 162 reflections, 144 (88.9%) students indicated an ethical dilemma that included issues related to autonomy and beneficence. Of these, 116 (71.6%) students found the two ethical principles in direct conflict. Students identified three common sources of this conflict: lack of communication; unclear understanding of clinical policies regarding family authority and psychiatric capacity; and medical negligence. Lastly, students suggested different solutions for dealing with and preventing this conflict.

CONCLUSION

Our findings suggest that an overwhelming number of students face ethical challenges when confronted with medical situations that raise conflicts between autonomy and beneficence. Their recommended solutions reveal an appeal among students to have tools and strategies in place to ease the need to make difficult decisions. Medical students might be better served by learning about the complexities of ethical decision-making and the likelihood of experiencing moral distress when they feel an inability to implement what they envision as the best solution.

"It really puts me in a bind", professionalism dilemmas reported by Chinese residents

Residents play a pivotal role in the healthcare system. However, few tools have systematically revealed the dilemmas and challenges faced by residents. This study aimed to develop a checklist for professionalism dilemmas based on a behavior-based professionalism framework and to examine the range and proportion of professionalism dilemmas heard of, witnessed, or experienced by Chinese residents. Mixed methods were used, comprising qualitative (document analysis and focus group interviews) and quantitative (a small-scale questionnaire survey) data. Document analysis summarized professionalism dilemma items from previous publications. For focus group interviews, we used narrative inquiry to explore and make sense of residents' experiences and perceptions of professionalism dilemmas. A small-scale questionnaire survey was conducted during each focus group to investigate the proportion of professionalism dilemma items that residents reported to have heard of, witnessed, or experienced. Through document analysis and focus group interviews, we developed a checklist of professionalism dilemmas based on a behavior-based professionalism framework. The checklist included 58 items over four domains, with 10 sub-domains (compassion, respect, communication, collaboration, integrity, duty, pursuit of excellence, fair stewardship of health care resources, patient confidentiality, and informed consent). We also sought a preliminarily subjective impression by exploring the proportion of residents who have heard of, witnessed, and experienced each of the professionalism dilemma items and residents' perspectives when faced with professionalism dilemmas. Residents inevitably encounter or experience a diverse range of professionalism dilemmas. This checklist of professionalism dilemmas that was developed could prove to be a significant reference for targeted professionalism education, both for the resident as well as for faculty. It can also act as a helpful tool for improving hospital management guidelines and patient education.

A systematic scoping review of undergraduate medical ethics education programs from 1990 to 2020

INTRODUCTION

Ensuring medical students are equipped with essential knowledge and portable skills to face complex ethical issues underlines the need for ethics education in medical school. Yet such training remains variable amidst evolving contextual, sociocultural, legal and financial considerations that inform training across different healthcare systems. This review aims to map how undergraduate medical schools teach and assess ethics.

METHODS

Guided by the Systematic Evidence-Based Approach (SEBA), two concurrent systematic scoping reviews were carried out, one on ethics teaching and another on their assessment. Searches were conducted on PubMed, Embase, PsycINFO and ERIC between 1 January 1990 and 31 December 2020. Data was independently analysed using thematic and content analysis.

RESULTS

Upon scrutinising the two sets of full-text articles, we identified 141 articles on ethics teaching and 102 articles on their assessments. 83 overlapped resulting in 160 distinct articles. Similar themes and categories were identified, these include teaching modalities, curriculum content, enablers and barriers to teaching, assessment methods, and their pros and cons.

CONCLUSION

This review reveals the importance of adopting an interactive, multimodal and interdisciplinary team-teaching approach to ethics education, involving community resource partners and faculty trained in ethics, law, communication, professionalism, and other intertwining healthcare professions. Conscientious effort should also be put into vertically and horizontally integrating ethics into formal medical curricula to ensure contextualisation and application of ethics knowledge, skills and attitudes, as well as protected time and adequate resources. A stage-based multimodal assessment approach should be used to appropriately evaluate knowledge acquisition, application and reflection across various practice settings. To scaffold personalised development plans and remediation efforts, multisource evaluations may be stored in a centralised portfolio. Whilst standardisation of curricula content ensures cross-speciality ethical proficiency, deliberative curriculum inquiry performed by faculty members using a Delphi approach may help to facilitate the narrowing of relevant topics.

Factors associated with medical students speaking-up about medical errors: A cross-sectional study

BACKGROUND

Training medical students to speak up when they witness a potential error is an important competency for patient safety, but details regarding the barriers that prevent medical students from effectively communicating are lacking. Therefore, this study aimed at exploring the factors affecting medical students' willingness to speak up for patient safety when a medical error was observed.

METHODS

This is a cross-sectional study at a medical university in Taiwan, and 151 medical students in clinical clerkship completed a survey including demographic characteristics, conflict of interests/social relationship, personal capability, and personality and characteristics of senior staff domains. Data were analyzed using t-test.

RESULTS

Three of five items in the conflict of interests/social relationship domain showed statistically significant importance, including 'I am afraid of being punished' (Mean difference, MD = 0.37; p < 0.01), 'I do not want to break unspoken rules' (MD = 0.55; p < 0.01), and 'I do not want to have bad team relationship' (MD = 0.58; p < 0.01). Two items (perception of knowledge/understanding and communication skills) in the personal capability domain were significantly important to speaking up. Six of 10 items in personality and characteristics of senior staff domain were rated significantly important in deciding to speak up. The top three factors of them were senior personnel with 'Grumpy' personality (MD = 1.20; p < 0.01), 'hierarchy gap' (MD = 1.12; p < 0.01), and senior personnel with 'Stubborn' personality (MD = 1.06; p < 0.01).

CONCLUSION

Our findings demonstrated medical students' perspectives on barriers to speaking up in the event of medical error. Some factors related to characteristics of senior staff could compromise medical students' ability to speak up in the event of medical error. These results might be important for medical educators in designing personalized educational activities related to medical students' ability to speak up for patient safety.

Communication skills learning through role models in Nepal; what are medical students really learning? A qualitative study

BACKGROUND

Communication skills (CS) are important and teachable, however, many Asian medical schools' curricula do not incorporate them. Patan Academy of Health Sciences in Nepal identifies CS within its' aims and curriculum. CS are taught from commencement of medical school and re-emphasised throughout preclinical learning (first 2 years). There is no explicit CS teaching in clinical years but placements allow students to learn through observation. These 'role-modelling' interactions form part of CS learning and development.

METHODS

This study is a qualitative evaluation of CS learning in PAHS, through participants' experiences. Through purposive sampling, twenty medical students from 2nd, 4th and Intern years were selected for inclusion. Data were collected via audio recorded, semi-structured interviews, employing a piloted schedule. Transcripts were manually coded and analysed thematically. Codes were organised into themes and subthemes. This paper discusses themes related to role-modelling.

RESULTS

The majority of participants described role-modelling in CS learning, recounting both positive and negative incidents, reflected in the themes of; Positive and Negative experiences. Subthemes of Personal Qualities and Inspiring, emerged from positive experiences, describing students' desire to imitate or aspire to be like their role models. Learners reported predominantly negative experiences and interns exclusively so. From these emerged subthemes of; Good doctors but.., Contradictory messages, How not to behave, Unprofessional behaviour and Affect-Emotional Distress. Learners received conflicting messages from observing behaviour contradictory to explicit CS teaching. Many identified learning "how not to behave" from such incidents, however, several described feeling distressed.

DISCUSSION

Role-modelling is a powerful and important CS learning tool, seen as positively reinforcing or negatively contradicting explicit CS teaching. Negative modelling created internal conflict, confusion and distress amongst learners, despite its' potential for positive learning. The worldwide problem of negative role-modelling is also prevalent in Nepal. Medical educators need to ensure the explicit curriculum aligns with implicit learning. Clinical tutors must be alerted to their powerful role-model position and supported in developing intentional modelling skills. Learners' reflections upon their experiences should be facilitated, enabling them to critically evaluate observations and hence consciously adopt or reject role-modelled behaviour and attitudes.

What Role Should Resistance Play in Training Health Professionals?

The role that resistance plays in medicine and medical education is ill-defined. Although physicians and students have been involved in protests related to the COVID-19 pandemic, structural racism, police brutality, and gender inequity, resistance has not been prominent in medical education's discourses, and medical education has not supported students' role and responsibility in developing professional approaches to resistance. While learners should not pick and choose what aspects of medical education they engage with, neither should their moral agency and integrity be compromised. To that end, the authors argue for professional resistance to become a part of medical education. This article sets out a rationale for a more explicit and critical recognition of the role of resistance in medical education by exploring its conceptual basis, its place both in training and practice, and the ways in which medical education might more actively embrace and situate resistance as a core aspect of professional practice. The authors suggest different strategies that medical educators can employ to embrace resistance in medical education and propose a set of principles for resistance in medicine and medical education. Embracing resistance as part of medical education requires a shift in attention away from training physicians solely to replicate and sustain existing systems and practices and toward developing their ability and responsibility to resist situations, structures, and acts that are oppressive, harmful, or unjust.

'I found myself a despicable being!': Medical students face disturbing moral dilemmas

CONTEXT

The psychological realm of medical students' moral experiences is explored tangentially in medical education literature, often in the context of ethics or professionalism education. This study deepens our understanding by (a) investigating the nature of moral dilemmas experienced at the onset of clinical practice, (b) exploring students' emotional response to these dilemmas, and (c) examining how students perceive the influence of these dilemmas on their professional development.

METHODS

This is a cross-sectional qualitative study carried out in 2017 that applied thematic template analysis to individual interviews performed with last-year medical students. The interviews followed the drawing of a Rich Picture representing moral dilemmas experienced by medical students at the onset of clinical practice.

RESULTS

Moral dilemmas have four intertwined dimensions. The first relates to students' struggle to prioritise, balance and apply conflicting moral values; the second comprises the clash between students' inner motivation and the external constraints that limit the moral action; the third refers to the conflict between students' current attitudes with the desired/idealised attitudes of the doctor they intend to become; and the fourth corresponds to weighting conflicting ethical principles during the moral decision. Students' emotional responses are intense and long-lasting, and with a remarkable residue effect, particularly when the moral decision does not align with their moral beliefs. Moral dilemmas are impactful experiences that affect the professional development of medical students and can culminate in both detachment and growth in moral courage.

CONCLUSION

Moral dilemmas are memorable, complex and emotionally intense experiences that impact the professional development of medical students. Understanding students' moral dilemmas can help educators to devise pedagogical activities to anticipate and reflect on these experiences. These activities should happen under the guidance of a non-judgemental facilitator, capable of listening and legitimating students' thoughts and feelings while providing insights to nurture their professional development.

Third year medical students impersonalize and hedge when providing negative upward feedback to clinical faculty

Medical students provide clinical teaching faculty with feedback on their skills as educators through anonymous surveys at the end of their clerkship rotation. Because faculty are in a position of power, students are hesitant to provide candid feedback. Our objective was to determine if medical students were willing to provide negative upward feedback to clinical faculty and describe how they conveyed their feedback. A qualitative analysis of third year medical students' open-ended comments from evaluations of six clerkships was performed using politeness theory as a conceptual framework. Students were asked to describe how the clerkship enhanced their learning and how it could be improved. Midway through the academic year, instructions to provide full names of faculty/residents was added. Overall, there were significantly more comments on what worked well than suggestions for improvement regarding faculty/residents. Instructing students to name-names increased the rate of naming from 35% to 75% for what worked well and from 13% to 39% for suggestions for improvement. Hedging language was included in 61% of suggestions for improvement, but only 2% of what worked well. Students described the variability of their experience, used passive language and qualified negative experiences with positive ones. Medical students may use linguistic strategies, such as impersonalizing and hedging, to mitigate the impact of negative upward feedback. Working towards a culture that supports upward feedback would allow students to feel more comfortable providing candid comments about their experience.

"Why have you done it that way?" Educator perceptions of student-initiated conversations about perceived deviations from evidence-based clinical practice

Students on clinical placement may encounter practice that deviates from what they perceive to be evidence-based. However, queries by students about the evidence-base of their clinical educators decision-making and practice can be a challenging conversation to initiate. It is unclear how these conversations occur, and what impact engaging in these challenging conversations may have on practice, the learning experience, and the relationship with the educator. This study sought to explore clinical educators' experiences of student-initiated discussions that question the evidence-base of their clinical practice. And to identify their preferred approaches for students to initiate these conversations. Individual interviews were conducted with 23 clinical educators from five professions at three different hospitals in Victoria, Australia. Semi-structured interviewing techniques were employed to identify participants' context and experiences. Participants described student-initiated conversations about deviations from evidence-based practice as challenging encounters with potential for positive or negative impact on clinical educators, students and patients. They noted that the perceived appropriateness of the discussion could be influenced by the method utilised by students to initiate the conversation. Elements identified by clinical educators as barriers or enablers to support students to appropriately initiate conversations about clinical practice may be utilised by education and health providers to enhance opportunities for learning conversations to occur.

Ending student mistreatment: early successes and continuing challenges

Problem: Student mistreatment represents an ongoing challenge for US medical schools. Students experiencing mistreatment may become marginalized and cynical, and they have higher rates of burnout, depression and substance use disorders. Although numerous attempts to eliminate mistreatment have been proposed, best practices remain elusive. We formed a unique student-faculty collaboration (the Ending Mistreatment Task Force) that allowed all voices to be heard and enabled identification of five interventions to reduce mistreatment.Intervention: The EMTF developed and implemented five key interventions: 1) a shared mistreatment definition; 2) measures to increase faculty accountability, including adding professionalism expectations to faculty members' contracts and performance reviews; 3) a Professionalism Office to respond promptly to students' reports of mistreatment and provide feedback to faculty; 4) tools to help teachers provide authentic learning environments for students, while addressing generational misunderstandings; and 5) student-produced videos, helping faculty understand the impact of mistreatment as seen through students' eyes.Context: These interventions occurred at one medical school where mistreatment reports were consistently above national averages.Impact: Over 6 years, the interventions helped reduce the rate of student-reported mistreatment by 36% compared with a 4% decline across all US medical schools.Lessons: The collaborations between students and faculty helped each party identify unexpected misunderstandings and challenges. We learned that students want hard questions, although faculty are often afraid to challenge students for fear of offending them or being reported. We clarified differences between mistreatment and sub-optimal learning environments and openly discussed the pervasive opinion that 'some' mistreatment is important for learning. We also identified ongoing challenges, including the need to solicit residents' perspectives regarding mistreatment and develop proper responses to disrespectful comments directed at patients, family and colleagues. The collaboration reinforced students' and faculty members' shared commitment to upholding a respectful learning and clinical care environment and ending mistreatment.

Changing the channel on medical ethics education: systematic review and qualitative analysis of didactic-icebreakers in medical ethics and professionalism teaching

As medical ethics and professionalism education continues to equip medical students and residents with long-lasting tools, educators should continue to supplement proven teaching strategies with engaging, relatable, and generationally appropriate didactic supplements. However, popular teaching aids have recently been criticized in the literature and summative information on alternatives is absent. The purpose of this review is to evaluate and assess the functional use and application of short form audiovisual didactic supplements or "icebreakers" in medical ethics and professionalism teaching. A systematic review of both the medical and humanities literature (i.e., PubMed/MEDLINE, Cochrane Library, and JSTOR) was conducted from inception to August 1, 2019. Final articles were subjected to a qualitative appraisal and thematic analysis. Thirteen articles were included for final analysis. Sixty-nine percent (n = 9) of the studies were published after 2000. Two studies were qualitative, one study was quantitative, and the remaining articles were commentaries. Short form audiovisual media was most popular outside of the United States (n = 10). Sixty-nine percent (n = 9) of articles advocated for self-contained media in the form of trigger films or short films/videos, while the remaining articles (n = 4) discussed the use of TV/film clips. Producibility of media was exclusive to short/trigger films. Nine themes were identified in the content analysis: adaptability, conversation catalyst, effective, engaging, nuance, practice, producibility, real, and subject diversity. The three most common themes in descending order of frequency were: conversation catalyst, realness, and adaptability. Trigger films represent an effective and unique pedagogical strategy in supplementing current medical ethics and professionalism teaching at the medical school level.

Predictors of medical students' ethical decision-making: A pilot study using the Theory of Interpersonal Behavior

OBJECTIVE

To understand medical students' (MS) ethical decision-making using the Theory of Interpersonal Behavior (TIB).

METHODS

We conducted two rounds of focus groups to develop a TIB-based questionnaire by eliciting students' perspectives on an ethical dilemma they will encounter in a standardized patient (SP) station, in which an SP "surgeon" asked them to intubate a sedated patient whom the student knew had requested no student involvement. We administrated questionnaires to 241 third-year MS following this SP station, asking for their decisions in the SP station and if a surgeon made the same request in their clerkship. Confirmatory factor analysis (CFA) was used to test whether observed data fit the proposed TIB-based model.

RESULTS

The CFA provided an acceptable fit to the a priori proposed model. Fifty-five percent of students indicated they would intubate in an actual situation versus 18% in the SP station (p < 0.05). Using logistic regression, TIB domains affect and facilitating factors reported significant association with students' decisions in both the SP and hypothesized actual situations.

CONCLUSIONS

The TIB appears to be an effective theoretical framework for explaining students' ethical decision-making.

PRACTICE IMPLICATIONS

The TIB may guide design and assessment of educational programs for professional formation.

Medical students as feedback assessors in a faculty development program: Implications for the future

Background: Little is known about simulated students' ability in assessing feedback received in Objective Structured Teaching Encounters (OSTEs). We aimed to assess to which extent students' perceptions matched objective analysis regarding quality of received feedback, to explore what elements of feedback they emphasized and what they learned about feedback.Methods: In this mixed-method study, 43 medical students participated as simulated residents in five OSTEs at Geneva University Hospitals. They assessed quality of feedback from faculty using a 15-item questionnaire and gave written/oral comments. Videotaped feedbacks were assessed using an 18-item feedback scale. During four focus groups, 25 students were asked about what they learned as feedback assessors.Results: 453 students' questionnaires and feedback scale were compared. Correlations were moderate for stimulating self-assessment (0.48), giving a balanced feedback (0.44), checking understanding (0.47) or planning (0.43). Students' feedback emphasized elements such as faculty's empathy or ability to give concrete advice. They reported that being a feedback assessor helped them to realize importance of making the learner active and that giving effective feedback required structure and skills.Conclusion: Medical students may identify quality of feedback. Involving them in OSTEs could be interesting to train them to become valid raters of supervisors' teaching skills.

What Do Students Perceive as Ethical Problems? A Comparative Study of Dutch and Indonesian Medical Students in Clinical Training

Previous studies show that medical students in clinical training face ethical problems that are not often discussed in the literature. In order to make teaching timely and relevant for them, it is important to understand what medical students perceive as ethical problems, as various factors may influence their perception, including cultural differences and working environment. The purpose of this qualitative study was to explore students’ perceptions of what an ethical problem is, during their clinical training in the hospital, and compare the results from two different countries. We observed a total of eighteen ethics group discussions and interviewed fifteen medical students at two medical schools, in Indonesia and the Netherlands. Data were interpreted and analyzed using content analysis. We found that students in both settings encounter problems which are closer to their daily work and responsibilities as medical students and perceive these problems as ethical problems. Indonesian students perceived substandard care and inequity in healthcare as ethical problems, while Dutch students perceived that cases which are not matters of life and death are less worthy to discuss. Our study suggests that there might be a gap between ethical problems that are discussed in class with teachers, and problems that students actually encounter in practice. Teachers should be aware of the everyday situations in clinical training which may be perceived by students as ethically problematic and should acknowledge and discuss these ethical problems with students as part of the learning processes in ethics education.

Medical Students' Perceptions of and Responses to Health Care Disparities During Clinical Clerkships

PURPOSE

To measure the frequency and nature of student-perceived clinician-driven health care disparities, and determine their impact on medical students' professional development.

METHOD

Retrospective study of fourth-year medical students at the University of California, San Francisco School of Medicine, August 2016 to June 2017. Conducted via an electronic survey asking about frequency/nature of directly witnessed health care disparities and barriers/facilitators to action during third-year clerkships; and individual, semistructured interviews focusing on clinical details and impact on students' professional development.

RESULTS

Respondents were 103/159 students (65%). In internal medicine clerkships, a majority perceived disparities as occurring sometimes (2-7 times in eight-week clerkship) or often (at least once weekly or nearly daily) based on language barriers (90%), patients' homelessness (77%), history of substance abuse (76%), obesity (67%), and race/ethnicity: Latino (72%), black (71%), and Asian (56%). Results from other clerkships were similar. Barriers to student action to perceived disparities included fear of poor evaluations, hierarchy/powerlessness, a "don't speak up" culture, the desire to be a team player, limited clinical experience, and perceiving doctors as "good people" who provide disparate care unintentionally. Impact on professional development varied, ranging from students' normalization of disparities as stemming from clinical constraints to increased motivation to provide equitable care.

CONCLUSIONS

Medical students routinely witness health care disparities during clerkships, and their observations spotlight specific clinical practices. For some students, these observations lead to a normalization of disparities; for others, they heighten commitment to equity. Clinical curricula should incorporate responding to health care disparities.

Ethical Issues Encountered During the Medical Student Surgical Clerkship

BACKGROUND

Data regarding ethical issues encountered by medical students during the surgical clerkship are sparse. Identification of such issues facilitates development of an ethics curriculum that ensures student preparation for issues most frequently encountered on the surgical rotation. To better understand these issues, we performed content analysis of reflections written by medical students about ethical issues encountered during their surgical clerkship.

MATERIALS AND METHODS

All medical students on the surgical clerkship at a university hospital from 4/2017 to 6/2018 submitted a written reflection regarding an ethical issue encountered during the clerkship. Two investigators performed content analysis of each reflection. References to ethical principles (beneficence, nonmaleficence, justice, autonomy) were tabulated. Ethical issues were classified into main categories and subcategories, based on a modified version of a previously published taxonomy.

RESULTS

134 reflections underwent content analysis. Nonmaleficence was the most frequently mentioned ethical principle. 411 specific ethical issues were identified. Ethical issues were distributed across ten main categories: decision-making (28%), communication among health care team members (14%), justice (12%), communication between providers, patients, and families (9%), issues in the operating room (9%), informed consent (9%), professionalism (5%), supervision/student-specific issues (5%), documentation (1%), and miscellaneous/other (8%). We identified two ethical issues infrequently discussed in previous reports: delivery of efficient yet high-quality care and poor communication between services/consultants.

CONCLUSIONS

Students encounter diverse ethical issues during their surgical clerkships. Ethical and contextual considerations related to these issues should be incorporated into a preclinical/clinical surgical ethics curriculum to prepare students to understand and engage the challenges they face during the clerkship.

On cultivating the courage to speak up: the critical role of attendings in the moral development of physicians in training

"Shut the door," the chief resident said to me. While I was green enough at the beginning of my clinical clerkships to believe that most of my medical education would happen at the bedside, at that moment, I was learning another important fact: a large part of my ethical education was going to happen behind the closed doors of a call room. The health care team was polluted by a pervasive atmosphere of frustration, as silent but tangible as a thick layer of fog, that obscured the patient's ability to evaluate the consequences of the choice that lay before her. The attending did not permit, let alone create, an environment that provided room for dissent. Institutions should encourage the leaders of clinical education to foster an emotionally safer learning environment in which honest moral dialogue may occur without fear of repercussions. If students cannot learn to apply the principles of ethics actively throughout their clerkships, it will be much harder to do so when they practice independently, and ultimately, patient care will suffer. Conversely, when students and trainees are empowered by their teachers, patient care improves.

Investigating US medical students' motivation to respond to lapses in professionalism

CONTEXT

As unprofessional behaviour in physicians can compromise patient safety, all physicians should be willing and able to respond to lapses in professionalism. Although students endorse an obligation to respond to lapses, they experience difficulties in doing so. If medical educators knew how students respond and why they choose certain responses, they could support students in responding appropriately.

OBJECTIVES

The aim of this study was to describe medical students' responses to professionalism lapses in peers and faculty staff, and to understand students' motivation for responding or not responding.

METHODS

We conducted an explorative, qualitative study using template analysis, in which three researchers independently coded transcripts of semi-structured, face-to-face interviews. We purposefully sampled 18 student representatives convening at a medical education conference. Preliminary open coding of a data subset yielded an initial template, which was applied to further data and modified as necessary. All transcripts were coded using the final template. Finally, three sensitising concepts from the Expectancy-Value-Cost model were used to map participants' responses.

RESULTS

Students mentioned having observed lapses in professionalism in both faculty staff and peers. Students' responses to these lapses were avoiding, addressing, reporting or initiating policy change. Generally, students were not motivated to respond if they did not know how to respond, if they believed responding was futile and if they feared retaliation. Students were motivated to respond if they were personally affected, if they perceived the individual as approachable and if they thought that the whole group of students could benefit from their actions. Expectancy of success, value and costs each appeared to be influenced by (inter)personal and system factors.

CONCLUSIONS

The Expectancy-Value-Cost model effectively explains students' motivation for responding to lapses. The (inter)personal and system factors influencing students' motivation to respond are modifiable and can be used by medical educators to enhance students' motivation to respond to lapses in professionalism observed in medical school.

Perceptions of patient safety culture among medical students: a cross-sectional investigation in Heilongjiang Province, China

OBJECTIVES

Medical school education plays an important role in promoting patient safety. In this study, we assess medical students' perceptions of patient safety culture, identify their educational needs and provide evidence on the most important content relating to patient safety for the medical school curriculum.

METHOD

This cross-sectional study was conducted in four medical universities in Heilongjiang province. Medical students in the first through five years completed an anonymous questionnaire-the Attitudes toward Patient Safety Questionnaire III. We analysed the differences in responses across the four universities and their cohorts.

RESULTS

The overall perceptions of patient safety culture across the four medical universities were positive. The highest positive response rate was for 'I have a good understanding of patient safety issues as a result of my undergraduate medical training' (range: 58.4%-99.8%), whereas the lowest positive response rate was for 'medical errors are a sign of incompetence' (14.7%-47.9%). Respondents in the earlier years of school tended to have more positive responses for items concerning working hours and team work; however, fourth and fifth year students had more positive responses for error inevitability. Items with the lowest positive response rates across the cohorts included items related to 'professional incompetence as a cause of error' and 'disclosure responsibility'.

CONCLUSIONS

While students generally had positive views of patient safety culture, none of them had been exposed to any formal curriculum content on patient safety. Policymakers should focus more on how educational needs vary across schools and cohorts in order to establish appropriate curricula.

Moving beyond the theoretical: Medical students' desire for practical, role-specific ethics training

BACKGROUND

It has been widely reported that medical trainees experience situations with profound ethical implications during their clinical rotations. To address this, most U.S. medical schools include ethics curricula in their undergraduate programs. However, the contents of these curricula vary substantially. Our pilot study aimed to discover, from the students' perspective, how ethics pedagogy prepares medical students for clerkship and what gaps might remain.

METHODS

This qualitative study organized focus groups of third- and fourth-year medical students. Participants recounted ethical concerns encountered during clerkship rotations and reflected on how their medical school ethics curriculum informed their responses to these scenarios. Transcripts of the focus-group sessions were analyzed using a grounded theory approach to identify common themes that characterized the students' experiences.

RESULTS

While students' accounts demonstrated a solid grasp of ethical theory and attunement to ethical concerns presented in the clinic, they also consistently evinced an inability to act on these issues given clerks' particular position in a complex learning hierarchy. Students felt they received too little training in the role-specific application of medical ethics as clinical trainees. We found a desire among trainees for enhanced practical ethics training in preparation for the clerkship phase of medical education.

CONCLUSION

We recommend several strategies that can begin to address these findings. The use of roleplaying with standardized patients can enable students to practice engagement with ethical issues. Conventional ethics courses can focus more on action-based pedagogy and instruction in conflict management techniques. Finally, clear structures for reporting and seeking advice and support for addressing ethical issues can lessen students' apprehension about acting on ethical concerns.

Institutional Ethics Resources: Creating Moral Spaces

Since 1992, institutions accredited by The Joint Commission have been required to have a process in place that allows staff members, patients, and families to address ethical issues or issues prone to conflict. While the commission's expectations clearly have made ethics committees more common, simply having a committee in no way demonstrates its effectiveness in terms of the availability of the service to key constituents, the quality of the processes used, or the outcomes achieved. Beyond meeting baseline accreditation standards, effective ethics resources are requisite for quality care for another reason. The provision of care to the sick is a practice with profound moral dimensions. Clinicians need what Margaret Urban Walker has called "moral spaces," reflective spaces within institutions in which to explore and communicate values and ethical obligations as they undergird goals of care. Walker proposed that ethicists needed to be concerned with the design and maintenance of these moral spaces. Clearly, that concern needs to extend beyond ethicists to institutional leaders. This essay uses Walker's idea of moral space to describe individuals and groups who are actual and potential ethics resources in health care institutions. We focus on four requisite characteristics of effective resources and the challenges to achieving them, and we identify strategies to build them. In our view, such moral spaces are particularly important for nurses and their colleagues on interprofessional teams and need to be expanded and strengthened in most settings.

Speaking Up: An Ethical Action Exercise

PROBLEM

Health care professionals encounter situations in which they need to speak up to prevent harm, ensure better care, and/or address unprofessional behavior. Speaking up is often difficult, especially for medical students; nonetheless, it is a skill students must practice, so they can better advocate for patients.

APPROACH

The authors have designed an ethical action exercise and incorporated it into a required bioethics course that meets concurrently with third-year clerkships. The exercise requires students to speak up to try to correct, resolve, or improve one situation during a clerkship. The exercise involves overt action, but students determine how, where, and when to act.

OUTCOMES

In 2013-2014, 111 students at State University of New York Upstate Medical University completed the exercise. Most spoke up about situations in which they thought that some aspect of patient care could be improved (n = 78; 70%); others spoke up when they perceived unprofessional conduct (n = 32; 29%). Although most students found speaking up to be difficult (n = 96; 86%), speaking up often led to improved care (n = 46; 41%). As a result of completing the ethical action exercise, 2 students reported becoming less likely to speak up in the future, whereas 64 students reported becoming more likely.

NEXT STEPS

Going forward, the authors want to address three issues: the development of lasting habits, the role of culture, and connections with other initiatives to improve care.

Patient safety culture perceptions in the college of dentistry

A positive safety culture is essential to patient safety because it improves quality of care. The aim of this study was to assess staff and student perceptions of the patient safety culture in the clinics of the College of Dentistry at King Saud University in Saudi Arabia.A cross-sectional study was conducted in the College of Dentistry at King Saud University in Saudi Arabia. It included 4th and 5th year students, interns, general practitioners, and dental assistants. The data were collected by using paper-based questionnaire of modified version of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture. Data were entered into SPSS Version 20. Score on a particular safety culture dimension was calculated.The overall response rate was 72.8% (390/536). Team work dimension had the highest average percent positive dimension score (72.3%) while staffing had the lowest score (10%). Dental assistant had high agreement in Teamwork dimension (87.8%); Supervisor/Manager Expectations and Actions Promoting Patient Safety dimension (66.9%); Organizational Learning-Continuous Improvement dimension (79.1%); Management Support for Patient Safety dimension (84.5%); Feedback and Communication About Error dimension (58.3%); Frequency of Events Reported dimension (54.0%); Teamwork Across Units dimension (73.2%). Most of areas perceived that there is no event reported (76.1-85.3%) in the past 12 months.Overall patient safety grade is more than moderate in the clinic. Teamwork within Units and Organizational Learning-Continuous Improvement dimension had the highest score while staffing had the lowest score. Dental assistants perceived positive score in most dimensions while students perceived slight negative score in most dimensions.

Must we remain blind to undergraduate medical ethics education in Africa? A cross-sectional study of Nigerian medical students

BACKGROUND

As the practice of medicine inevitably raises both ethical and legal issues, it had been recommended since 1999 that medical ethics and human rights be taught at every medical school. Most Nigerian medical schools still lack a formal undergraduate medical ethics curriculum. Medical education remains largely focused on traditional medical science components, leaving the medical students to develop medical ethical decision-making skills and moral attitudes passively within institutions noted for relatively strong paternalistic traditions. In conducting a needs assessment for developing a curriculum germane to the Nigerian society, and by extension most of Sub-Saharan Africa, this study determined the views of Nigerian medical students on medical ethics education, ethical issues related to the doctor-patient relationship and the ethical/professional dilemmas they are confronted with.

METHODS

Using self-administered 63-item structured questionnaires, a cross-sectional survey of the final year medical students of the University of Nigeria was conducted in July 2015.Using the Statistical Package for the Social Sciences software (SPSS Version 17), frequency counts and percentages were generated.

RESULTS

The sample included 100 males (71.4%) and 40 females (28.6%), with the respective mean (SD) age being 24.6(5.61) and 21.8 (6.38) years. Only 35.7% were satisfied with their medical ethics knowledge, and 97.9% indicated that medical ethics should be taught formally. Only 8.6% had never witnessed a medical teacher act unethically. The dilemmas of poor communication between physicians and patients, and the provision of sub-standard care were reported highest for being encountered 'often'. A majority (60.7%) indicated that "a doctor should do his best always, irrespective of the patient's wishes". No significant difference in responses across gender was noted.

CONCLUSION

There is a strong desire by the contemporary Nigerian medical student for medical ethics education. Their lack of exposure in medical ethics in an ethically challenging environment suggest a dire need for the development of an appropriate medical ethics curriculum for them and the provision of an ethically conducive learning environment.

How do emergency ambulance paramedics view the care they provide to people who self harm?: Ways and means

The UK has one of the highest rates of self harm (SH) in Europe, and almost four times more people die by suicide than in road traffic collisions. Emergency ambulance paramedics are often the first health professionals involved in the care of people who have self-harmed, yet little is known about the care provided or issues raised in these encounters. The aim of this study is to explore paramedics' perceptions and experiences of caring for people who SH, to inform education and policy. Semi structured interviews were conducted with paramedics, and themes generated by constant comparison coding. This paper reports two emerging themes: Firstly, professional, legal, clinical and ethical tensions, linked to limited decision support, referral options and education. The second theme of relationships with police, revealed practices and surreptitious strategies related to care and detention, aimed at overcoming complexities of care. In the absence of tailored education, guidance or support for self-harm care, 'ways and means' have evolved which may negatively influence care and challenge ethical and legal frameworks. There is an urgent need to include evidence from this study in revised guidance and educational materials for paramedics working with people who self-harm in the prehospital emergency setting.

Measuring Moral Courage for Interns and Residents: Scale Development and Initial Psychometrics

PURPOSE

To develop a practical and psychometrically sound set of survey items that measures moral courage for physicians in the context of patient care.

METHOD

In 2013, the 731 internal medicine and surgical interns and residents from two northeastern U.S. academic medical centers were invited to anonymously complete a survey about moral courage, empathy, and speaking up about patient safety breaches.

RESULTS

Of the eligible participants, 352 (48%) responded. Principal components analysis of the moral courage items demonstrated a single, meaningful, nine-item factor labeled the Moral Courage Scale for Physicians (MCSP). All item-total score correlations were significant (P < .001) and ranged from 0.57 to 0.76. The Cronbach alpha for the MCSP was 0.90. Consistent with expectations based on theory, MCSP scores were negatively associated with being an intern versus resident (B = -4.17, P < .001), suggesting discriminant validity. MCSP scores were positively associated with respondents' Jefferson Scale of Physician Empathy perspective-taking score (B = 0.53, P < .001), a construct conceptually relevant to moral courage, suggesting convergent validity. Finally, MCSP scores were positively correlated with self-reported speaking up about patient safety breaches (r = 0.19, P = .008), an action that involves moral courage, suggesting concurrent validity.

CONCLUSIONS

The authors provided initial evidence for the reliability and validity of a measure of moral courage for physicians. The MCSP may help researchers and educators to tangibly measure physician moral courage as a concept, and track progress on a set of desired behaviors in response to curricular interventions.

A Curriculum for Clerkship Students to Foster Professionalism Through Reflective Practice and Identity Formation

INTRODUCTION

Research suggests that students become less patient-centered and empathetic in response to both internal and external factors, including the organizational culture, or hidden curriculum, of medical school. Students often feel compelled to make compromises when they experience tension between competing values in clinical teaching environments. To address this, we implemented a modular, longitudinal professionalism curriculum for third-year medical students, based on a conceptual model that highlights a student's ideal, as well as the internal and environmental forces that can either sustain or change their ideal over time.

METHODS

As students progressed through the third year, they participated in various modules linked to different clerkships, each focusing on a different aspect of the conceptual model. Each module includes a reflective writing exercise followed by a faculty-facilitated discussion.

RESULTS

In general, students rated the group discussions and faculty facilitation as the most useful parts of each session and the writing exercises as the least useful. Written comments were mostly favorable and suggested that the session facilitated self-reflection and provided a safe environment for students to discuss stressors of third-year clerkships.

DISCUSSION

This curriculum represents a unique approach to fostering professional role formation through its broad potential applicability to multiple types and levels of learners, its adaptability to fit various course lengths and learning environments, and its incorporation of a conceptual model that allows individual learners to address different facets of the sustaining and acculturating forces that impact their personal professional identity formation for future encounters.

Ethical issues identified by obstetrics and gynecology learners through a novel ethics curriculum

OBJECTIVE

Obstetrics and gynecology (ob/gyn) is fraught with bioethical issues, the professional significance of which may vary based on clinical experience. Our objective was to utilize our novel ethics curriculum to identify ethics and professionalism issues highlighted by ob/gyn learners and to compare responses between learner levels to further inform curricular development.

STUDY DESIGN

We introduced an integrated and dynamic ob/gyn ethics and professionalism curriculum and mixed methods analysis of 181 resulting written reflections (case observation and assessments) from third-year medical students and from first- to fourth-year ob/gyn residents. Content was compared by learner level using basic thematic analysis and summary statistics.

RESULTS

Within the 7 major ethics and professionalism domains, learners wrote most frequently about miscellaneous ob/gyn issues such as periviability and abortion (22% of students, 20% of residents) and problematic treatment decisions (20% of students, 19% of residents) rather than professional duty, communication, justice, student-/resident-specific issues, or quality of care. The most commonly discussed ob/gyn area by both learner groups was obstetrics rather than gynecology, gynecologic oncology, or reproductive endocrinology and infertility, although residents were more likely to discuss obstetrics-related concerns than students (65% vs 48%; P = .04) and students wrote about gynecologic oncology-related concerns more frequently than residents (25% vs 6%; P = .002). In their reflections, sources of ethical value (eg, the 4 classic ethics principles, professional guidelines, and consequentialism) were cited more frequently and in greater number by students than by residents (82% of students cited at least 1 source of ethical value vs 65% of residents; P = .01). Residents disagreed more frequently with the ethical propriety of clinical management than did students (67% vs 43%; P = .005).

CONCLUSION

Our study introduces an innovative and dynamic approach to an ob/gyn ethics and professionalism curriculum that highlights important learner-identified ethics and professionalism issues both specific to ob/gyn and common to clinical medicine. Findings will help ob/gyn educators best utilize and refine this flexible curriculum such that it is appropriately focused on topics relevant to each learner level.

Cross-cultural perspectives on the patient-provider relationship: a qualitative study exploring reflections from Ghanaian medical students following a clinical rotation in the United States

BACKGROUND

In international health experiences, learners are exposed to different culturally-based patient care models. Little is known about student perceptions of patient-provider interactions when they travel from low-to high-resource settings. The purpose of this study was to explore these reflections among a subset of Ghanaian medical students who participated in clinical rotations at the University of Michigan Medical School (UMMS).

METHODS

In-depth, semi-structured interviews lasting 60-90 min were conducted with 15 individuals who had participated in 3-to 4-week clinical rotations at UMMS between January 2008 and December 2011. Interviews were conducted from March to August 2012 and transcribed verbatim, then independently coded by three investigators. Investigators compared open codes and reached a consensus regarding major themes.

RESULTS

Participating Ghanaian medical students reported that their perspectives of the patient-provider relationship were significantly affected by participation in a UMMS rotation. Major thematic areas included: (1) observations of patient care during the UMMS rotation, including patient comfort and privacy, physician behavior toward patients, and patient behavior; (2) reflections on the role of humanism and respect within patient care; (3) barriers to respectful care; and (4) transformation of student behaviors and attitudes. Students also reported integrating more patient-centered care into their own medical practice upon return to Ghana

DISCUSSION

Participation in a US-based clinical rotation has the potential to introduce medical students from resource-limited settings to a different paradigm of patient-provider interactions, which may impact their future behavior and perspectives regarding patient care in their home countries.

CONCLUSIONS

Students from under-resourced settings can derive tremendous value from participation in clinical electives in more affluent settings, namely through exposure to a different type of medical care.

Must we be courageous?

Courage is indispensable. Telling caregivers they must be courageous in difficult circumstances is sometimes a back-handed endorsement of oppression, however.

An investigation of students' perceptions of ethical practice: engaging a reflective dialogue about ethics education in the health professions

The ethical climate in which occupational therapists, and other health practitioners, currently practice is increasingly complex. There have been a number of calls for greater attention to ethics education within health science curricula. This study investigated occupational therapy students' perceptions of the meaning of ethical practice as a means of engaging in a dialogue about the aims of ethics education in contemporary health science contexts. A phenomenological methodological approach was adopted for the study. Interviews were conducted over 2 years with 25 student participants. The data were analyzed using phenomenological methods of analysis. Seven themes depict students' views about the meaning of ethical practice and include: being faithful to the tenets of your practice, being communicative, being in tune with your values, understanding the client's needs, weighing the pros and cons, negotiating the grey zones, and taking time to reflect. The findings contribute to understanding students' conceptions of the meaning of ethical practice that include and move beyond traditional codes, principles, and professional standards to encompass a range of dimensions of ethical practice. These additional dimensions raise insights of relevance to those who design and facilitate ethics education with health professionals.

Imagining alternative professional identities: reconfiguring professional boundaries between nursing students and medical students

The transition of a medical student or a nursing student into a health care practitioner requires many changes. Among these is the development of an appropriate professional identity, which assists in the establishment of a sound base for professional practice and therefore should be a focus for health professions educators. There is evidence, however, that medical education and nursing education face challenges in guiding students' development of appropriate professional identities. In medicine, there is concern that medical education may contribute to the development of professional identities that alienate patients rather than identities that are patient centered. The nursing profession struggles with poor retention rates in the workforce, which have been attributed in part to discrepancies between the professional identities that students develop during nursing school and the realities of professional practice.In this Perspective, the authors explore the importance of and the pedagogical strategies used to facilitate professional identity formation for medical and nursing students. They argue that medical and nursing educators aim to instill in their students strong occupational identities which may perpetuate hierarchical disciplinary boundaries. They suggest that health professions educators should move beyond current disciplinary silos and create interprofessional education opportunities for medical students and nursing students to learn together to facilitate the development of the collaborative interprofessional identities necessary for the delivery of high-quality, patient-centered health care.

Ethical violations in the clinical setting: the hidden curriculum learning experience of Pakistani nurses

Background

The importance of the hidden curriculum is recognised as a practical training ground for the absorption of medical ethics by healthcare professionals. Pakistan’s healthcare sector is hampered by the exclusion of ethics from medical and nursing education curricula and the absence of monitoring of ethical violations in the clinical setting. Nurses have significant knowledge of the hidden curriculum taught during clinical practice, due to long working hours in the clinic and front-line interaction with patients and other practitioners.

Methods

The means of inquiry for this study was qualitative, with 20 interviews and four focus group discussions used to identify nurses’ clinical experiences of ethical violations. Content analysis was used to discover sub-categories of ethical violations, as perceived by nurses, within four pre-defined categories of nursing codes of ethics: 1) professional guidelines and integrity, 2) patient informed consent, 3) patient rights, and 4) co-worker coordination for competency, learning and patient safety.

Results

Ten sub-categories of ethical violations were found: nursing students being used as adjunct staff, nurses having to face frequent violence in the hospital setting, patient reluctance to receive treatment from nurses, the near-absence of consent taken from patients for most non-surgical medical procedures, the absence of patient consent taking for receiving treatment from student nurses, the practice of patient discrimination on the basis of a patient’s socio-demographic status, nurses withdrawing treatment out of fear for their safety, a non-learning culture and, finally, blame-shifting and non-reportage of errors.

Conclusion

Immediate and urgent attention is required to reduce ethical violations in the healthcare sector in Pakistan through collaborative efforts by the government, the healthcare sector, and ethics regulatory bodies. Also, changes in socio-cultural values in hospital organisation, public awareness of how to conveniently report ethical violations by practitioners and public perceptions of nurse identity are needed.

The emotions of graduating medical students about prior patient care experiences

OBJECTIVES

To determine the emotional responses to patient care activities described by fourth year medical students.

METHODS

Qualitative content analysis for emerging themes in letters written by graduating medical students to patients during a Capstone Course. The patient need not be alive and the letter would never be sent.

RESULTS

Six themes emerged from student letters: (1) Sorrow for the depths of patient suffering; (2) Gratitude towards patients and their families; (3) Personal responsibility for care provided to patients; (4) Regret for poor care provided by the student or student's team; (5) Shattered expectations about medicine and training; and (6) Anger towards patients. Students expressed sensitivity to vulnerable patients, including those who were alone, unable to communicate, or for whom care was biased. Students' expressed powerlessness (inability to cure, managing a work-life balance, and challenges with hierarchy) in some essays.

CONCLUSION

At graduation, medical students describe strong emotions about previous patient care experiences, including difficulty witnessing suffering, disappointment with medicine, and gratitude to patients and their families

PRACTICE IMPLICATIONS

Providing regular opportunities for writing throughout medical education would allow students to recognize their emotions, reflect upon them and promote wellness that would benefit students and their patients.

Caring for tomorrow's workforce: Moral resilience and healthcare ethics education

BACKGROUND

Preparing tomorrow's healthcare workforce for managing the growing complexity of care places high demands on students, educators, and faculties. In the light of worrying data about study-related stress and burnout, understanding how students manage stressors and develop resilience has been identified as a priority topic of research. In addition to study-related stressors, also moral stressors are known to characterize the students' first clinical experiences.

OBJECTIVES

However, current debates show that it remains unclear how healthcare ethics education should address them. In order to clarify this issue, this study first develops the notion of moral resilience as a response to moral stressors involving both situations of moral complexity and moral wrongness. Second, it explores the potential of healthcare ethics education in fostering moral resilience. For this purpose, it defines moral resilience operationally as a reduction of moral distress in a given axis of time measured by a validated tool.

RESEARCH DESIGN, PARTICIPANTS, AND CONTEXT

The educational transferability was assessed within an explorative, quantitative pre-post interventional study with a purposive sample of 166 nursing students. The educational intervention comprised a lecture introducing the typology of moral stressors. Before and after the lecture, students were presented vignettes depicting morally stressful situations.

ETHICAL CONSIDERATIONS

The competent research ethics committee confirmed that no ethical approval was needed. Informed consent was obtained from participants.

FINDINGS

Three of four vignettes showed a modest but statistically significant reduction in measured levels of distress after the lecture (p < 0.05, α = 5%).

DISCUSSION

The study shows the potential of healthcare ethics education in providing students with transformative knowledge that fosters moral resilience.

CONCLUSION

In times of global scarcity of educational resources, healthcare ethics education has an important contribution to offer in the promotion of students' mental and physical health by strengthening the knowledge base of moral resilience. This legitimates its costs for societies, faculties, and professional bodies.

The good and bad of group conformity: a call for a new programme of research in medical education

CONTEXT

Given that a significant portion of medical education occurs in various social settings (small groups, large classes, clinical environments), it is critical to examine how group members interact. One type of influence on these interactions is conformity, whereby an individual changes his or her own behaviour to match incorrect responses of others in a group. Conformity to peer pressure has been replicated in experimental research conducted in many countries over the last 60 years. There is newly emerging empirical evidence of this effect in medical education, suggesting that subtle motivations and pressures within a group may prevent students from challenging or questioning information that seems incorrect.

OBJECTIVES

This narrative review aims to present an overview of theory and findings in research into conformity in the fields of social psychology, business, sociology and aviation theory to demonstrate its direct relevance to medical education and the health professions.

METHODS

We searched online databases (MEDLINE, PubMed, PsycINFO and ProQuest) from the University of Calgary catalogue. We also searched citations in articles reviewed and references provided by colleagues. We limited our narrative review to publications released between 1950 and 2012.

RESULTS

Group conformity behaviour may be one of a number of communication challenges associated with interprofessional care, and may represent a factor contributing to the burden of adverse events. This paper calls for a new programme of research into conformity in medical education that provides systematic empirical evidence of its relevance and applications in education, health care and practice.

CONCLUSIONS

This review reveals decades of anecdotal and empirical evidence that conformity is a pervasive phenomenon across disciplines. Further research is needed to elucidate which situations pose the greatest risk for the occurrence of conformity, how to manage it in practice and its implications for patient safety.

Teaching medical ethics to meet the realities of a changing health care system

The changing context of medical practice--bureaucratic, political, or economic--demands that doctors have the knowledge and skills to face these new realities. Such changes impose obstacles on doctors delivering ethical care to vulnerable patient populations. Modern medical ethics education requires a focus upon the knowledge and skills necessary to close the gap between the theory and practice of ethical care. Physicians and doctors-in-training must learn to be morally sensitive to ethical dilemmas on the wards, learn how to make professionally grounded decisions with their patients and other medical providers, and develop the leadership, dedication, and courage to fulfill ethical values in the face of disincentives and bureaucratic challenges. A new core focus of medical ethics education must turn to learning how to put ethics into practice by teaching physicians to realistically negotiate the new institutional maze of 21st-century medicine.

Negative ethical behaviors in Saudi hospitals: How prevalent are they perceived to be? - Statement agreement study

BACKGROUND:

There is limited information about the prevalence of unethical behavior and how is perceived among health care providers. The aim of this study is to assess such behavior and how is perceived.

MATERIALS AND METHODS:

This is a cross-sectional study among three groups of professionals. Total participants were 370 and included medical staff, medical residents, and nurses in five medical specialties in four tertiary hospitals in Saudi Arabia (two Ministry of Health Hospitals and two military Hospitals). Participants were asked to rate their agreement with occurrence of 15 “negative” unethical behavior scenarios in their workplace. The scenarios covered areas of “respect for persons”, “interprofessional relationships”, and “empathy with patients”.

RESULTS:

Majority of respondents agreed that “unethical” behavior occurred in their workplace, including confidentiality being compromised (36.3%), informed consent not taken properly (60.2%), and bad news not well-delivered (62.2%). Other significant area agreement included doctors lacking empathy (47.8%), patient autonomy not fully respected (42.5%), discrimination (41.2%), and being pressurized to write inaccurate reports (31.2%). Respondents in medicine had the lowest rate of agreement and those in psychiatry had the highest (mean of 49.8% and 82.3%, respectively). Respondents with length of employment of less than 6 years had significantly higher agreement that unethical behavior occurs compared to those with length of employment of more than 6 years. Males were more likely than females to agree that unethical behavior occurs. The biggest difference was seen in the behavior of “informed consent not properly taken” with a gender margin of 18.7% (P = 0.001).

CONCLUSION:

There is high prevalence of behavior that is considered unethical as perceived by various health care workers at Saudi hospitals.

Ethical dilemmas in clerkship rotations

A sound clinical education should include the opportunity for medical students to engage in a spirited and informed discussion with faculty about the ethical challenges they will undoubtedly face. Unfortunately, in many medical schools today this goal is thwarted by many factors, including denial that a problem exists, relentless system overload, unprofessional behavior, breakdown in communication, and inertia. What is worse is that this problem is not new, and the fallout is not insignificant. Another potential contributing factor is burnout, which is well documented in a high percentage of medical students, residents, and faculty, and two of its most serious consequences are patient dissatisfaction and medical error.The authors draw on hundreds of student reflections on ethical dilemmas submitted during classroom exercises to examine persistent themes. They posit that classroom and didactic teaching is not enough to enable students to face ethical dilemmas. The authors call for a major culture change in medical education: "buy in" from top administration, especially the dean (and associate/assistant deans), chairs of all departments, and clerkship and residency training directors; the appointing of an ombudsperson and/or ethicist to oversee and resolve issues as they arise; instructional workshops and materials to enhance and impart skills for all teachers; remediation or retiring of errant faculty; and ongoing research and dialogue between and among medical centers about novel solutions.

Undesirable features of the medical learning environment: a narrative review of the literature

The objective of this narrative review of the literature is to draw attention to four undesirable features of the medical learning environment (MLE). First, students' fears of personal inadequacy and making errors are enhanced rather than alleviated by the hidden curriculum of the clinical teaching setting; second, the MLE projects a denial of uncertainty, although to a lesser degree than in the past; third, many students feel publicly belittled and subject to other forms of abuse; and fourth, the MLE fails in overcoming students' prejudice against mental illness and reluctance to seek help when emotionally distressed. The variability of students' appreciation of the MLE across medical schools, as well as across clinical departments within medical schools, suggests that the unwanted aspects of the MLE are modifiable. Indeed, there have been calls to promote a "nurturing" MLE, in which medical students are treated as junior colleagues. It stands to reason that faculty cannot humiliate medical students and still expect them to respect patients, just as it is impossible to ignore students' distress, and still teach them to empathize with patients. Hopefully, an egalitarian attitude to students will make them also realize that they are not alone in their fears, and that their instructors share their doubts. Therefore, a major challenge of contemporary medical education is to advance a clinical MLE, where errors and uncertainties are acknowledged rather than denied, and trainees are trusted and supported, rather than judged and, occasionally, derided.

Enculturation of unsafe attitudes and behaviors: student perceptions of safety culture

PURPOSE

Safety culture may exert an important influence on the adoption and learning of patient safety practices by learners at clinical training sites. This study assessed students' perceptions of safety culture and identified curricular gaps in patient safety training.

METHOD

A total of 170 fourth-year medical students at the University of California, San Francisco, were asked to complete a modified version of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture in 2011. Students responded on the basis of either their third-year internal medicine or surgery clerkship experience. Responses were recorded on a five-point Likert scale. Percent positive responses were compared between the groups using a chi-square test.

RESULTS

One hundred twenty-one students (71% response rate) rated "teamwork within units" and "organizational learning" highest among the survey domains; "communication openness" and "nonpunitive response to error" were rated lowest. A majority of students reported that they would not speak up when witnessing a possible adverse event (56%) and were afraid to ask questions if things did not seem right (55%). In addition, 48% of students reported feeling that mistakes were held against them. Overall, students reported a desire for additional patient safety training to enhance their educational experience.

CONCLUSIONS

Assessing student perceptions of safety culture highlighted important observations from their clinical experiences and helped identify areas for curricular development to enhance patient safety. This assessment may also be a useful tool for both clerkship directors and clinical service chiefs in their respective efforts to promote safe care.

Exploring the hidden curriculum: a qualitative analysis of clerks' reflections on professionalism in surgical clerkship

BACKGROUND

Professionalism is an important part of the hidden curriculum that is gaining attention in surgical education. McMaster University, Hamilton, Ontario, Canada, has introduced a small group discussion model using critical incident reports (CIRs) to elicit students' reflections on ethical, communication, and professionalism challenges during surgical clerkship. We described the themes identified by surgical clerks in their CIRs.

METHODS

Using thematic analysis, 4 investigators coded 64 CIRs iteratively until conceptual saturation. Rigor and validity were ensured throughout the process. Data were further explored to compare the CIRs of junior and senior clerks.

RESULTS

Twenty-seven themes and 4 relationship domains emerged: the clerk's relationship to patients, the health care team, the health care system, and self. Challenges with communication, the consent process, and breaking bad news were most commonly cited. Theme frequencies differed between junior and senior clerks.

CONCLUSIONS

Small group discussions of critical incident reports allow surgical clerks to reflect on their developing professional relationships. The themes that have been identified can be used to guide professionalism education and uncover the hidden curriculum.

"It's just a clash of cultures": emotional talk within medical students' narratives of professionalism dilemmas

Recent investigations into the UK National Health Service revealed doctors' failures to act with compassion and professionalism towards patients. The British media asked questions about what happens to students during their learning that influences such behaviour as doctors. We listened to 200 medical students' narratives of professionalism dilemmas during workplace learning (n = 833) to understand the range of dilemmas experienced and emotional reactions to them. 32 group and 22 individual interviews were held across three medical schools (England, Wales, Australia). Data were analysed thematically (Framework Analysis), for negative emotional content (Linguistic Inquiry and Word Count) and a narrative analysis of one exemplar narrative was also conducted. While a wider range of professionalism dilemmas than previously identified were found, most were classified to five main sub-themes. Within these sub-themes, clinical students' narratives contained more negative emotion words than pre-clinical students' narratives (p = 0.046, r = -0.36). Narratives of 'patient safety and dignity breaches by students' contained fewer anger words (p = 0.003, r = -0.51), 'patient safety and dignity breaches by healthcare professionals' contained more anger words (p = 0.042, r = -0.37), 'identity' narratives contained fewer anxiety words (p = 0.034, r = 0.38), and 'abuse' narratives contained more sadness words (p = 0.013, r = -0.47). The narrative analysis revealed a complex interplay between identities, attribution of blame, narrated emotions and emotional residue. Analysing emotional talk within narratives suggests that medical students sometimes struggle with contradictory formal and informal learning experiences around professionalism arising from a cultural clash. We provide educational recommendations to facilitate students' coping with their emotional reactions to professionalism dilemmas and to facilitate cultural change.

Ethical problems in pediatrics: what does the setting of care and education show us?

Background

Pediatrics ethics education should enhance medical students' skills to deal with ethical problems that may arise in the different settings of care. This study aimed to analyze the ethical problems experienced by physicians who have medical education and pediatric care responsibilities, and if those problems are associated to their workplace, medical specialty and area of clinical practice.

Methods

A self-applied semi-structured questionnaire was answered by 88 physicians with teaching and pediatric care responsibilities. Content analysis was performed to analyze the qualitative data. Poisson regression was used to explore the association of the categories of ethical problems reported with workplace and professional specialty and activity.

Results

210 ethical problems were reported, grouped into five areas: physician-patient relationship, end-of-life care, health professional conducts, socioeconomic issues and health policies, and pediatric teaching. Doctors who worked in hospitals as well as general and subspecialist pediatricians reported fewer ethical problems related to socioeconomic issues and health policies than those who worked in Basic Health Units and who were family doctors.

Conclusions

Some ethical problems are specific to certain settings: those related to end-of-life care are more frequent in the hospital settings and those associated with socioeconomic issues and public health policies are more frequent in Basic Health Units. Other problems are present in all the setting of pediatric care and learning and include ethical problems related to physician-patient relationship, health professional conducts and the pediatric education process. These findings should be taken into consideration when planning the teaching of ethics in pediatrics.

Trial registration

This research article didn't reports the results of a controlled health care intervention. The study project was approved by the Institutional Ethical Review Committee (Report CEP-HIJG 032/2008).

Ethical issues confronted by medical students during clinical rotations

OBJECTIVES

This study aimed to examine the most common and important ethical issues confronting medical students during clinical rotations so that ethics-related topics can be prioritised according to students' needs and this information used to develop a curriculum for the ethics course.

METHODS

In a cross-sectional approach, we reviewed the medical ethics-related cases recorded in the logbooks of all medical students (n=241) at Tehran University of Medical Sciences who attended the medical ethics course during October 2006 to July 2007. As part of a graded assignment, each student was required to record three encounters with ethics-related issues in his or her logbook. A total of 713 cases were assessed. Information related to the ethical issues and the conditions in which ethical issues arose was extracted and recorded by two experts, whose analysis showed agreement of kappa 0.77. In cases of discrepancy, both experts reviewed and discussed the record until they achieved agreement.

RESULTS

A total of 713 cases were analysed. The most common issues reported by students related to ethics in medical education (20.1%, n=143), professionalism (18.8%, n=134), confidentiality (7.6%, n=54), the doctor-patient relationship (7.3%, n=52), informed consent (7.0%, n=50) and the doctor-peer relationship (7.0%, n=50). After adjusting for length of rotation, the highest numbers of ethics-related incidents were reported from urology, general surgery, orthopaedics, internal medicine, neurology, and obstetrics and gynaecology wards.

CONCLUSIONS

The results of this study indicate that professionalism and related elements represent one of the most important areas of concern that need to be addressed when planning courses for medical students. The other significant area of concern is that of ethics in medical education, which, although the subject is not considered essential for medical practitioners, should be taught and respected so that student sensitivity to medical ethics is maintained and even increased.

Humanities in undergraduate medical education: a literature review

PURPOSE

Humanities form an integral part of undergraduate medical curricula at numerous medical schools all over the world, and medical journals publish a considerable quantity of articles in this field. The aim of this study was to determine the extent to which the literature on humanities in undergraduate medical education seeks to provide evidence of a long-term impact of this integration of humanities in undergraduate medical education.

METHOD

Medline was searched for publications concerning the humanities in undergraduate medical education appearing from January 2000 to December 2008. All articles were manually sorted by the authors. Two hundred forty-five articles were included in the study. Following a qualitative analysis, the references included were categorized as "pleading the case," "course descriptions and evaluations," "seeking evidence of long-term impact," or "holding the horses."

RESULTS

Two hundred twenty-four articles out of 245 either praised the (potential) effects of humanities on medical education or described existing or planned courses without offering substantial evidence of any long-term impact of these curricular activities on medical proficiency. Only 9 articles provided evidence of attempts to document long-term impacts using diverse test tools, and 10 articles presented relatively reserved attitudes toward humanities in undergraduate medical education.

CONCLUSIONS

Evidence on the positive long-term impacts of integrating humanities into undergraduate medical education is sparse. This may pose a threat to the continued development of humanities-related activities in undergraduate medical education in the context of current demands for evidence to demonstrate educational effectiveness.