In-depth learning: one school's initiatives to foster integration of ethics, values, and the human dimensions of medicine

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.

Combining Ethics Inquiry and Clinical Experience in a Premedical Health Care Ethics Internship

PROBLEM

The professional formation of physicians begins in the premedical years, and educators are now recommending that medical ethics and humanities courses be considered essential components to becoming a physician rather than elective prerequisites for medical school admission. As a result, questions have arisen about how to teach students ethical reasoning skills before their professional training, as they have limited opportunities now to develop these skills and the related competencies in a real-world medical context.

APPROACH

The authors describe Santa Clara University's Health Care Ethics Internship (HCEI), an undergraduate college experience that emphasizes ethical inquiry and immerses students in health care settings to foster deep learning. The HCEI includes mentored clinical rotations integrated with classroom inquiry into ethical theory, structured reflection, and professional development considerations. A survey of former students (academic years 2001-2002 to 2017-2018) explored their perceptions of these program components and the impact of the experience on their preprofessional readiness, career choice, and professional capabilities.

OUTCOMES

Of 185 former students who could be contacted, 89 (48.1%) completed the survey. Students reported that the HCEI: (1) assisted them in gaining admission to medical school, (2) had a positive influence on their career decisions, (3) increased their professional capabilities, (4) helped them develop preprofessional competencies, (5) gave them knowledge and experience they used in their personal and professional ethical decision making, and (6) increased their moral sensitivity and ethical responsibility.

NEXT STEPS

Integrating clinical rotations into ethics education exposes premedical students to real-world ethical questions, helps them develop a nuanced understanding of a health care career, and prepares them for the medical school admissions process. Other universities should consider implementing a similar program to prime their students for continued professional and moral development during medical school and residency.

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.

[Mentoring for medical students : Description and evaluation of a differentiated mentoring program at a medical school]

In recent years, mentoring programs for medical students have been increasingly implemented in medical schools in Germany. This article describes a voluntary mentoring program for students, which is differentiated into a common mentoring program (AP), a mentoring program for excellent students (EP) and a mentoring plus program (PP) for students with academic difficulties, and its evaluation.The evaluation is based on annual evaluation surveys among the participating mentees, who evaluate the mentoring relationship as well as the impact on their studies.The three student groups differ significantly with regard to sociodemographic variables. The satisfaction with the mentoring program is generally high: 84-94% are mentored by their preferred mentor, the majority assesses the conversational atmosphere as open (78-91%), and 89-98% would recommend participation in the program to others. The programs differ with regard to specific aspects. While PP mentees report the highest ratings on the mentor's accessibility, trustworthiness and feedback, EP mentees report the highest ratings on the mentor's competence as well as increased identification with the faculty and early career promotion through the mentoring program.The different assessments of the three programs as well as the generally high acceptance and satisfaction ratings indicate that such a differentiated mentoring program provides a framework of individual support, which is highly appreciated by most students.

Building bridges between medicine and the humanities: The role of scaffolds and articulation in surgical learning

Introduction: Learning about medicine from the humanities is a complex process that requires pedagogical strategies to avoid fragmentation and the paradox of transference. Instructional design in surgical education for these purposes is limited. Objective: To present the results of an educational strategy for the integration of surgery and the medical humanities based on the theoretical perspectives of the cognitive apprenticeship model and to assess its association with the students’ perceptions of learning. Materials and methods: An instructional design was developed for the teaching of clinical conditions through the medical humanities. Students’ perceptions of teachers’ support and articulation for the integration of both disciplines, as well as students’ self-perceptions of learning, were evaluated using validated questionnaires. Linear regression models were used to test the proposed association. Results: A total of 216 students was included in the analysis. High scores were obtained for each variable. The increase of one unit of teacher support and articulation for the integration of both disciplines was associated with an increase in student perception of learning (b) of 0.45 (CI 95% 0.30-0.60) and 0.40 (CI 95% 0.25 -0.55) (R2=0.64, p<0.001), respectively. Conclusions: Educational strategies focused on the techniques of support and articulation with the aim of integrating the medical humanities and surgery, demonstrated positive associations with students’ perceptions of learning. Further studies are needed to evaluate the effects of these interventions on memory and long-term learning.

The medical students' perspective of faculty and informal mentors: a questionnaire study

BACKGROUND

Student mentoring is an important aspect of undergraduate medical education. While medical schools often assign faculty advisors to medical students as mentors to support their educational experience, it is possible for the students to pursue mentors informally. The possible role of these informal mentors and their interactions with the students in a faculty mentorship program has not been reported. This study builds upon previous work that suggested many students have informal mentors, and that there might be interplay between these two types of mentors. This study was conducted to report the experience of undergraduate medical students in a faculty mentorship program of their faculty mentors and if applicable, of their informal mentors.

METHODS

One month before residency (post-graduate training for Canadians) ranking, the survey was administered to the graduating class of 2014 at the University of Calgary's Cumming School of Medicine. The survey was created from focus groups of the previous graduating class of 2013. The survey investigated meeting characteristics and the students' perceptions of faculty advisors and informal mentors, and the students' intended choice for residency.

RESULTS

The study response rate was 86% (95 of 111); 58% (54 of 93) of the students reported having an informal mentor. There was no reported difference in satisfaction ratings of the Faculty mentorship program between students with only faculty mentors and those with also informal mentors. Students' reporting of their satisfaction with the Faculty mentorship program and the faculty mentors did not differ between the students with informal mentors and those with faculty mentors only. The students' meeting frequency, discussed topics, and perceived characteristics of faculty mentors were not associated with having an informal mentor. The students generally perceived their informal mentors more positively than their faculty mentors. The reported student career intention was associated with the discipline of informal mentors and not with the discipline of faculty mentors.

CONCLUSIONS

Informal mentorship was common for medical students. The presence of an informal mentor was not associated with dissatisfaction with the Faculty advisor or with the mentorship program. It is likely students may pursue informal mentorship for career-related reasons.

Mentorship: concepts and application to plastic surgery training programs

BACKGROUND

Countless articles have demonstrated and emphasized the importance of mentoring in academic medicine. However, the upcoming role of mentors in the evolving medical field is poorly defined. As translational medicine, collaboration, and health care priorities change, so too must the goals and use of mentoring. The aims of this article are to demonstrate key aspects of effective mentoring in academic plastic surgery, show institutions how to cultivate mentoring relationships among their faculty and trainees, and provide direction for how to optimize the future use of mentoring to best prepare the next generation of plastic surgeons.

METHODS

The authors reviewed the current literature regarding mentorship and the evolution of academic plastic surgery.

RESULTS

Mentors not only facilitate their protégés' entrance into the field and future success, but can also attract medical students and residents to careers in research and reduce the racial and gender discrepancies in plastic surgery and academia. Ideally, faculty should undergo some form of training before they enter mentoring relationships. This will ensure that they are aware of their specific duties as mentors, are able to communicate with mentees, and can avoid potential pitfalls.

CONCLUSIONS

Mentorship is a tool. If used correctly, it can help recruit and retain talented physician-scientists to plastic surgery to satisfy the growing demand. This will require institutions to actively support mentorship, provide opportunities and resources for training mentors, and enable faculty to allocate time to this vital pursuit.

Medical students hierarchy of values and sense of responsibility

BACKGROUND

Ethical skills and personal values contribute to making students competent and humane physicians. However, there is not much research done on medical students' personal values and sense of responsibility.

PURPOSES

The study was designed to examine differences in personal values and sense of responsibility between medical students and their peers.

METHODS

The students performed demographic survey and reliable tests: Scheler's Value Scale and Responsibility Scale.

RESULTS

Medical students scored higher in responsibility, also in values of hedonism and truth, and scored lower in values of holy, both religion and secularism. They did not differ from the control group in values of vitality, aesthetics, morals, physical fitness as well as strength and stamina.

CONCLUSION

Medical students differ from their peers from other faculties at the level of responsibility and hierarchy of values. They rate higher at such values as hedonism and truth and lower values of holy.

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.

Mentoring programs for medical students--a review of the PubMed literature 2000-2008

BACKGROUND

Although mentoring is acknowledged as a key to successful and satisfying careers in medicine, formal mentoring programs for medical students are lacking in most countries. Within the framework of planning a mentoring program for medical students at Zurich University, an investigation was carried out into what types of programs exist, what the objectives pursued by such programs are, and what effects are reported.

METHODS

A PubMed literature search was conducted for 2000 - 2008 using the following keywords or their combinations: mentoring, mentoring program, medical student, mentor, mentee, protégé, mentorship. Although a total of 438 publications were identified, only 25 papers met the selection criteria for structured programs and student mentoring surveys.

RESULTS

The mentoring programs reported in 14 papers aim to provide career counseling, develop professionalism, increase students' interest in research, and support them in their personal growth. There are both one-to-one and group mentorships, established in the first two years of medical school and continuing through graduation. The personal student-faculty relationship is important in that it helps students to feel that they are benefiting from individual advice and encourages them to give more thought to their career choices. Other benefits are an increase in research productivity and improved medical school performance in general. Mentored students also rate their overall well-being as higher. - The 11 surveys address the requirements for being an effective mentor as well as a successful mentee. A mentor should empower and encourage the mentee, be a role model, build a professional network, and assist in the mentee's personal development. A mentee should set agendas, follow through, accept criticism, and be able to assess performance and the benefits derived from the mentoring relationship.

CONCLUSION

Mentoring is obviously an important career advancement tool for medical students. In Europe, more mentoring programs should be developed, but would need to be rigorously assessed based on evidence of their value in terms of both their impact on the career paths of juniors and their benefit for the mentors. Medical schools could then be monitored with respect to the provision of mentorships as a quality characteristic.

Encouraging scholarship: medical school programs to promote student inquiry beyond the traditional medical curriculum

Many medical curricula now include programs that provide students with opportunities for scholarship beyond that provided by their traditional, core curricula. These scholarly concentration (SC) programs vary greatly in focus and structure, but they share the goal of producing physicians with improved analytic, creative, and critical-thinking skills. In this article, the authors explore models of both required and elective SC programs. They gathered information through a review of medical school Web sites and direct contact with representatives of individual programs. Additionally, they discuss in-depth the SC programs of the Warren Alpert Medical School of Brown University; the University of South Florida College of Medicine; the University of California, San Francisco; and Stanford University School of Medicine. The authors describe each program's focus, participation, duration, centralization, capstone requirement, faculty involvement, and areas of concentration. Established to address a variety of challenges in the U.S. medical education system, these four programs provide an array of possible models for schools that are considering the establishment of an SC program. Although data on the impact of SC programs are lacking, the authors believe that this type of program has the potential to significantly impact the education of medical students through scholarly, in-depth inquiry and longitudinal faculty mentorship.

How to measure success: the impact of scholarly concentrations on students--a literature review

PURPOSE

Scholarly concentrations (SCs) are elective or required curricular experiences that give students opportunities to study subjects in-depth beyond the conventional medical curriculum and require them to complete an independent scholarly project. This literature review explores the question, "What impact do SC programs have on medical students?"

METHOD

In 2008, the authors retrieved published articles using Medline, ERIC, and PsycINFO electronic databases and scanned reference lists to locate additional citations. They extracted data from selected articles using a structured form and used Kirkpatrick's evaluation model to organize learner outcomes into four categories: reactions, learning, behavior, and results.

RESULTS

Of 1,640 citations, 82 full-text papers were considered, and 39 studies met inclusion criteria. Most articles described SC programs that offered students research opportunities. Fourteen articles provided evidence that SC experiences influenced students' choice of clinical specialty or fostered their interest in research. Eight articles reported that SCs improved students' understanding of research principles and methods. Nineteen articles reported publications and presentations to document students' ability to apply acquired knowledge and skills. Twelve studies confirmed the entry of SC graduates into academic medicine with continued engagement in research or success in obtaining grant funding. Students' criticisms focused on requiring research during clinical training and the effort needed to complete scholarly projects.

CONCLUSIONS

The diversity of articles and variable results prevent definitive conclusions about the value of SCs. Findings suggest several implications for future SC program evaluations and educational research. The authors advocate increased rigor in evaluation designs to demonstrate SCs' true impact.

Required vs. elective research and in-depth scholarship programs in the medical student curriculum

The ability to understand and integrate new knowledge into clinical practice is a necessary quality of good physicians. Student participation in in-depth scholarship could enhance this skill in physicians while also creating a larger cadre of physician-scientists prepared to advance the field of medicine. However, because no definitive data exist demonstrating that in-depth scholarship in medical school leads to improved patient care or to productive academic careers, whether such scholarship should be required as part of the medical school curriculum is unclear. In this article, the authors present both sides of this debate. Theoretical benefits to students of a required scholarly program include closer mentorship by individual faculty, enhanced capabilities in critical interpretation of research findings, and increased confidence to investigate conundrums encountered in clinical care. Society may also benefit by having physicians available to create and apply new knowledge related to biomedicine. These theoretical benefits must be balanced, however, by pragmatic considerations of required scholarly projects including their impact on medical school applications, their effect on the medical curriculum, their costs, the availability of mentors, and their effects on the school's educational culture.

Implementation of a longitudinal mentored scholarly project: an approach at two medical schools

An increasing number of medical schools have implemented or are considering implementing scholarly activity programs as part of their undergraduate medical curricula. The goal of these programs is to foster students' analytical skills, enhance their self-directed learning and their oral and written communication skills, and ultimately to train better physicians. In this article, the authors describe the approach to implementing scholarly activities at a school that requires this activity and at a school where it is elective. Both programs have dealt with significant challenges including orienting students to a complex activity that is fundamentally different than traditional medical school courses and clerkships, helping both students and their mentors understand how to "stay on track" and complete work, especially during the third and fourth years, and educating students and mentors about the responsible conduct of research, especially involving human participants. Both schools have found the implementation process to be evolutionary, requiring experience before faculty could significantly improve processes. A required scholarly activity has highlighted the need for information technology (IT) support, including Web-based document storage and student updates, as well as automatic e-mails alerting supervisory individuals to student activity. Directors of the elective program have found difficulty with both ensuring uniform outcomes across different areas of study and leadership changes in a process that has been largely student-driven. Both programs have found that teamwork, regular meetings, and close communication have helped with implementation. Schools considering the establishment of a scholarly activity should consider these factors when designing programs.

[Medical ethics teaching]

In most European countries, medical ethics has become a more or less established subject in medical school curricula. Accordingly, the need to evaluate its success has arisen. In our paper, we describe the controversial debate about the proper goals of teaching medical ethics. Secondly, we present an overview of current efforts to measure and evaluate the outcome and effect of different medical ethics teaching programmes on medical students and young physicians. We conclude that medical ethics teaching is amenable to a great variety of teaching and evaluation methods. Finally, we argue that medical ethics teaching should include: (1) the teaching of moral reasoning skills, (2) the instruction about relevant ethical knowledge, as well as (3) the development of certain character traits. Methods to evaluate ethical knowledge and moral reasoning skills are readily available, while the evaluation of the development of character traits poses important conceptual difficulties.

Back to the basic sciences: an innovative approach to teaching senior medical students how best to integrate basic science and clinical medicine

Abraham Flexner persuaded the medical establishment of his time that teaching the sciences, from basic to clinical, should be a critical component of the medical student curriculum, thus giving rise to the "preclinical curriculum." However, students' retention of basic science material after the preclinical years is generally poor. The authors believe that revisiting the basic sciences in the fourth year can enhance understanding of clinical medicine and further students' understanding of how the two fields integrate. With this in mind, a return to the basic sciences during the fourth year of medical school may be highly beneficial. The purpose of this article is to (1) discuss efforts to integrate basic science into the clinical years of medical student education throughout the United States and Canada, and (2) describe the highly developed fourth-year basic science integration program at the University of Pittsburgh School of Medicine. In their critical review of medical school curricula of 126 U.S. and 17 Canadian medical schools, the authors found that only 19% of U.S. medical schools and 24% of Canadian medical schools require basic science courses or experiences during the clinical years, a minor increase compared with 1985. Curricular methods ranged from simple lectures to integrated case studies with hands-on laboratory experience. The authors hope to advance the national discussion about the need to more fully integrate basic science teaching throughout all four years of the medical student curriculum by placing a curricular innovation in the context of similar efforts by other U.S. and Canadian medical schools.

Critical care recognition, management and communication skills during an emergency medicine clerkship

BACKGROUND

Medical students need to learn how to recognize and manage critically ill patients; to communicate in critical situations with patients, families, and the healthcare team; and finally, to integrate technical knowledge with communication skills in caring for these patients. Meeting their needs will help prepare them to demonstrate, as physicians, the ability to synthesize information while simultaneously caring for patients, that the American Medical Association recently characterized as vital.

AIMS

Responding to these needs, we developed and implemented a curriculum to enable students in a required emergency medicine clerkship to recognize, manage, and simultaneously communicate with critically ill patients.

METHODS

The curriculum consisted of lectures and exercises on caring for the critically ill including: an introduction to the systematic approach; an interactive lecture on comprehensive communication; observation and discussion of real patients in the emergency department; participation in a single standardized patient encounter while peers and a faculty member observed them; assessment of students' own videotaped performance of the examination by using critical care and communication/interpersonal skills checklists; and receipt of private feedback based on the checklists from the faculty and the standardized patient. Students evaluated the curriculum at the end of the clerkship.

RESULTS

Complete performance data for 46 students and curriculum evaluation data from 42 students were available. According to faculty assessment, students as a group performed 79.6% (SD 0.15) of the critical care and 70.9% (SD 11.5%) of the communication skills. Students most often demonstrated Basic Interpersonal Skills (97.9%, SD 0.056) and least often demonstrated Empathy skills (41.7%, SD 0.235). Students rated the curriculum positively.

CONCLUSIONS

It is feasible to integrate the teaching of communication skills with the recognition and management of critically ill patients. The next step will be to revise the curriculum to address student deficiencies and to evaluate its effectiveness more rigorously.

Values and ethics: a collection of curricular reforms for a new generation of physicians

In recent years, medical educators have expressed concern that the reductionist-positivist mode of medical education fails to equip physicians with the skills and attitudes to meet the full range of patients' physical and emotional needs. Indeed, the authors suggest that neither patients nor physicians are satisfied. Among the factors responsible are a pervasive industrialization of clinical practice, a progressive segmentation of patient care, and a deepening shortage of both primary care and specialty physicians. But underlying these system issues is a lack of adequate schooling in the values, ethics, and culture of caring. Today's physicians must simultaneously be analytical, perceptive, and self-reflective. They must have the capacity to see their patients as individuals with differing psychological, social, and historical natures. And they must have insight into their own values and behaviors. All of this contributes to making a competent and humane physician. To aid medical students in achieving these characteristics, the authors contend that medical education must be radically restructured so that knowledge and skills are taught within the context of values and ethics. This commentary explores such reform through the lens of three articles published in the current issue of Academic Medicine, by Litzelman and Cottingham, Kanter and colleagues, and Dobie. These articles are the product of a national call that resulted in more than thirty abstracts, testimony to the fertile thinking already being applied to this problem. It is the authors' hope that this series of papers will stimulate still more thinking and lead to the curricular reform that future generations of physicians deserve.