Understanding the clinical dilemmas that shape medical students' ethical development: questionnaire survey and focus group study

Assessment of professionalism in a chiropractic college: A design and implementation of a rubric

OBJECTIVE

To describe the design, implementation, and revision of a rubric used in assessing professionalism that was in alignment with Council on Chiropractic Education meta-competency 5 (professional ethics and jurisprudence, curricular objective C: Expected professional conduct).

METHODS

The rubric was designed using a grading scale from 0 to 5 by which students needed to meet all criteria to earn full points for each defined dimension of professionalism. A comments section allowed for explanation of deductions and/or comments on exceptional behavior. Comments on professionalism were collected in a log during the trimester and used to populate the rubric. After initial use, the rubric was revised to incorporate criteria that had not initially been included and to allow for greater point deductions for multiple/repeat infractions or egregious behavior. Feedback from other faculty members was also gathered during in-service presentations of the rubric and taken into consideration. Professionalism score was 10% of the course grade.

RESULTS

From 2016 to 2020, the average professionalism grade changed from 95.6% to 98.9%. A review of the frequency distributions of average professionalism grades in a calendar year showed that some students were earning grades between 70% and 79%. Only achieving 70% to 75% of the professionalism grade affected the final course grade by 2.5% to 3.0%.

CONCLUSION

In training chiropractic students on expected behaviors related to professionalism, a rubric assessment of professionalism guided communications between the clinical educator and students to discuss professionalism and remediate unprofessional behaviors. A rubric defining expected classroom behaviors aligns with educational best practices to use assessment methods to develop professionalism in health care students.

Applying the American Dental Education Association (ADEA) tool on action on professionalism in dental education in Iran and applying in a cross-sectional study

Background

Professionalism is a multidimensional concept, defined as conducting oneself with responsibility, integrity, accountability, and excellence. This study aimed to contextualize American Dental Education Association (ADEA) tool on action on professionalism in dental education in Mashhad and apply it in a cross-sectional study.

Materials and Methods

This descriptive-analytic study was conducted on all students of Mashhad School during 2018-2019. The ADEA tool for action on professionalism in dental education was applied. It was firstly contextualized, validated, and its reliability was confirmed by test-retest and Cronbach's alpha. Then, it was applied in a cross-sectional study. Data were analyzed using Lisrel, and SPSS: 16. ANOVA and Tukey's honestly significant difference tests were used to compare the study variables.

Results

The tool was valid and reliable for applying in the Iranian context (x2/df <3, RMSEA ≈ 0.1 and indices of comparative fit index, incremental fit index, goodness-of-fit index, and adjusted GFI are >0.7). In the cross-sectional study for measuring professionalism, the mean score of 1^st-year dental students was significantly higher than 3^rd-year dental students (F = 2.75, P = 0.002). Furthermore, the mean score of 1^st-year dental students was also significantly higher than 6^th-year students (F = 4.53, P = 0.001). The comparison of the component of professionalism among 1^st-to 6^th-year students showed that there was no statistically significant difference between the total score of males and females. In addition, no statistically significant difference was found between the total score of local and nonlocal students.

Conclusion

The Tool is valid and reliable for applying in the Iranian context. Dental students need to be trained and also practice professional behaviors during their senior years of college.

Student and clinician perceptions of medical student mistreatment: a cross-sectional vignette survey

OBJECTIVES

The mistreatment of medical students remains pervasive in medical education. Understanding the extent to which clinicians and students recognise mistreatment can assist in creating targeted interventions that reduce mistreatment. The objective of this study was to use clinical vignettes to assess perceptions of medical student mistreatment among medical students and clinical faculty at an Australian university.

DESIGN, SETTING AND PARTICIPANTS

This cross-sectional study used a survey of medical students and clinical faculty in a Doctor of Medicine (MD) programme at Macquarie University in Sydney, Australia. Data were collected via an online survey between 13 July and 27 July 2020.

OUTCOME MEASURES

Fourteen clinical vignettes were developed based on commonly reported themes of mistreatment. An additional control vignette was also included, and these 15 vignettes were distributed via email to all 169 MD students and 42 teaching faculty at this teaching site. Participants were asked to rate whether the vignettes portrayed mistreatment on a 5-point Likert scale (strongly disagree to strongly agree).

RESULTS

Respondents included 83 MD students and 34 clinical faculty. On average, students perceived mistreatment in 9 of 14 vignettes and faculty in 8 of 14 vignettes. Faculty and student perceptions aligned in themes of sexual abuse, physical abuse and in the control vignette depicting a constructive teaching style. Perceptions differed significantly between faculty and students (p<0.05) for five vignettes across the themes of gender discrimination, requests of students to perform non-educational tasks, humiliation, specialty choice discrimination and requests to perform a task beyond the student's capacity.

CONCLUSION

Agreement on what constitutes appropriate behaviour is crucial to ensuring that a culture of mistreatment can be replaced with one of kindness, equity and respect. This study demonstrated the successful use of vignettes to compare perceptions of mistreatment, with faculty and student perceptions differing across a variety of themes.

Exploring Professionalism Dilemma and Moral Distress through Medical Students' Eyes: A Mixed-Method Study

This study aims to understand professionalism dilemmas medical students have experienced during clinical clerkships and the resulting moral distress using an explanatory mixed-method sequential design-an anonymous survey followed by in-depth interviews. A total of 153 students completed and returned the survey, with a response rate of 21.7% (153/706). The top three most frequently occurring dilemmas were the healthcare team answering patients' questions inadequately (27.5%), providing fragmented care to patients (17.6%), and withholding information from a patient who requested it (13.7%). Students felt moderately to severely distressed when they observed a ward mate make sexually inappropriate remarks (81.7%), were pressured by a senior doctor to perform a procedure they did not feel qualified to do (77.1%), and observed a ward mate inappropriately touching a patient, family member, other staff, or student (71.9%). The thematic analysis based on nine in-depth interviews revealed the details of clinicians' unprofessional behaviors towards patients, including verbal abuse, unconsented physical examinations, bias in clinical decisions, students' inaction towards the dilemmas, and students' perceived need for more guidance in applying bioethics and professionalism knowledge. Study findings provide medical educators insights into designing a professional development teaching that equips students with coping skills to deal with professionalism dilemmas.

Thinking about social power and hierarchy in medical education

CONTEXT

Social power has been diversely conceptualised in many academic areas. Operating on both the micro (interactional) and macro (structural) levels, we understand power to shape behaviour and knowledge through both repression and production. Hierarchies are one organising form of power, stratifying individuals or groups based on the possession of valued social resources.

DISCUSSION

Medicine is a highly organised social context where work and learning are contingent on interaction and thereby influenced greatly by social power and hierarchy. Despite the relevance of power to education research, there are many unrealized opportunities to use this construct to expand our understanding of how physicians work and learn. Hierarchy, when considered in our field, is typically gestured to as an omnipresent feature of the clinical environment that harms low-status individuals by repressing their ability to communicate openly and exercise their agency. This may be true in many circumstances, but this conceptualization of hierarchy neglects consideration of other aspects of hierarchy that may be generative for understanding the experiences of medical learners. For example, medical learners may experience the superimposition of multiple hierarchies, some of which are fluid and some of which are calcified, some of which are productive and helpful and some of which are oppressive and harmful. Power may work 'up' and 'across' hierarchical ranks, rather than just from higher status to lower status individuals.

CONCLUSION

The conceptualizations of how social power shapes human behaviour are diverse. Often paired with hierarchy, or social arrangement, these social scientific ideas have much to offer our collective study of the ways that health professionals learn and practice. Accordingly, we posit that a consideration of the ways social power works through hierarchies to nurture or harm the growth of learners should be granted explicit consideration in the framing and conduct of medical education research.

Knowledge and Attitudes Towards Abortion and Euthanasia Among Health Students in Papua New Guinea

PURPOSE

The purpose of this study was to explore knowledge and attitudes of health program students towards ethical issues pertaining to the beginning and the end of human life, and associations between these attitudes and demographic variables.

PARTICIPANTS AND METHODS

The study took a mixed-method approach with self-administered survey questionnaires and in-depth interviews. A total of 88 students participated in the survey, and 10 students participated in interviews. The study was conducted among students in the Health Extension Program at a Christian university in Papua New Guinea.

RESULTS

Students showed a higher acceptance of abortion than euthanasia. More year-4 students presented significantly deeper knowledge of euthanasia and abortion compared to year-1 students. There were no gender differences regarding knowledge and attitude towards these two bioethical issues. The majority of students opposed the idea of women's right to abortion, which is attributed mainly to socio-cultural reasons. The qualitative analysis indicated a very strong perception that having children 'defines' womanhood and also revealed general disapproval of any form of euthanasia. A low level of acceptance of various forms of euthanasia is associated with a respect for older people in Melanesian society and beliefs that ancestors' support is required for achieving prosperity in life.

CONCLUSION

The study offered a comprehensive description and analysis of students' knowledge and attitudes towards ethical issues pertaining to the beginning and the end of human life. Presented a low level of knowledge towards bioethical issues, together with a small proportion of the knowledge gained from lectures and tutorials, indicated inadequate teaching of bioethics and calls for further improvement. In the perspective of rapid social and cultural changes in the Papua New Guinea society, further studies on changing attitudes towards bioethics issues would be valuable.

Implementation of a Medical Ethics Course in Undergraduate Dental Education and Assessment of Knowledge and Attitudes

Objectives

A medical ethics course was launched in 2012 in a French University Dental School. We compared knowledge and attitudes, before and after implementation of that course. The aim of this study was to compare students who received an ethics course (third year) to those who did not have such training, however, most of them did have some clinical traineeship.

Materials and Methods

An anonymous questionnaire was sent to the second-, third-, and sixth-year students. It comprised questions with Likert item format answers and clinical vignettes with open responses. The results were analyzed by two approaches: a statistical analysis (chi-square or Fischer exact tests) and a content analysis using a predefined grid.

Results

A total of 299 respondents replied (75% students) the questionnaire. The analysis showed a statistically significant association between knowledge of the law and information procedures (P < 0.0001), access to medical files (P = 0.004), and recording consent (P = 0.049). It was also significant between knowledge of the law and the principles of biomedical ethics (P < 0.0001 for autonomy and beneficence). The third-year students could state the principles of medical ethics with their percentage always greater than the sixth-year students. After the third year, the students' attitudes switched from a social to a medical emphasis, and their point of view regarding patient's autonomy evolved. Patient's refusal of care raised potential conflicts between autonomy, professional judgment, information, and consent.

Conclusion

Ethics teaching could offer a way to turn positive attitudes into real competencies and should be considered at an early stage.

Challenges and Opportunities for Clinical Pharmacogenetic Research Studies in Resource-limited Settings: Conclusions From the Council for International Organizations of Medical Sciences-Ibero-American Network of Pharmacogenetics and Pharmacogenomics Meeting

PURPOSE

The symposium Health and Medicines in Indigenous Populations of America was organized by the Council for International Organizations of Medical Sciences (CIOMS) Working Group on Clinical Research in Resource-Limited Settings (RLSs) and the Ibero-American Network of Pharmacogenetics and Pharmacogenomics (RIBEF). It was aimed to share and evaluate investigators' experiences on challenges and opportunities on clinical research and pharmacogenetics.

METHODS

A total of 33 members from 22 countries participated in 2 sessions: RIBEF studies on population pharmacogenetics about the relationship between ancestry with relevant drug-related genetic polymorphisms and the relationship between genotype and phenotype in Native Americans (session 1) and case examples of clinical studies in RLSs from Asia (cancer), America (diabetes and women health), and Africa (malaria) in which the participants were asked to answer in free text their experiences on challenges and opportunities to solve the problems (session 2). Later, a discourse analysis grouping common themes by affinity was conducted.

FINDINGS

The main result of session 1 was that the pharmacogenetics-related ancestry of the population should be considered when designing clinical studies in RLSs. In session 2, 21 challenges and 20 opportunities were identified. The social aspects represent the largest proportion of the challenges (43%) and opportunities (55%), and some of them seem to be common.

IMPLICATIONS

The main discussion points were gathered in the Declaration of Mérida/T'Hó and announced on the Parliament of Extremadura during the CIOMS-RIBEF meeting in 4 of the major Latin American autochthonous languages (Náhualth, Mayan, Miskito, and Kichwa). The declaration highlighted the following: (1) the relevance of population pharmacogenetics, (2) the sociocultural contexts (interaction with traditional medicine), and (3) the education needs of research teams for clinical research in vulnerable and autochthonous populations.

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.

Conscientious Objection: A Talmudic Paradigm Shift

Conscientious objection remains a very heated topic with strong opinions arguing for and against its utilization in contemporary health care. This paper summarizes and analyzes various arguments in the bioethical literature, favoring and opposing conscientious objection, as well as some of the proposed solutions and compromises. I then present a paradigm shifting compromise approach that arises out of very recent Jewish bioethical thought that refocuses the discussion and can minimize the frequency with which conscientious objection is required.

Korean medical students' attitudes toward academic misconduct: a cross-sectional multicenter study

PURPOSE

This study investigated medical students' attitudes toward academic misconduct that occurs in the learning environment during the pre-clinical and clinical periods.

METHODS

Third-year medical students from seven medical schools were invited to participate in this study. A total of 337 of the 557 (60.5%) students completed an inventory assessing their attitudes toward academic misconduct. The inventory covered seven factors: scientific misconduct (eight items), irresponsibility in class (six items), disrespectful behavior in patient care (five items), dishonesty in clerkship tasks (four items), free riding on group assignments (four items), irresponsibility during clerkship (two items), and cheating on examinations (one item).

RESULTS

Medical students showed a strict attitude toward academic misconduct such as cheating on examinations and disrespectful behavior in patient care, but they showed a less rigorous attitude toward dishonesty in clerkship tasks and irresponsibility in class. There was no difference in students' attitudes toward unprofessional behaviors by gender. The graduate medical school students showed a stricter attitude toward some factors of academic misconduct than the medical college students. This difference was significant for irresponsibility in class, disrespectful behavior in patient care, and free riding on group assignments.

CONCLUSION

This study indicates a critical vulnerability in medical students' professionalism toward academic integrity and responsibility. Further study evidence is needed to confirm whether this professionalism lapse is confined only to this population or is pervasive in other medical schools as well.

Medical student strategies for actively negotiating hierarchy in the clinical environment

CONTEXT

Medical learning takes place in an extremely hierarchical environment. Medical students may struggle to understand how to succeed in such a rule-bound environment that leaves them vulnerable to the influences of social power. This study explores how medical students experience the clinical learning environment from their low-status positions in the social hierarchy.

METHODS

Using constructivist grounded theory, we collected 88 hours of observation and 13 interviews with medical students completing clinical clerkships. Data collection focused on students' interactions with their supervisors, colleagues and other staff members as they completed the core rotations of their clinical clerkships. Data analysts used a constant comparative approach to remain alert to the different ways in which medical students experienced and responded to social power used by their supervisors and colleagues.

RESULTS

We describe a cyclical theory of how medical students appraised the environment, the needs and preferences of their supervisors and their personal resources in order to select and enact a strategy for interacting. They used these strategies when in the presence of supervisors, but also when supervisors were absent in preparation for the next interaction. The ways in which medical students chose and employed these strategies reflect a significant use of social and cognitive resources.

CONCLUSIONS

Power is an important component of the social culture of clinical learning environments; understanding the ways in which medical students experience and react to power can help educators, learners and administrators optimise learning opportunities. Medical education increasingly encourages students to exercise agency in seeking feedback and directing their own learning; this may be particularly challenging for students who cannot interpret social cues well, and those who lack social capital.

Significados sobre bioética que emergen en los pacientes participantes en los procesos de formación médica. Medellín-Colombia, 2017

Objetivo: comprender los significados sobre bioética que emergen entre los pacientes atendidos en las prácticas académicas en los procesos de formación médica de pregrado y posgrado en Medellín en 2017.Materiales y métodos: se realizaron 17 entrevistas semiestructuradas en mayores de edad, con un enfoque hermenéutico basado en el paradigma constructivista. El análisis se efectuó con el uso de técnicas de la teoría fundamentada.Resultados: como significado central emergió la instrumentalización del paciente cuando participa en el proceso de aprendizaje de los estudiantes, perciben que prima el interés formativo sobre la atención. Otros significados que surgieron son: la subordinación jerárquica en las relaciones clínicas y académicas, la limitación del reconocimiento de derechos y deberes, así como diversidad en la satisfacción con la atención; se resalta su aporte al aprendizaje, pero expresaron molestia cuando se sentían ignorados en la comunicación docente-estudiantes.Discusión y conclusión: existe una disposición favorable de los pacientes para participar en la formación médica en procesos no invasivos, pero con limitación del número de estudiantes y con un docente responsable de la atención. La formación médica debe otorgar al paciente un papel activo en las prácticas académicas, reconocer sus necesidades de diálogo, confidencialidad, intimidad, respeto a su autonomía y dignidad, promoviendo relaciones de ellos con estudiantes y profesores basados en valores y principios bioéticos.

Missed opportunities in the way medical schools evaluate the ethical domain in clerkship rotations

Background

Several lines of evidence indicate that medical schools have been failing to adequately nurture empathy and the ethical dimension in their graduates, the lack of which may play a central role in the genesis of medical errors, itself a major source of avoidable deaths, incapacity and wasted resources. It has been widely proposed that medical schools should adopt evaluation strategies as a means to promote a culture of respectful relationships. However, it is not clear if evaluation strategies in medical schools have addressed key domains related to that aim, such as ethics, through the perspective of their students. Hence, we conducted a national survey of instruments used by Brazilian medical schools to assess clerkship rotations from the perspective of students, with a main focus on the ethical domain.

Methods

The authors invited 121 randomly selected institutions to participate in the study. Key informants answered a questionnaire about clerkship rotations and sent copies of any instrument used to assess the quality of clerkship rotations according to the students’ perspectives.

Results

Twenty-six (53%) of 49 participating schools used an instrument to assess the quality of clerkship rotations according to the perspective of students. Just 13 (27%) schools had instruments containing at least one question encompassing the ethical domain. Only 2 (4%) schools asked students specifically about the occurrence of any negative experience concerning the ethical domain during rotations. Merely 1 (2%) school asked students about having witnessed patient mistreatment and none asked about mistreatment against students themselves.

Conclusions

There are several missed opportunities in the way medical schools assess the quality of clerkship rotations regarding the ethical domain. Closing the gap between usual institutional discourses regarding ethics and how that dimension is assessed within clerkship rotations might represent an important step towards the improvement of medical education and healthcare systems.

Goals, Recommendations, and the How-To Strategies for Developing and Facilitating Patient Safety and System Integration Simulations

PURPOSE

The aim of this article is to outline overall goals, recommendations, and provide practical How-To strategies for developing and facilitating patient safety and system integration (PSSI) simulations for healthcare team members and organizations.

BACKGROUND

Simulation is increasingly being used as a quality improvement tool to better understand the tasks, environments, and processes that support the delivery of healthcare services. These PSSI simulations paired with system-focused debriefing can occur prior to implementing a new process or workflow to proactively identify system issues. They occur as part of a continuous cycle of quality improvement and have unique considerations for planning, implementation, and delivery of healthcare.

METHOD

The Delphi technique was used to develop the recommendations and How-To strategies to guide those interested in conducting a PSSI simulations. The Delphi technique is a structured communication technique and systematic process of gathering information from a group of identified experts through a series of questionnaires to gain consensus regarding judgments on complex processes, where precise information is not available in the literature. The Delphi technique permitted an iterative and multistaged approach to transform expert opinions into group consensus.

RESULTS

The goals, recommendations, and How-To strategies include a focus on project management, stakeholder engagement, sponsorship, scenario design, prebriefing and debriefing, and evaluation metrics. The intent is to proactively identify system issues and disseminate actionable findings.

CONCLUSIONS

This article highlights salient features to consider when using simulation as a strategy and tool for patient safety and quality improvement.

Improving patient safety by enhancing raising concerns at medical school

BACKGROUND

Doctors and medical students have a professional responsibility to raise concerns. Failure to raise concerns may compromise patient safety. It is widely known that medical students frequently encounter unprofessional behaviours in the workplace, but little is known about the barriers to raising concerns amongst medical students. This paper explores these issues and discusses some innovations in the medical undergraduate curriculum, offering a good practice model for other medical and healthcare curricula. We set out to ascertain the attitudes and experiences of medical students in relation to raising concerns. This data was then used to innovate the raising concerns curriculum, and access to the raising concerns system, in order to fundamentally improve patient safety and experience, as well as the student experience.

METHODS

The authors conducted a mixed methods quantitative and qualitative research study. Research was based at a UK medical school and involved data collection using an anonymous, voluntary survey emailed to all medical students (n = 363) as well as voluntary attendance focus groups (n = 24) recruited by email. Both tools investigated student attitudes towards raising concerns and explored student ideas for solutions to improving the process. The focus group data was thematically analysed by three researchers.

RESULTS

The authors identified five key themes which described medical student attitudes towards raising concerns. This article discusses these themes and the resulting work to enhance medical education within the medical school curriculum.

CONCLUSIONS

More research is needed to further address the barriers that medical students find in raising concerns. However, despite being a single study in one UK medical school, the authors propose some changes which they hope may inspire other educators to build upon their raising concerns curricula to foster more transparent undergraduate cultures and ultimately improve patient experience and safety.

Ethical dilemma of identity disclosure faced by medical students in clinical clerkships: A nationwide multicenter study in China

Objective

Medical students in China are currently facing a dilemma of whether to clarify their identity as students to patients. Further investigation is needed to support policy-making. The aim was to identify factors influencing medical students’ decision on whether or not to clarify their identity to patients and to examine the effects of their decision.

Methods

The study was a cross-sectional nationwide multicenter survey consisting of 947 medical students. A self-designed questionnaire was composed of 19 structured questions investigating the present situation and participants’ perception of the ethical dilemma surrounding medical student identity. The questionnaires were distributed randomly in teaching hospitals affiliated with 13 medical schools across China from June 2015 to January 2016.

Results

A total of 947 valid questionnaires were retrieved with a valid response rate of 83.7%. Most medical students (71.4%) tended to be ambiguous about their student identity in front of patients. The frequency of encountering distrust and patients’ or patient relatives’ refusal to allow students to perform procedures was significantly lower for students who explicitly stated their identity than for those who were ambiguous about their identity (p<0.001). Less experience in clinical rotations (<0.5 y/0.5–1 y, OR 2.7, 95% CI 1.7–4.3; <0.5 y/>1 y, OR 3.6, 95% CI 2.0–6.5), preceptors’ straightforward introduction of the students (OR 8.7, 95% CI 5.4–13.8) and students’ acknowledgment of patients’ right to know (OR 2.3, 95% CI 1.2–4.5) were related to students’ clear self-introduction to patients.

Conclusion

It is beneficial for medical students to clearly explain their identity to patients in order to decrease patient distrust and prevent the refusal to have certain appropriate procedures performed. Several methods, including emphasizing the role of mentors, developing curriculum for medical students, and creating clear regulations and guidelines for revealing the identity of medical students on the healthcare team can help address and ideally resolve this ethical dilemma of identity disclosure.

Exploring practices of Dermatologists in Ethical Dilemmas in Pakistan: A narrative analysis

Background and Objective:

Specialists in dermatology come across ethical issues in their practice. The topic is subjective so dialogue and reflection is required. The main objective of this study was to explore how dermatologists deal with ethical dilemmas in their clinical practice.

Methods:

This was a qualitative narrative analysis. It was conducted by involving dermatologists working in tertiary care hospitals across Pakistan from January to June 2017. Open ended semi structured in-depth interviews of twelve dermatologists were recorded and transcribed manually through transcribers verbatim. Thematic interactional analysis was done by NVivo 11.

Results:

Ethical dilemmas were narrated. Thematic analysis showed that compromises in standard medical and ethical practices were made on academics and training. Ethics were left to individual choice. Consultation of patients suffered due to quality of patient physician relationships and breeched patient’s confidentiality. In cosmetic dermatology unrestrained role of media, injudicious procedures and improper counseling created difficulties. Pharmaceuticals relation revolved around conflict of interest. In sexually transmitted diseases disclosure were difficult due to sociocultural limitations. In teledermatology practices patient’s confidentiality and consent were compromised while consultation remained challenging for dermatologists being visual only.

Conclusion:

Dilemmas appearing in everyday life needs peer discussion, reflections and protocols that should be role modeled.

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.

Student-derived solutions to address barriers hindering reports of unprofessional behaviour

BACKGROUND

Barriers hinder medical students from reporting breaches in professional behaviour, which can adversely impact institutional culture. No studies have reported student perspectives on how to address these barriers successfully. Our study (i) evaluated the likelihood of reporting based on violation severity, (ii) assessed barriers to reporting and (iii) elicited students' proposed solutions.

METHODS

Four medical students designed a cross-sectional study in 2015. In response to seven scenarios, students rated the likelihood of reporting the violation, indicated perceived barriers and identified solutions. Additional questions investigated the perceived importance of professionalism, confidence in understanding professionalism and trust in administrative protection from negative consequences.

RESULTS

Two hundred and seventy-two students in their clinical years (MS2-4) responded to the survey (RR = 50%). Students were 70-90% likely to report major violations, but < 30% likely to report minor or moderate violations. Barriers included concerns about an uncomfortable relationship (41%), potential negative repercussions on grades or opportunities (23%), and addressing by direct discussion rather than reporting (23%). Solutions included simplified reporting, control over report release date, improved feedback to reporters, training for real-time resolution of concerns and a neutral resource to help students triage concerns. No differences existed between classes regarding the importance or understanding of professionalism. In linear regression, only importance of professionalism predicted likelihood of reporting and this did not change with training.

CONCLUSIONS

Hindered by common barriers, students are unlikely to report a violation unless it is a serious breach of professionalism. Student-derived solutions should be explored by medical school administrators to encourage reporting of violation of professionalism.

Assessing the Culture of Residency Using the C - Change Resident Survey: Validity Evidence in 34 U.S. Residency Programs

BACKGROUND

A practical instrument is needed to reliably measure the clinical learning environment and professionalism for residents.

OBJECTIVE

To develop and present evidence of validity of an instrument to assess the culture of residency programs and the clinical learning environment.

DESIGN

During 2014-2015, we surveyed residents using the C - Change Resident Survey to assess residents' perceptions of the culture in their programs.

PARTICIPANTS

Residents in all years of training in 34 programs in internal medicine, pediatrics, and general surgery in 14 geographically diverse public and private academic health systems.

MAIN MEASURES

The C - Change Resident Survey assessed residents' perceptions of 13 dimensions of the culture: Vitality, Self-Efficacy, Institutional Support, Relationships/Inclusion, Values Alignment, Ethical/Moral Distress, Respect, Mentoring, Work-Life Integration, Gender Equity, Racial/Ethnic Minority Equity, and self-assessed Competencies. We measured the internal reliability of each of the 13 dimensions and evaluated response process, content validity, and construct-related evidence validity by assessing relationships predicted by our conceptual model and prior research. We also assessed whether the measurements were sensitive to differences in specialty and across institutions.

KEY RESULTS

A total of 1708 residents completed the survey [internal medicine: n = 956, pediatrics: n = 411, general surgery: n = 311 (51% women; 16% underrepresented in medicine minority)], with a response rate of 70% (range across programs, 51-87%). Internal consistency of each dimension was high (Cronbach α: 0.73-0.90). The instrument was able to detect significant differences in the learning environment across programs and sites. Evidence of validity was supported by a good response process and the demonstration of several relationships predicted by our conceptual model.

CONCLUSIONS

The C - Change Resident Survey assesses the clinical learning environment for residents, and we encourage further study of validity in different contexts. Results could be used to facilitate and monitor improvements in the clinical learning environment and resident well-being.

Twelve tips on how to establish a new undergraduate firm on a critical care unit

BACKGROUND

Little is known about undergraduate teaching in critical care unit (CrCU) and many undergraduate curricula lack placements in CrCU.

AIMS

To describe how our CrCU succeeded in developing a novel placement for Year 3 undergraduate medical students.

METHODS

Particular emphasis was placed on a robust timetable incorporating a variety of activities, a dedicated and thorough induction, and a mix of teaching methods such as formal and informal, consultant-led, and skills. Services allied to CrCU were also utilized.

RESULTS

Our new firm has exceeded all expectations and, based on student feedback, received the "Firm of the Year" award for several years in succession. It now serves as a model of undergraduate teaching in our hospital.

CONCLUSIONS

Educationalists and intensivists should work together to unlock the full potential of this rich learning environment. Professional societies in critical care medicine should take the opportunity to develop more interest in undergraduate medical education.

The Hidden Curriculum of Veterinary Education: Mediators and Moderators of Its Effects

The "hidden curriculum" has long been supposed to have an effect on students' learning during their clinical education, and in particular in shaping their ideas of what it means to be a professional. Despite this, there has been little evidence linking specific changes in professional attitudes to the individual components of the hidden curriculum. This study aimed to recognize those components that led to a change in students' professional attitudes at a UK veterinary school, as well as to identify the attitudes most affected. Observations were made of 11 student groups across five clinical rotations, followed by semi-structured interviews with 23 students at the end of their rotation experience. Data were combined and analyzed thematically, taking both an inductive and deductive approach. Views about the importance of technical competence and communication skills were promoted as a result of students' interaction with the hidden curriculum, and tensions were revealed in relation to their attitudes toward compassion and empathy, autonomy and responsibility, and lifestyle ethic. The assessment processes of rotations and the clinical service organization served to communicate the messages of the hidden curriculum, bringing about changes in student professional attitudes, while student-selected role models and the student rotation groups moderated the effects of these influences.

The Hidden Ethics Curriculum in Two Canadian Psychiatry Residency Programs: A Qualitative Study

OBJECTIVE

The authors describe the hidden ethics curriculum in two postgraduate psychiatry programs.

METHODS

Researchers investigated the formal, informal, and hidden ethics curricula at two demographically different postgraduate psychiatry programs in Canada. Using a case study design, they compared three sources: individual interviews with residents and with faculty and a semi-structured review of program documents. They identified the formal, informal, and hidden curricula at each program for six ethics topics and grouped the topics under two thematic areas. They tested the applicability of the themes against the specific examples under each topic. Results pertaining to one of the themes and its three topics are reported here.

RESULTS

Divergences occurred between the curricula for each topic. The nature of these divergences differed according to local program characteristics. Yet, in both programs, choices for action in ethically challenging situations were mediated by a minimum standard of ethics that led individuals to avoid trouble even if this meant their behavior fell short of the accepted ideal.

CONCLUSIONS

Effective ethics education in postgraduate psychiatry training will require addressing the hidden curriculum. In addition to profession-wide efforts to articulate high-level values, program-specific action on locally relevant issues constitutes a necessary mechanism for handling the impact of the hidden curriculum.

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.

Why medical schools are tolerant of unethical behavior

The exposure to unethical and unprofessional behavior is thought to play a major role in the declining empathy experienced by medical students during their training. We reflect on the reasons why medical schools are tolerant of unethical behavior of faculty. First, there are barriers to reporting unprofessional behavior within medical schools including fear of retaliation and lack of mechanisms to ensure anonymity. Second, deans and directors do not want to look for unethical behavior in their colleagues. Third, most of us have learned to take disrespectful circumstances in health care institutions for granted. Fourth, the accreditation of medical schools around the world does not usually cover the processes or outcomes associated with fostering ethical behavior in students. Several initiatives promise to change that picture.

Medical ethics as practiced by students, nurses and faculty members in Shiraz University of Medical Sciences

INTRODUCTION

Assuming any social role has obligations and fulfilling the related responsibilities has ethical aspects that must be addressed carefully. Each role requires extensive training, which usually takes place in university institutions. Ethics is applied in at least three academic areas, including: a) in education of students' personal growth, b) in patient care, and c) in university communion in population-based health care. Given the importance of this issue in the moral domain, this study examines the correlation among the students, nurses and teacher's opinions regarding principles of medical ethics at Shiraz University of Medical Sciences.

METHODS

This is a descriptive-analytic and cross-sectional study conducted in 2010. The participants of this research consisted of all medical students, nurses in public hospitals, and faculty members in Shiraz University of Medical Sciences. For validity evaluation, the expert panel method and for reliability evaluation, test-retest method was used.

RESULTS

Based on the medical ethics' scores in these three groups, there was a significant relationship between the mean scores of student-nurses and employed nurses, but there was no significant relationship between those of student-faculties. Also the mean score of the students was the highest in medical ethics.

CONCLUSION

In this study, we presented a list of virtues and moral characteristics of medical staff and found out the method of practicing medical ethics in everyday life of students to improve the moral reasoning of teachers, nurses and students. Moreover, medical ethics, with the presentation of specific criteria for ethical behavior in various domains of human life, especially in dealing with patients, can help practice ethical values in the medical community.

[Development of a code of professional conduct for medical students and residents]

PURPOSE

The purpose of this study was to describe the development of a code of professional conduct that should be practiced by medical students and residents.

METHODS

The content of a draft version of a code of professional conduct was generated through extensive literature reviews and the results of surveys that were administered to students and residents. The content validity for the draft version was reviewed by an expert panel: five experts in medical ethics and eight specialists in medical education. The survey was distributed as an email questionnaire and included closed-ended items and open comments. SPSS for Windows version 12.0 (SPSS Inc.) was used for the analysis.

RESULTS

After analyzing the experts' reviews and holding a reiterative discussion, we developed the final version of a code of conduct for professional behavior. It consists of nine categories and 44 items for students and 44 items for residents. The nine categories were academic integrity, responsibility during clerkship or hospital work, endeavor to improve clinical competency, respect for patients and keeping confidentiality, honesty in patient care, boundary issues and conflicts of interests, impaired physician behaviors, respect for others, and research ethics.

CONCLUSION

Because our code of conduct for professional behaviors cannot extensively include all aspects of medical professionalism, we focused on behaviors that can be used to monitor and prevent misconduct by medical learners. Further studies and discourse among stakeholders should be performed to develop a national consensus statement or code of conduct to reinforce professionalism for learners in medicine.

Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem

INTRODUCTION

The issues of medical errors and medical malpractice have stimulated significant interest in establishing transparency in health care, in other words, ensuring that medical professionals formally report medical errors and disclose related outcomes to patients and families. However, research has amply shown that transparency is not a universal practice among physicians.

METHODS

A review of the literature was carried out using the search terms "transparency," "patient safety," "disclosure," "medical error," "error reporting," "medical malpractice," "doctor-patient relationship," and "physician" to find articles describing physician barriers to transparency.

RESULTS

The current literature underscores that a complex Web of factors influence physician reluctance to engage in transparency. Specifically, 4 domains of barriers emerged from this analysis: intrapersonal, interpersonal, institutional, and societal.

CONCLUSION

Transparency initiatives will require vigorous, interdisciplinary efforts to address the systemic and pervasive nature of the problem. Several ethical and social-psychological barriers suggest that medical schools and hospitals should collaborate to establish continuity in education and ensure that knowledge acquired in early education is transferred into long-term learning. At the institutional level, practical and cultural barriers suggest the creation of supportive learning environments and private discussion forums where physicians can seek moral support in the aftermath of an error. To overcome resistance to culture transformation, incremental change should be considered, for example, replacing arcane transparency policies and complex reporting mechanisms with clear, user-friendly guidelines.

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.

Formation of medical student professional identity: categorizing lapses of professionalism, and the learning environment

BACKGROUND

Acquiring the values of medical professionalism has become a critical issue in medical education. The purpose of this study was to identify lapses in professionalism witnessed by medical students during their four year MD curriculum, and to categorize, from the students' perspective, who was responsible and the settings in which these occurred.

METHODS

An electronic survey, developed by faculty and medical students, was sent to all students with two email reminders. It included quantitative responses and some open-ended opportunities for comments. All analyses were performed with SAS version 9.1.

RESULTS

The response rate was 45.6% (255 of 559 students) for all four years of the medical school curriculum. Thirty six percent of students had witnessed or been part of an exemplary demonstration of professionalism; 64% responded that they had witnessed a lapse of professionalism. At the pre-clerkship level, the most frequent lapses involved students: arrogance (42.2%), impairment (24.2%), followed by cultural or religious insensitivity (20.5%). At the clerkship level of training, where students are exposed to real clinical situations, the lapses involved primarily faculty (including preceptor and clinician) or other staff; these included arrogance (55.3%), breach of confidentiality (28.3%), and cultural or religious insensitivity (26.6%); impairment involved mostly students (25.5%). These findings are analyzed from the perspective of role modeling by faculty and in the context of the learning environment.

CONCLUSIONS

Medical students witnessed a lapse of professionalism involving both fellow students as well as faculty and administrative staff, in several domains. Results from this study emphasize the importance of role modeling and the need for faculty development, to improve the learning environment. This study adds to the limited emerging literature on the forces that influence medical student professional identity formation.

Confronting the caring crisis in clinical practice

CONTEXT

In light of the call for humanistic caring in the contemporary health care system globally and in China, the issue of improving the caring skills that are essential to student success, high-quality nursing practice and positive patient outcomes is at the forefront of nursing education.

OBJECTIVES

The aim of this mixed-methods quantitative and qualitative study was to investigate baccalaureate nursing students' caring ability in the context of China and to explore the role of clinical practice learning in the development of students' caring skills.

METHODS

A two-phase, descriptive study utilising a mixed methodology consisting of a caring ability survey and focus group interviews was conducted. In the quantitative phase, 598 baccalaureate nursing students at two colleges in Yunnan Province in southwest China were surveyed using the Caring Ability Inventory (CAI). In the qualitative phase, 16 of the students who had participated in the quantitative phase were interviewed.

RESULTS

Students obtained lower scores on the CAI than have been reported elsewhere by other researchers. In addition, students in the clinical stage of training scored lower than students in the pre-clinical stage. Three themes concerning facilitation by and three themes concerning the obstructive effects of clinical practice learning in the development of caring ability were identified. Themes pertaining to facilitation were: (i) promoting a sense of professional responsibility and ethics; (ii) providing an arena in which to practise caring, and (iii) learning from positive role models. Themes pertaining to obstruction were: (i) a critical practice learning environment; (ii) encountering inappropriate clinical teachers, and (iii) experiencing shock at the contrast between an idealised and the real environment.

CONCLUSIONS

The key to developing students' ability to care lies in highlighting caring across the entire health care system. By diminishing exposure to negative role models, and adopting appropriate pedagogical ideas about education in caring, such as truth telling and helping students to think in a critical manner, educators can help students to improve their caring ability.

Perceptions and practices of medical practitioners towards ethics in medical practice - a study from coastal South India

Ethics is the application of values and moral rules to human activities. Medical practitioners are expected to not only have the skills and knowledge relevant to their field but also with the ethical and legal expectations that arise out of the standard practices. The present research was conducted with an aim to study the perceptions and practices of medical practitioners towards healthcare ethics in Indian scenario and to strengthen the evidence in the field of ethics training. A cross-sectional study was carried out in three associate hospitals of a Medical College in Southern India. Medical practitioners included in the study were administered a pre-tested, semi-structured questionnaire. Data was collected based on their responses on a 5 point Likert scale and analyzed using SPSS version 11.5. The majority of the participants mentioned that their perceptions of ethics in medical practice were based on information obtained during their undergraduate training, followed by experience at work. The medical practitioners had a positive perception on issues relating to consent in medical practice. However, the same degree of perception was not observed for issues related to confidentiality and their dealing with patients during emergency conditions. The majority of the medical practitioners agreed that ethical conduct is important to avoid legal and disciplinary actions. Among the medical practitioners, the responses of specialists and non-specialists were mostly similar with major differences of opinion for a few issues. A highest level of knowledge, awareness and understanding of ethics are expected in medical practice as it is the foundation of sound healthcare delivery system.

Podiatric medical students' perceptions of professionalism in the clinical setting: a qualitative analysis

BACKGROUND

The teaching and assessment of professionalism have become central areas of research and practice in medicine and in allopathic and osteopathic undergraduate and graduate medical education generally. In contrast, discussion of professionalism as it relates to podiatric medical education is nearly nonexistent in the literature.

METHODS

A study of podiatric medical students' perceptions of professionalism-related issues in the clinical setting was performed using a qualitative analysis. A written survey was sent to 88 students who had recently completed their clinical training experiences. The survey was completed anonymously, and all identifying information was redacted before analysis of the data, which was performed using thematic content analysis with constant comparative analysis. In addition, basic demographic information was acquired as part of the data collection process.

RESULTS

Sixty-six students (75%) responded and agreed to participate in the survey. Students provided written reports of lapses in professional behavior that they had witnessed, heard about, or been personally involved in performing. The study confirmed that podiatric medical students had experienced various types of professional lapses in behavior, and six predominant themes were identified.

CONCLUSIONS

This study, which was performed with a selected group of individuals at a single institution, serves as an initial assessment of the needs of podiatric medical students and will be useful for developing professionalism-related instructional activities that could benefit students in the future.

Undergraduate healthcare ethics education, moral resilience, and the role of ethical theories

BACKGROUND

This article combines foundational and empirical aspects of healthcare education and develops a framework for teaching ethical theories inspired by pragmatist learning theory and recent work on the concept of moral resilience. It describes an exemplary implementation and presents data from student evaluation.

OBJECTIVES

After a pilot implementation in a regular ethics module, the feasibility and acceptance of the novel framework by students were evaluated.

RESEARCH DESIGN

In addition to the regular online module evaluation, specific questions referring to the teaching of ethical theories were added using simple (yes/no) and Likert rating answer formats.

PARTICIPANTS AND RESEARCH CONTEXT

At the Bern University of Applied Sciences, a total of 93 students from 2 parallel sub-cohorts of the bachelor's program in nursing science were sent the online survey link after having been exposed to the same modular contents. A total of 62% of all students participated in the survey.

ETHICAL CONSIDERATIONS

The survey was voluntary and anonymous. Students were free to write their name and additional comments.

FINDINGS

Students consider ethical theories-as taught within the proposed framework-as practically applicable, useful, and transferable into practice.

DISCUSSION

Teaching ethical theories within the proposed framework overcomes the shortcomings described by current research. Students do not consider the mutually exclusive character of ethical theories as an insurmountable problem.

CONCLUSION

The proposed framework is likely to promote the effectiveness of healthcare ethics education. Inspired by pragmatist learning theory, it enables students to consider ethical theories as educative playgrounds that help them to "frame" and "name" the ethical issues they encounter in daily practice, which is seen as an expression of moral resilience. Since it does not advocate a single ethical theory, but is open to the diversity of traditions that shape ethical thinking, it promotes a culturally sensitive, ethically reflected healthcare practice.

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.

Development of an inventory assessing medical students' attitudes towards academic misconduct

PURPOSE

Identifying medical students' perceptions of and experiences with unprofessional behavior in school can help them develop and maintain higher standards of professional ethics. The aim of this study was to develop an instrument that assesses medical students' attitudes toward academic misconduct.

METHODS

A draft version of the questionnaire form was developed, based on an extensive literature review and iterative discussions. The validity of the content of this draft form was evaluated by medical students, physicians, and education specialists. A total of 803 medical students answered the questionnaire. Exploratory factor analysis was performed using principal axis factoring and Varimax rotation. A confirmatory factor analysis was also conducted by root mean square error of approximation (RMSEA) and comparative fit index (CFI). The internal consistency of the scales was calculated using the Cronbach alpha statistic.

RESULTS

The exploratory factor analysis generated 6 factors with 29 items: scientific misconduct (8 items); irresponsibility in the class (6 items); disrespectful behavior in patient care (5 items); dishonesty in clerkship tasks (4 items); free-riding on group assignments (4 items); and irresponsibility during clerkship (2 items). After adding a single item that addressed cheating on examinations, a 30-item inventory was developed. A confirmatory factor analysis demonstrated a favorable RMSEA (0.082) and reasonable fit (CFI, 0.844). The coefficient alpha for each factor varied between 0.80 and 0.90.

CONCLUSION

Our instrument is useful in identifying students' ethical standards with regard to academics and examining the prevalence of unprofessional behavior in medical students.

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.

Narrative, emotion and action: analysing 'most memorable' professionalism dilemmas

OBJECTIVES

Although previous studies have explored medical learners''most memorable' experiences, these have typically focused on patient deaths or mistakes. Drawing on multiple theoretical perspectives to understand the interplay between narrative, emotion and action, this paper aims to explore the whats and hows of written narratives of most memorable professionalism dilemmas: what types of dilemma are most memorable? When and where do they take place? How do students act? What characteristics relate to these dilemmas? How are dilemmas narrated?

METHODS

A total of 680 students from 29 of 32 UK medical schools provided a written narrative of their most memorable dilemma as part of their responses to an online questionnaire exploring the impact of professionalism dilemmas on moral distress. We employed quantitative thematic and discourse analysis of all narratives using Linguistic Inquiry Word Count software (LIWC) and conducted a narrative analysis of one exemplar.

RESULTS

The most common themes across all narratives concerned dilemmas that related to issues of patient care with reference to the actions of health care professionals or students, student abuse, and consent and intimate examination. A total of 41.1% of experiences had occurred over 6 months previously and 80.1% had taken place in hospital settings. Overall, 54.9% of narrators reported having done something in the face of their dilemma, although only 13.2% described taking obvious or direct action. Numerous characteristics were related to most memorable dilemmas (e.g. narratives citing intimate examinations were more likely to take place in surgical settings). A total of 92.6% of narratives included negative emotion talk and numerous significant relationships emerged between types of emotion talk and most memorable dilemmas (e.g. more anger talk in abuse narratives). Our narrative analysis of one exemplar illustrates the richness of emotion talk and more subtle devices to establish emotional tone.

DISCUSSION

Findings extend previous research into issues related to professionalism by exploring relationships between narrative, emotion and action in the context of written narratives of most memorable dilemmas. We encourage medical educators to help students construct coherent and emotionally integrated narratives to make sense of negative professionalism dilemmas.

"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.

Meaning and value in medical school curricula

RATIONALE, AIMS AND OBJECTIVES

Bioethics and professionalism are standard subjects in medical training programmes, and these curricula reflect particular representations of meaning and practice. It is important that these curricula cohere with the actual concerns of practicing clinicians so that students are prepared for real-world practice. We aimed to identify ethical and professional concerns that do not appear to be adequately addressed in standard curricula by comparing ethics curricula with themes that emerged from a qualitative study of medical practitioners.

METHOD

Curriculum analysis: Thirty-two prominent ethics and professionalism curricula were identified through a database search and were analysed thematically. Qualitative study: In-depth, semi-structured interviews were conducted with 20 medical practitioners. Participants were invited to reflect upon their perceptions of the ways in which values matter in their practices and their educational experiences. The themes emerging from the two studies were compared and contrasted.

RESULTS

While representations of meaning and value in ethics and professionalism curricula overlap with the preoccupations of practicing clinicians, there are significant aspects of 'real-world' clinical practice that are largely ignored. These fell into two broad domains: (1) 'sociological' concerns about enculturation, bureaucracy, intra-professional relationships, and public perceptions of medicine; and (2) epistemic concerns about making good decisions, balancing different kinds of knowledge, and practising within the bounds of professional protocols.

CONCLUSIONS

Our findings support the view that philosophy and sociology should be included in medical school and specialty training curricula. Curricula should be reframed to introduce students to habits of thought that recognize the need for critical reflection on the social processes in which they are embedded, and on the philosophical assumptions that underpin their practice.

Ethical participation of children and youth in medical education

Children and youth (referred to as 'children' in the present statement), whether actual patients or volunteers, frequently participate in medical education. The present position statement discusses the numerous ethical challenges that may arise including respect for persons, truth telling and confidentiality. The statement provides guidelines that may be helpful to educators from a wide variety of disciplines.