EXECUTIVE SUMMARY
Lack of resources, pressure to reduce classroom time, and students’ shorter attention spans are some current challenges to improving medical ethics education. Institutions are trying the following approaches:
- offering small-group teaching and case-based learning,
- having students shadow clinicians to see how ethical issues are handled in clinical practice, and
- using simulated patients for practice obtaining informed consent and giving bad news.
Currently, the more than 140 medical schools in the U.S. teach ethics “in just about 140 different ways,” says D. Micah Hester, PhD, a professor at University of Arkansas for Medical Sciences in Little Rock. Hester is also a clinical ethicist at Arkansas Children’s Hospital.
“My hope is that we do, in fact, begin to have a more robust and sustained national conversation about medical ethics education,” says Hester.
Janet Malek, PhD, associate professor at Baylor College of Medicine’s Center for Medical Ethics and Health Policy in Houston, names the following obstacles to improving ethics education: pressure to reduce classroom time, lack of dedicated resources, and resistance or mixed messages coming from institutional cultures.
Most attempts at improving medical ethics education occur at the local level, with individual schools making decisions about curriculum. “Some schools have integrated ethics into other courses, like ‘doctoring’ courses,” notes Hester.
Ethics education has made a great deal of progress in recent years, according to Michael Green, MD, MS, vice chair of the Department of Humanities and chair of the Hospital Ethics Committee at Milton S. Hershey (PA) Medical Center. “Previously, some places taught ethics and some didn’t — it was optional,” he explains. “We had to fight hard to get it into the curriculum.”
While ethics is part of virtually every medical school curriculum, there is much variation in how it’s taught. A recent report evaluated the current state of medical ethics education in the U.S.1 “We wanted to come up with a framework to build some consensus around that,” says Green, one of the report’s authors.
Malek, another of the report’s authors, says the goal was to offer an overview of the current landscape in ethics education and to identify issues that schools and educators should be thinking about. “We hope that readers might find some guidance about how to meet changing accreditation requirements and the types of problems they will need to find answers to,” she says.
One reason for inconsistencies in ethics education is that the resources available at institutions vary widely. “Some places have one part-time person, and others have robust ethics programs with a dozen people,” Green says. “So you can’t expect the same sort of curriculum.”
Malek sees many medical schools and residencies offering more curricular time and faculty support for education in medical ethics. This is in part because it supports the achievement of the Accreditation Council for Graduate Medical Education’s core competencies and related milestones.
“Ethics educators are working to develop new approaches that fit within evolving paradigms of medical education,” says Malek.
Shorter attention spans
Green directed a course on medical ethics and professionalism for medical students at Penn State College of Medicine for more than two decades. In recent years, he’s noticed that students, while bright and motivated, seem less interested in reading materials and attending lectures. “Every year, we end up shortening the amount of readings we provide — and every year they say it’s still too much,” he says. “One of the biggest challenges for us is how to successfully engage the students.”
Instructors now emphasize small-group teaching and experiential learning. “Having students listen to lectures and read philosophical texts doesn’t work as well today,” says Green. “The students respond much better to case-based approaches.”
Using simulated patients, students practice eliciting informed consent, ensuring confidentiality, and giving bad news. “We are not only delivering information, which is important, but we are also helping them develop skills to act ethically,” Green says.
Hester says some institutions are making a concerted effort to infuse ethics into clerkship education. This allows students to see “real-life” examples of ethical challenges. “Others have attempted different modalities for imparting ethics education, from simulation to problem-based learning,” says Hester.
Loyola’s educators use a “Medical Ethics Bowl” competition as a curricular modality to both provide case content and evaluation. “It requires research, argument, and teamwork to address ethically challenging issues in healthcare,” says Hester.
Looking forward, Malek expects to see ethics integrated throughout medical education, rather than separated into free-standing courses. “We may also see a movement toward the use of OSCEs [Objective Structured Clinical Exams] and virtual patients to teach and evaluate ethics and professionalism,” says Malek.
The following are some current concerns involving medical ethics education:
• Students often receive very little ethics education during residency.
Most institutions provide ethics education only during the first two years of medical school, strictly in a classroom setting. “During the clinical years when they really need ethics the most, there are fewer opportunities for such teaching,” explains Green.
Early on, ethical problems are just theoretical for students. “These problems aren’t real; they haven’t lived them,” says Green.
Only after students begin working in the hospital wards, or are residents working as doctors, do they really experience the dilemmas — yet there tends to be very little ethics education offered at that point, Green says.
“Ethics is not considered the most important topic for doctors to keep up with,” says Green. “But I think this just means we need to find more creative ways to reach these learners.”
• Students often lack good role models in clinical practice settings.
“Everything we do can be easily — and often is — undermined in a short amount of time by role models who don’t embody the things we’ve been telling them,” says Green.
For instance, ethicists teach students to represent themselves accurately and honestly. “Then, in one brief moment, an attending physician introduces them as ‘Doctor X,’ and says that the young doctor will be getting informed consent for an upcoming procedure,” says Green. Now the student has to decide whether to contradict the attending who misrepresented them, and how to deal with the consent issue — which really is the responsibility of the attending physician and not the student. “It’s a powerful negation of what we teach,” says Green.
To really make a difference, Green says ethics education has to find a way to affect the culture of medicine more generally. “That means having a culture of respect. This is long, hard, challenging work,” says Green.
Green says ethicists need more engaging ways to reach broader audiences in the clinical practice setting. “Any experienced clinician will tell you that some of the most challenging cases they face are those that raise ethical dilemmas, rather than scientific challenges,” he says.
J.S. Blumenthal-Barby, PhD, Cullen Associate Professor of Medical Ethics and associate director of medical ethics at Baylor College of Medicine’s Center for Medical Ethics and Health Policy in Houston, says ethicists need to teach healthcare professionals more about how to behave ethically, rather than just ethical principles that identify the right thing to do.
“We know from the moral psychology literature that people are often prey to certain biases that impact their moral behavior in ways that are subtle and unconscious,” says Blumenthal-Barby. For example, putting eyes above the coffee donation box at work makes it more likely that people will do the right thing and pay for the coffee they are using.
“Or, as the Zimbardo prison experiments demonstrated, people will hurt other people if an authority figure is doing so or is asking them to,” says Blumenthal-Barby. “In such cases, the moral agents know the right thing to do; they just don’t do it.”
Blumenthal-Barby says ethicists need to teach healthcare professionals how their behavior is shaped by their environment. “Only then will the principles that we teach have any utility in terms of translating into actual behavior,” she says.
• There is lack of evidence on how different content, modalities, and materials achieve the stated aims of ethics education.
Hester sees this as the primary challenge to improving ethics education. In general, medical ethics education aims at clarifying the nature of an ethical issue, developing sensitivity to the appearance of ethical concerns in medical situations, and providing tools for addressing ethical concerns once they are recognized.
“However, even after 40+ years of medical ethics teaching, what content, teaching modalities, and materials achieve these goals is an open question,” Hester says.
It’s very difficult to evaluate what kind of effect educational efforts have on learners. “Because medical ethics courses are often integrated with other courses and take place over a period of time, confounding factors make it nearly impossible to discern the impact of the course itself,” Malek says.
The goal of ethics education is to affect behavior that won’t take place for many years. “So the effectiveness of an intervention could only be measured by longitudinal studies that are difficult and expensive to run,” says Malek.
It is challenging to evaluate the extent to which a student, resident, or physician is “ethical,” since there is no consensus definition of this and no established tool to assess this characteristic and its associated behaviors.
“Without the ability to determine which educational interventions are effective and which are not, it is hard to improve those approaches,” says Malek.
REFERENCE
- Carrese JA, Malek J, Watson K, et al. The essential role of medical ethics education in achieving professionalism: the Romanell Report. Acad Med 2015; 90(6):744-752.
SOURCES
- J.S. Blumenthal-Barby, PhD, Cullen Associate Professor of Medical Ethics/Associate Director of Medical Ethics, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston. Phone: (713) 798-3785. Email: [email protected].
- Michael Green, MD, MS, Vice Chair, Department of Humanities, and Chair, Hospital Ethics Committee, Milton S. Hershey Medical Center, Hershey, PA. Phone: (717) 531-8778. Email: [email protected].
- D. Micah Hester, PhD, Professor, University of Arkansas for Medical Sciences, Little Rock. Phone: (501) 661-7970. Email: [email protected].
- Janet Malek, PhD, Associate Professor, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston. Phone: (713) 798-5169. Email: [email protected].
