Reflecting on senior medical students' ethics reports at the University of Auckland

In January 2010, fifth year medical students in the medical programme at the University of Auckland were asked to write a 1200-word report as part of their ethics assessment. The purpose of the report was to get students to reflect critically on the ethical dimension of a clinical case or situation they had been involved in during the past 2 years. Students were required to identify and discuss the salient ethical issues that arose as they saw them, and consider what they had personally learnt from the situation. The purpose of the following discussion is twofold: first, to outline some of the ethical issues raised by year five medical students in their ethics reports; and second, to reflect on what we, as educators and health professionals can learn from their experiences and insights.     

What do medical students know about chronic pain and its management?

A questionnaire on chronic pain management was completed by 114 third year, and 80 fifth (final) year medical students. The results demonstrated a significant improvement in most facets of chronic pain knowledge and management by the end of the medical course. A postal survey was undertaken of all pain clinics in Northern Ireland to identify current activity, as these figures are not collected in Korner returns. Despite the improvement in knowledge by final year, there were still many students who did not know what type of problem to refer to a pain clinic (30%), who ran the clinics (> 40%), or the types of treatment commonly employed. More formal education is required on this subject, at both undergraduate and postgraduate level.     

Evaluating ethical sensitivity in medical students: using vignettes as an instrument

As a preliminary step to beginning to assess the usefulness of clinical vignettes to measure ethical sensitivity in undergraduate medical students, five clinical vignettes with seven to nine ethical issues each were created. The ethical issues in the vignettes were discussed and outlined by an expert panel. One randomly selected vignette was presented to first, second and third year students at the University of Toronto as part of another examination. The students were asked to list the issues presented by the patient problem. Responses from 281 students were obtained. These students identified an average of 2.72 ethical issues per vignette. Each response was classified under the domains of autonomy, beneficence and justice. Comparisons were made between classes and between vignettes. There was considerable variation between classes and the responses to different vignettes seem to indicate that different vignettes measure the various domains in different ways. It does appear that the use of vignettes is one way to measure aspects of ethical sensitivity in medical students but more study is required to clarify exactly what is being measured.     

An ethical paradox: the effect of unethical conduct on medical students' values

OBJECTIVE: To report the ethical development of medical students across four years of education at one medical school. DESIGN AND SETTING: A questionnaire was distributed to all four classes at the Wake Forest University School of Medicine during the Spring of 1996. PARTICIPANTS: Three hundred and three students provided demographic information as well as information concerning their ethical development both as current medical students and future interns. MAIN MEASUREMENTS: Results were analyzed using cross-tabulations, correlations, and analysis of variance. RESULTS: Results suggested that the observation of and participation in unethical conduct may have disparaging effects on medical students' codes of ethics with 35% of the total sample (24% of first years rising to 55% of fourth years) stating that derogatory comments made by residents/attendings, either in the patient's presence or absence, were "sometimes" or "often" appropriate. However, approximately 70% of the sample contended that their personal code of ethics had not changed since beginning medical school and would not change as a resident. CONCLUSIONS: Results may represent an internal struggle that detracts from the medical school experience, both as a person and as a doctor. Our goal as educators is to alter the educational environment so that acceptance of such behaviour is not considered part of becoming a physician.     

Helping medical students to find their moral compasses: ethics teaching for second and third year undergraduates

The paper describes a two week course that has been offered as a special study module to intermediate level (second and third year) undergraduate medical students at Dundee University Medical School for the past five years. The course requires students to research the various aspects of ethical dilemmas that they have identified themselves, and to "teach" these issues to their colleagues in a short PowerPoint presentation as well as to prepare an extended 3000 word essay discussion. The course specifically asks students not to disclose their own ethical positions, as these are probably still in formation and the objective is to promote critical thinking capacity in ethical and moral issues as a prelude to the development of practical skills in dealing with clinical problems. The course is easy to resource for the school and has received universally high evaluations from the students since its inception.     

A national online survey of final year medical students' opinion on the General Medical Council's proposed reforms to the undergraduate medical assessment system

BACKGROUND: The General Medical Council (GMC) is holding consultations in order to decide on the proposed changes to the undergraduate medical assessment. In the last round of consultation only eight medical students formally responded nationally. AIM: To determine the views of a larger proportion of final year medical students across the country on the proposed changes to the undergraduate medical assessment. Method: An online national survey of 10 medical schools, from which 401 responses from final year medical students were collected. Results and discussion: The results indicate the medical students' views on the GMC's proposed changes to standardise the assessment system. The majority of the students were in favour of having a say in any changes to their future assessment. They agreed with the principle that there should be a consistency between assessments at different medical schools and currently their results did not represent preparedness to practice.     

Evaluating medical school graduates of a reduced course program: a preliminary report

The performance of 32 medical school graduates who had pursued a reduced course load ("extended program") for one or more years during medical school was examined during the first postgraduate year (PGY-1) of training. Those with academic problems as undergraduates performed at only a slightly lower than average level, while those who had extended their curricula to pursue personal or extracurricular interests tended to perform at a better than average level in the PGY-1 residency. Graduates with significant emotional disorders in medical school who pursued a reduced course load had a high (35 percent) dropout rate during the residency that occurred despite expert psychiatric care and substantial support during medical school and the residency. The authors suggest that extended programs may be useful for students seeking personal enrichment and for some with academic problems but that they do not seem particularly helpful to students with major emotional disturbances.     

How do we teach medical ethics?

Recently there has been debate about how much medical students are taught on ethical problems. In practice the problem often arises in a different way, as is illustrated in the following seminar for medical students in their first clinical year in a teaching hospital. The discussion takes place in the ward side-room, and is led by a visiting clinician.     

Students' attitudes and potential behaviour to a competent patient's request for withdrawal of treatment as they pass through a modern medical curriculum

OBJECTIVE: To examine students' attitudes and potential behaviour to a competent patient's request for withdrawal of treatment as they pass through a modern medical curriculum. DESIGN: Cohort design. SETTING: University of Glasgow Medical School, United Kingdom. SUBJECTS: A cohort of students entering Glasgow University's new learner centred, integrated medical curriculum in October 1996. METHODS: Students' responses before and after year 1, after year 3, and after year 5 to the assisted suicide vignette of the Ethics in Health Care Survey instrument, were examined quantitatively and qualitatively. Analysis of students' multichoice answers enabled measurement of the movement towards professional consensus opinion. Analysis of written justifications helped determine whether their reasoning was consistent with professional consensus and enabled measurement of change in knowledge content and recognition of the values inherent in the vignette. Themes on students' reasoning behind their decision to withdraw treatment or not were also identified. RESULTS: Students' answers were found to be consistent with professional consensus opinion precurriculum and remained so throughout the curriculum. There was an improvement in the knowledge content of the written responses following the first year of the curriculum, which was sustained postcurriculum. However, students were found to analyse the section mainly in terms of autonomy, with few responses considering the other main ethical principles or the wider ethical perspective. Students were unclear on their legal responsibilities. CONCLUSIONS: Students should be encouraged to consider all relevant ethical principles and the wider ethical perspective when deliberating ethical dilemmas. Students should have a clear understanding of their legal responsibilities.     

Finding a faster route to practice: from medical student to board certified physician

An examination of two types of educational tracks used by medical students seeking a faster route to practice: 1) "3+3" programs that combined the final year of medical school with the first year of a primary care residency, and 2) graduating from medical school after only three years. The "3+3" programs were discontinued despite reports indicating their success. Three year medical school options are still available at a handful of medical schools. Finally, the paper will explore why and how medical schools might wish to enact a three year curricular option.     

王焘医事考

王焘甫一成年,即开始学习医学,所从学者为有道的高医,并多次从其游学,完全掌握了其师的医学思想和医疗技术,具有高深的医学造诣。天宝五、六载（746、747）担任门下省给事中时判弘文馆事,以其医学背景和工作之便,从弘文馆秘藏图书中检得五六十种晋唐方书,后加以整理,于天宝十一载（752）撰成千古名著《外台秘要》。     

Teaching medical students on the ethical dimensions of human rights: meeting the challenge in South Africa.

SETTING: Previous health policies in South Africa neglected the teaching of ethics and human rights to health professionals. In April 1995, a pilot course was run at the University of Cape Town in which the ethical dimensions of human rights issues in South Africa were explored. OBJECTIVES: To compare knowledge and attitudes of participating students with a group of control students. DESIGN: Retrospective cohort study. SUBJECTS: Seventeen fourth-year medical students who participated in the course and 13 control students from the same class, matched for gender. INTERVENTIONS: Students participated in a one-week module on ethics and human rights. Five months after the course had been run, students completed a semi-structured questionnaire exploring their knowledge and attitudes with regards to ethics and human rights issues. MAIN OUTCOME MEASURES: Knowledge scores, attitude scores and various individual indicators of attitude. RESULTS: Clear benefits for overall knowledge score, for four out of five individual knowledge questions and for one of the attitude questions, were demonstrated. Participating students also appeared to be more convinced of the need for teaching on the ethical dimensions of human rights at postgraduate level and that such teaching should also be integrated in the curriculum. The low response rate amongst controls may have selected students who were more socially conscious, thereby leading to an underestimate of the true impact of the course. CONCLUSION: The evaluation indicates clear benefits of the course for undergraduate students, and supports arguments for the inclusion of such courses in the training of health professionals. This is particularly important given the challenges posed by the Truth and Reconciliation Commission to the health professions to address past complicity in human rights abuses through reorientation of medical training in South Africa.     

The medical student global health experience: professionalism and ethical implications

Medical student and resident participation in global health experiences (GHEs) has significantly increased over the last decade. In response to growing student interest and the proven impact of such experiences on the education and career decisions of resident physicians, many medical schools have begun to establish programmes dedicated to global health education. For the innumerable benefits of GHEs, it is important to note that medical students have the potential to do more harm than good in these settings when they exceed their actual capabilities as physicians-in-training. While medical training programmes are beginning to provide students with the knowledge to put their GHEs in context, they must remember that they also bear the responsibility of training their students in a framework to approach these experiences in a principled and professional way. It is necessary that these institutions provide adequate and formalised preparation for both clinical and ethical challenges of working in resource-poor settings. This paper outlines potential benefits and risks of GHEs and delineates recommendations to some of the current issues.     

Making a difference: the early impact of an Aboriginal health undergraduate medical curriculum

OBJECTIVE: To describe the implementation of an integrated Aboriginal health curriculum into the medical course at the University of Western Australia (UWA) and the early effect on students' perceptions of their knowledge and ability in the area of Aboriginal health. DESIGN, SETTING AND PARTICIPANTS: Final-year medical students at UWA in 2003 (first cohort) and 2004 (second cohort) were surveyed by questionnaire (with answers on a five-point Likert scale) to assess their attitudes to various aspects of Aboriginal health. A subset of students provided open-ended comments on key priorities in Aboriginal health, cultural security and suggestions for Aboriginal health policy. INTERVENTIONS: Integrated learning experiences were implemented within each year of the medical course, based on specific learning outcomes in Aboriginal health. MAIN OUTCOME MEASURES: Changes in students' self-perceptions of their preparedness for and future commitment to working for change in Aboriginal health. RESULTS: Response rates were 76% and 85% in the 2003 and 2004 cohorts, respectively. Compared with first-cohort students, second-cohort students were more likely to agree with items relating to their preparedness and ability to work with and care for Aboriginal and Torres Strait Islander people (P < 0.05); second-cohort students also reported greater preparedness to advocate and improve the health of Aboriginal people (P < 0.05); 65% of respondents in the second cohort (versus 34% in the first) agreed they had a social responsibility to work for change in Aboriginal health (P < 0.05). CONCLUSION: With a relatively small amount of targeted and structured teaching and learning in Aboriginal health, significant shifts in students' self-perceived levels of knowledge, skills and attitudes are possible.     

Changes in undergraduate attitudes toward medical ethics

To detect any change in medical students' attitudes toward medical ethics, students from the same class were given a questionnaire on their first day of medical school and again near the end of their fourth year of study. The results showed a strong shift away from the students' initial expectations that they would rely on specialists or scholarly sources in the future; the need for a medical ethics course in the curriculum, while still felt, was less important to them by the fourth year. The reasons for these changes were not apparent, for the students' levels of knowledge and perceptions of the role of ethics in medicine in the first and fourth years did not differ. It is recommended that medical school faculty actively reinforce the initially positive attitudes of students during clinical supervision.     

Integrating cost awareness with ethics in the undergraduate medical curriculum

The challenge to train medical students in cost awareness regarding medical care led to a program at the Oregon Health Sciences University that integrates concern for costs with medical ethics. Cost awareness is a perspective that balances the physician's ethical obligations toward individual patients with their duties toward society whose pooled resources pay for medical services. The program integrates the subject of cost awareness into major required courses spanning the four-year curriculum. First-year students see costs in the context of an overview of social aspects of medical care. For second-year students, cost awareness is incorporated into training in basic clinical skills. Third- and fourth-year students are shown the bill for one of their patients and analyze their ward experiences from the perspective of resource utilization. Junior and senior students examine the impact of the legal system and professional ethics on health care costs. Elective course work on cost awareness is also available.     

Differences in medical students' attitudes to academic misconduct and reported behaviour across the years--a questionnaire study

OBJECTIVES: This study aimed to determine attitudinal and self reported behavioural variations between medical students in different years to scenarios involving academic misconduct. DESIGN: A cross-sectional study where students were given an anonymous questionnaire that asked about their attitudes to 14 scenarios describing a fictitious student engaging in acts of academic misconduct and asked them to report their own potential behaviour. SETTING: Dundee Medical School. PARTICIPANTS: Undergraduate medical students from all five years of the course. METHOD: Questionnaire survey. MAIN MEASUREMENTS: Differences in medical students' attitudes to the 14 scenarios and their reported potential behaviour with regards to the scenarios in each of the years. RESULTS: For most of the scenarios there was no significant difference in the response between the years. Significant differences in the responses were found for some of the scenarios across the years, where a larger proportion of year one students regarded the scenario as wrong and would not engage in the behaviour, compared to other years. These scenarios included forging signatures, resubmitting work already completed for another part of the course, and falsifying patient information. CONCLUSION: Observed differences between the years for some scenarios may reflect a change in students' attitudes and behaviour as they progress though the course. The results may be influenced by the educational experience of the students, both in terms of the learning environment and assessment methods used. These differences may draw attention to the potential but unintentional pressures placed on medical students to engage in academic misconduct. The importance of developing strategies to engender appropriate attitudes and behaviours at the undergraduate level must be recognised.     

Effects of teaching first-year medical students skills to read medical literature

A required first-year course at George Washington University School of Medicine and Health Sciences, entitled Studying a Study: Methods for Reading the Medical Literature, was evaluated by the author to determine the students' perception of the course's effectiveness, changes in the students' perception of their competence in reading medical literature, the students' knowledge of research study design and statistics, and the effect of the course on the students' journal reading. Students who took the course were questioned before and after the course and as fourth-year students and were compared with fourth-year students in a prior class that had not been offered the course. Students rated the course as effective. The students who took the course rated themselves as more competent and had greater knowledge than did the class that did not take the course. These students' ratings and scores declined, however, from the first to the fourth year. A required preclinical course in study design and statistics can be well received and can affect students' knowledge and perceptions of their competence. Reinforcement is necessary to maintain the results.     

Medical Students in Canadian Universities: Report of Statistics, 1963-64 and 1964-65

Recognizing Canada's urgent need of physicians Canadian medical faculties have continued to increase first-year enrolment for the sixth successive year. Returns from the 12 medical schools showed that 1133 students began medical studies in 1964 compared with 1086 the previous year. Firstyear female students showed a decrease for the first time since 1959: 124 compared with 146 in 1963. Every tenth graduate is a woman; six years ago this ratio was one in 20. Loss of students from withdrawals and dismissals in 1963-64 occurred chiefly in the first year (9.2% as compared with 8.7% in 1962-63). Almost half of the loss in all four years of the course was for non-academic reasons. A decrease in American and a slight increase in Commonwealth and foreign first-year students was noted. Total foreign student enrolment continued to decline from a high of 485 in 1959-60 (13.7%) to 400 in 1964-65 (10.3%).     

“新时代”背景下医学人文素养贯穿医学生全过程培育现状的调查研究

目的 以“新医科”为背景构建以“育人为驱动力—立德树人为核心”的全过程育人路径，为医学院校人文素质教育改革与创新发展，提供决策依据。方法 以齐齐哈尔医学院五年制临床医学（大一至大五）学生为研究对象，利用文献分析等方法构建临床医学生人文素质评价模型和调查问卷。通过问卷星平台对临床医学本科生采取随机抽样进行调研和数据收集工作。采用SPSS 26.0软件进行卡方检验，探讨构建全过程育人的路径。结果 实证调研对医学生人文素养培育情况的医学生人文态度评分均值为（3.47±0.75）分。从性别上来看，男生人文认知、态度、行为评分为2.81分、3.68分和3.22分，全部高于女生的2.52分、3.22分和2.95分，且差异有统计学意义（P<0.05）。从大一到大五年级数据显示：人文认知、态度、行为评分均呈现出年级升高而递增的趋势，运用“知信行 （Knowledge，Attitude/Belief，Practice，KAP）”模型发现医学生对人文素养认知率较为理想，不同年级医学生知晓率不同，并利用交叉分析去研究学校对医学生开展的思想品德和政治素养教育效果与多选题的交叉关系，呈现出显著性。结论 临床医学生人文素质有待提高，培育医学人文素养需贯穿大一至大五的全过程，从而提高职业能力的综合培养，促进医学生的全面发展。