Health care ethics teaching for medical students

This paper describes an innovatory teaching programme in health care ethics for medical undergraduates. The general aims and objectives are outlined and the 1990 course is discussed specifically. The course has several unusual features, including the use of performers and the presentation of ethically based decisionmaking implements, which are highlighted. The course is evaluated. The 1990 results are encouraging.     

An innovation in teaching ethics to medical students

There is growing agreement among the medical profession that medical ethics should be taught at undergraduate level. We present a model which can be taught in a way which is lively and entertaining, and which allows students to discuss ethical problems freely in small groups. This brief teaching package maximizes the learning experience. It could be used as part of a more extensive programme of ethics teaching.     

Health promotion in the medical curriculum

It has been argued that health promotion should be included in the medical curriculum, if medical education is to match the needs and health goals of communities. In spite of the medical profession's awareness of the importance of health promotion, few universities in the UK have introduced a substantive course on the subject. This paper describes the teaching of health promotion in Nottingham Medical School. It identifies the aims and objectives of the course which are amongst others to develop an understanding of: the factors which influence the perception and experience of health and illness; the concepts of health promotion and health education; the scientific basis of health promotion; the relative effectiveness of approaches used; the measurement of health status and health behaviour; and health policy and planning. An innovative element of the teaching involves a community project which gives students experience of health promotion in practice. Evaluation of the impact of the course suggests that students perceive it to be interesting, stimulating and enjoyable, whilst examination and continuous assessment indicate that it has also influenced students' knowledge and understanding of the subject.     

Teaching psychiatric ethics

In the last decade, we have witnessed a burgeoning of interest in ethical issues amongst psychiatrists. Teaching of the subject, however, remains at a rudimentary stage. Various approaches to such instruction are available, particularly modelling (students observe their experienced counterpart), the case method (examining specific clinical situations which involve a need for ethical decision-making), and the seminar approach (trainees are exposed to a core body of knowledge, mainly theoretical in nature). Faced with these different teaching models, the University of Oxford Department of Psychiatry has opted for a blend of all three approaches, which incorporates two goals: an increase in the trainees' sensitivity to the many intricate moral dilemmas facing the psychiatric profession; and their familiarity with salient concepts in moral philosophy which constitute a basis for ethical reasoning and which have a bearing on clinical practice. The teaching programme comprises the following: a pair of trainees prepares a presentation on an aspect of psychiatric ethics under the supervision of a senior psychiatrist. A moral philosopher assumes the role of discussant of the ethical problems raised by the trainees; this is followed by a general discussion. Topics have included involuntary hospitalization, dual loyalty, suicide, psychiatric diagnosis, and ethical issues in various spheres of psychiatric practice such as sex therapy, psychotherapy and child psychiatry. The approach has worked effectively and proved rewarding to all participants involved.     

Context in medical education: the informal ethics curriculum

As some formal bioethics instruction has become the norm in American medical schools, a trend has emerged toward increased attention to context in both bioethics education and bioethical decision-making. A focus on classical dilemmas and a textbook knowledge of principles is yielding its previous dominance to permit a more detailed examination of ethical behaviour in actual practice in medicine. After documenting and analysing this emerging trend in bioethics education and its parallel in bioethics theory and research, we turn to the context of medical education itself to look beyond formal bioethics instruction to the ' informal curriculum ' that is so central to the moral development of medical students and residents.
A qualitative research strategy is being used to study the informal curriculum through analysing tape-recorded informal conversations students and residents have with their friends and colleagues at work about issues bearing on their professional development. Data presented are documenting 'the unwritten code' for medical students on a surgical clerkship and the senior residents' informal ways of producing a ' practical ethics of conduct ' that shapes understanding of what is good, skilful, and right on that surgical service. How conceptions of appropriate conduct are conveyed, rewarded and sanctioned also reveals how professional demeanour is taught, permitting discussion about what should be retained and what changed. The context in which ethical issues arise enhances understanding of ethical practice in medicine.     

Teaching bioethics to medical students: the Newcastle experience

Summary. Over the past two decades in the USA, bioethics has become an accepted component of medical education, whereas in Australia, 10 years or even less would encompass the history of most existing programmes. Given the legendary conservatism of medical schools in Australia and the intractability of the medical curriculum, this is still a remarkable achievement. But does the teaching of bioethics change the thinking and/or decision-making behaviour of medical students or practitioners exposed to such courses? Those involved know only too well how difficult such courses are to design and evaluate since the connection between ethics education and practice is not known and may never be demonstrated to the satisfaction of critics. Critics not only seek answers to the questions of whether the teaching of bioethics makes a difference, which is a fair question, but they also seek answers to the question of whether bioethics should be taught in medical schools. Can bioethics be taught? Whose bioethics is being taught? What does the trained bio-ethicist contribute? Some of these questions arise from misunderstanding and some reflect the still too dominant view in medical schools which divides disciplines into those which provide ‘practical skills’, and those which contribute only theoretical and therefore peripheral knowledge. The authors will address these questions in the light of their experience at Newcastle, Australia, where the Faculty of Medicine has been teaching bioethics for over a decade.     

Teaching of medical ethics in Sri Lanka

Medical ethics as taught by members of the Department of Forensic Medicine in three of five medical colleges in Sri Lanka is a 'rule ethic' ('normative ethic') based on 'traditional' or 'classical' ethics. Instruction includes the teaching of moral principles, illustrated with examples. Also included are aspects concerning the functions of the Sri Lanka Medical Council. The topic is evaluated in the essay, multiple choice question and oral components of the third MBBS (Part II) examination (end of fourth year). As presently taught the syllabus is thoroughly inadequate for dealing with modern (medical) ethical issues. The shortcomings and limitations in the present programme are pointed out and requisite improvements suggested. A case is made for an eclectic view of ethics, in which a 'situation ethic' would play a part. Finally, the training of a highly moral responsible medical professional is emphasized.     

Teaching student-centred educational approaches to general practice teachers

Summary. The people responsible for undergraduate medical education are being urged to devise curricula which are more learner centred and community oriented. This has huge implications for teacher training. A project is reported aimed at helping general practice teachers develop learner-centred educational approaches through one-day workshops, themselves arranged on learner-centred lines. An evaluation indicates these workshops met their aim, and seem most useful when participants have an opportunity to practise newly acquired skills as soon afterwards as possible.     

Teaching of medical ethics: implications for an integrated curriculum

This paper reports on an investigation into the teaching of medical ethics and related areas in the medical undergraduate course at the University of Queensland. The project was designed in the context of a major curriculum change to replace the current 6 year course by an integrated, problem-based, 4 year graduate medical course, which began in 1997. A survey of clinical students, observations of clinical teaching sessions, and interviews with clinical teachers were conducted. Data obtained have contributed to curriculum development and will provide a baseline for comparison and evaluation of the graduate course in this field. A view of integrated ethics teaching is advanced in the light of the data obtained.     

Advanced training in biomedical ethics: a curriculum in clinical specialty programmes

Summary. Medical ethics play an essential role in the practice of medicine, in the care of individual patients, in the allocation of health care resources, and in the formulation of health care policy. A specific body of knowledge, ‘biomedical ethics’, has developed which applies ethical theory to biomedical practice. This has provided doctors with tools systematically to integrate rational ethical analysis into clinical decision-making. Training in the discipline of biomedical ethics is now required for all doctors in Canada. The goals, content areas, learning objectives, and learning methods considered appropriate for advanced training in this field for medical specialists are provided in this paper. Six topic areas are discussed: introduction to ethical theory, clinical ethics, professional ethics, ethics of human experimentation, ethics of health policy, and independent study. Ways this curriculum could be organized and evaluated are also offered.     

Attitudes of medical students to the teaching of medical ethics

Summary. The teaching of ethics to medical students has recently become a topic of much importance to all concerned with medical education. However, those most involved, the students themselves, have been consulted very little. This paper reports the views of a sample of medical students at Oxford University on what ethics teaching they receive, of how much value they consider it to be and what form of teaching they would like to see included in their curriculum.     

Review of ethics curricula in undergraduate medical education

Medical ethics education, it has been said, has 'come of age' in recent years in terms of its formal inclusion in undergraduate medical curricula. This review article examines the background to its inclusion in undergraduate curricula and goes on to examine the consensus that has arisen on the design of ethics curricula, using Harden's curriculum and S.P.I.C.E.S models as templates. While there is consensus on content for undergraduate medical ethics education, there is still significant debate on learning and teaching methods. Despite the broad agreement on the need to apply adult education principles to ethics teaching, there would appear to be some tension between balancing the need for experiential learning and achieving the 'core curriculum'. There are also as yet unresolved difficulties with regards to resources for delivery, academic expertise, curriculum integration and consolidation of learning. Assessment methods also remain contentious. Although there is consensus that the ultimate goal of medical ethics, and indeed of medical education as a whole, is to create 'good doctors', the influence of the 'hidden curriculum' on students' development is only beginning to be recognized, and strategies to counteract its effects are in their infancy. The need for proper evaluation studies is recognized. It is suggested that the areas of debate appearing in the literature could be used as a starting point for evaluation studies, which would form the empirical basis of future curriculum development.     

Medical students'' evaluations of different levels of medical ethics teaching: implications for curricula

Although medical ethics has become a part of the curriculum of almost every medical school, medical students' perceptions of the value of medical ethics have not been documented. This paper reports the evaluations given by 137 preclinical and 216 clinical medical students to different levels of medical ethics teaching at the College of Human Medicine and the College of Osteopathic Medicine of Michigan State University. The results indicate (1) that students' satisfaction with medical ethics teaching is directly linked to how much they receive, (2) that students overwhelmingly prefer the input of both ethicists and doctors to teaching by either alone, and (3) that a preclinical medical ethics course followed by explicit medical ethics teaching in clinical training is a promising model for achieving an adequate level of medical ethics teaching within medical education.     

Family attachments and medical sociology: a valuable partnership for student learning

This paper reports association within a curriculum of a theoretical programme in medical sociology for undergraduate medical students with a practical family attachment. These two components constitute the 'sociology' element of a course in behavioural science, and have equal weight for assessment purposes. Recognition of, on one hand, the mutuality of the two elements, and on the other, their similar but distinct theoretical underpinnings, suggests that such an association has the benefit of retaining the individual contributions of each component to student learning, while enabling theoretical and practical components to inform each other. Both are administered from the Department of General Practice of the University of Sheffield, UK. The consequences of such an educational provision are discussed.     

Elaborated learning in undergraduate medical education

Southampton Medical School holds its major examination of basic knowledge after rather than before students enter their first clinical attachments. An interview survey investigated its educational effects, and found that students adopt one of four revision approaches. The most successful, not just in terms of examination grade but more particularly in students' subsequent ability to retrieve and use the knowledge gained, occurred when students related their preclinical revision to their clinical experiences. One of these approaches, an elaboration of knowledge, is considered to be essential for effective clinical thinking yet is probably rare elsewhere in medical education since it appears to be a consequence of a particular curricular arrangement. An explanation is given in terms of current thinking in cognitive psychology, and this challenges the theoretical assumptions on which other research in medical education has been uncritically based. Some implications for medical education and further research are discussed.     

A conference on ethics for obstetric and gynaecological clerkship students

Integrating the teaching of medical ethics into medical students' clinical education is challenging, given the competing demands on students' time and the need for teaching to be clinically relevant. This paper describes a model programme for incorporating ethics teaching into the obstetrics and gynaecology clerkship for third-year medical students. The programme is taught by two attending teachers and a medical ethicist with experience teaching in the clinical setting of obstetrics and gynaecology. Objective pretests and posttests showed substantial improvement in students' knowledge, and student feedback has been very positive.     

A curriculum on medical ignorance

The information and technology explosions in medicine have exposed the vast realm of ignorance in human biology as well as the transiency of accepted knowledge and shortcomings of instructional methods which foster rote memorization, excessive reliance on conflicting data bases, and short-answer testing. To circumvent this serious deficiency in medical education, we have initiated a multifaceted Curriculum on Medical Ignorance consisting of 'questioning' seminars and hands-on clinical and laboratory experiences. This teaching programme not only emphasizes medicine's current deficiencies and limited insight into disease processes (i.e. ignorance) but also assists students in developing attitudes and behaviours to investigate basic biologic and clinical unknowns while rendering sound everyday clinical decisions in the face of fragmentary understanding. Based on evaluative feedback over the past 3 years, participants have made substantial progress towards recognizing and dealing constructively with medical ignorance and the limitations of 'knowledge of the day', thereby preparing them for the certain uncertainty of future medical practice.     

Teaching of cardiopulmonary resuscitation by medical students

Ten first-year medical students were taught basic cardiopulmonary resuscitation (CPR) according to the guidelines laid down by the American Heart Association. Following a 7.5-hour instruction period they, in turn, taught 40 secondary school pupils. On formal assessment using models, all the school children were able to perform basic CPR.     

Teaching of primary health care in practice: a model using local health centres in undergraduate medical education

In Finland primary health care has a long historical background. The local communities, the state and the church have at various times and places been responsible for primary health care during the last few centuries. In 1972, a major reform took place when a new Primary Health Care Act came into force. In the same year two new medical faculties, at Kuopio and Tampere Universities, began to educate undergraduate medical students. In both of these new medical schools special attention was focused on the teaching of primary health care. Today practical teaching, which takes place at a primary health care centre, forms an important part of medical education at Kuopio University. This teaching of undergraduate students is part of the regular duties of general practitioners and public health nurses in the primary health care centres of eastern Finland that have agreed to collaborate in the teaching programme. The main principles are presented for the teaching programme in primary health care at the University of Kuopio.     

Evaluation of lectures on medical ethics through students' drawings

Summary. The authors have encouraged medical students to express their impressions of and reactions to lectures on medical ethics by drawing illustrations on their attendance cards. This gives students a sense of participation in the lecture, and also it provides teachers with useful feedback concerning students' understanding of and interest in the subject.