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.     

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.     

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.     

A process evaluation of medical ethics education in the first year of a new medical curriculum

BACKGROUND: Despite the recent increase in activity in the field of medical ethics education, few evaluative studies have been carried out. Most studies have taken place in North America, in curricula where teaching is discipline-based, and have concentrated on outcome rather than on the curricular processes adopted. AIM: To evaluate the process of medical ethics education in the first year of a new learner-centred, problem-based, integrated medical curriculum. METHOD: A qualitative, multi-method approach was adopted using open questionnaires, focus groups and tutor evaluation rating scales. The study involved all 238 students in the first year of the new medical curriculum, and the 30 clinical tutors who facilitated ethics learning. A stratified sampling technique was used to choose focus group participants. RESULTS: Small group teaching proved highly acceptable to both students and tutors. Tutors' teaching skills were central to its effectiveness. Tutors played an important role in promoting students' appreciation of the relevance of medical ethics to clinical practice, and in establishing a climate where constructive criticism of colleagues' actions is acceptable. Course integration, including the provision for students of clinical experiences on which to reflect, was an important aid to learning. Students and tutors were noted to be driving the ethics curriculum towards having a contextual rather than theoretical base. CONCLUSION: This evaluation identified those aspects of the medical ethics course which contributed to its effectiveness and those which detracted from it. This information will be used to inform future development.     

The cost of problem-based vs traditional medical education

It is generally accepted that teachers' salaries are a major factor in the cost of medical education. Little is known about the effects of curriculum on teaching time. A comparison of teaching time devoted to each of two different medical education curricula is presented. In a traditional teacher-centered, subject-oriented curriculum, 61% of the total teaching effort expended by twenty-two teachers took place in the absence of students, i.e. in preparation for student contact. Only 39% of the effort devoted by these teachers to medical education took place in the presence of students. In a problem-based, student-centered curriculum which focuses upon small-group tutorial learning and early extended primary care experience in a rural community setting, 72% of the total teaching effort devoted to medical education was spent with students and only 28% was spent in preparation for student contact. Overall, there were no differences in the total amount of teaching time required by each of the two curricular approaches to medical education. There were, however, major differences in how teachers spent their teaching time.     

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.     

Postgraduate education in medical ethics in Japan

The objective of this paper was to investigate what kind of postgraduate education in medical ethics medical residents in Japan receive and what they want for ethical education and guidelines. Sixteen teaching hospitals that provide a general internal medicine residency programme in Japan were used (145 medical residents working at the departments of general internal medicine). A total of 114 residents participated in our survey, yielding a response rate of 79%. Of these, 28% received education in medical ethics more than once a month; 24% were offered it only when ethical problems were involved in actual patient care; and 18% answered that opportunities were very rare and sporadic. A full 30% had received no education in medical ethics at all. Many residents (71%) learned medical ethics from individual supervising doctors. A majority of the residents had been taught about informed consent (79%) and doctor–patient relationships (54%); 46% had learned about the appropriateness of truth telling and of ethical decisions regarding withholding and withdrawing a life-sustaining treatment, respectively. A total of 85 residents (75%) wanted to have more comprehensive education in medical ethics, 13% could not decide, and 12% did not want it. Many (66%) thought that both doctors and ethical philosophers should jointly teach medical ethics in postgraduate residency programmes. The results suggest that many residents desire more comprehensive and interdisciplinary education in medical ethics and educators in Japan should aim to develop education programmes to meet these desires.     

Computer education: attitudes and opinions of first-year medical students

Summary: students' attitudes towards medical informatics were evaluated with self-administered questionnaires, answered by 140 (77%) first-year medical and dental students. Fourteen per cent classified their computer literacy as negligible and 49% as deficient. Ninety-six per cent had used a computer before and 59% used one regularly. Nineteen per cent had computer education in secondary school and a further 16% attended courses given by a computer company. Only 16% read regularly about informatics. These results are similar to those observed in more industrialized countries, except that high-school education is more deficient. To 93% of these students, computer literacy is important for doctors, and to 85% computers may be very useful in many areas of health care. In the opinion of 66% of students, the computer-based patient record will be available within the next 3 to 10 years. Women showed lesser computer literacy (77% computer illiteracy to 39% in men), but there were no relevant differences in attitudes, behaviour and beliefs towards medical informatics between gender, for the same level of computer literacy. Computer education in the undergraduate curriculum was demanded by 92%, and 75% of these preferred an elective course. Weekly hours suggested for lectures should be 1 (54%) or 2 (42%), and for hands-on practice 2 (54%) or 4 (31%) hours. The curriculum should include medical applications (83% of students), information science theory and technology (44%), micro-informatics (44%), bibliographic database search (27%), programming languages (23%) and statistical packages (23%). Gender, computer literacy or course did not correlate significantly with students' opinions about the contents of undergraduate education.     

Ethical issues confronted by medical students during clinical rotations

Medical Education 2010: 44 : 723–730 Objectives This study aimed to examine the most common and important ethical issues confronting medical students during clinical rotations so that ethics‐related topics can be prioritised according to students’ needs and this information used to develop a curriculum for the ethics course. Methods In a cross‐sectional approach, we reviewed the medical ethics‐related cases recorded in the logbooks of all medical students (n = 241) at Tehran University of Medical Sciences who attended the medical ethics course during October 2006 to July 2007. As part of a graded assignment, each student was required to record three encounters with ethics‐related issues in his or her logbook. A total of 713 cases were assessed. Information related to the ethical issues and the conditions in which ethical issues arose was extracted and recorded by two experts, whose analysis showed agreement of kappa 0.77. In cases of discrepancy, both experts reviewed and discussed the record until they achieved agreement. Results A total of 713 cases were analysed. The most common issues reported by students related to ethics in medical education (20.1%, n = 143), professionalism (18.8%, n = 134), confidentiality (7.6%, n = 54), the doctor–patient relationship (7.3%, n = 52), informed consent (7.0%, n = 50) and the doctor–peer relationship (7.0%, n = 50). After adjusting for length of rotation, the highest numbers of ethics‐related incidents were reported from urology, general surgery, orthopaedics, internal medicine, neurology, and obstetrics and gynaecology wards. Conclusions The results of this study indicate that professionalism and related elements represent one of the most important areas of concern that need to be addressed when planning courses for medical students. The other significant area of concern is that of ethics in medical education, which, although the subject is not considered essential for medical practitioners, should be taught and respected so that student sensitivity to medical ethics is maintained and even increased.     

Ethical reasoning and decision-making in the clinical setting: assessing the process

Clinical ethical reasoning and analysis are skills as central to good patient care as the efficient application of biomedical knowledge to diagnosis and prognosis. However, experience in teaching clinical ethics to senior medical students has indicated that simply trying to ‘apply’ the knowledge learnt about ethical theories, principles, concepts and rules in the clinical setting does not ensure ethical competence in clinical decision-making. In 1992, we developed and piloted a three-session programme that focused on a more systematic approach to the way students identified and attempted to manage ethical issues in their clinical practice. This programme was modified and improved in 1993 and further expanded in 1994. Our experience suggests that many students are now better able to bridge what has been called the ‘gap’ between the possession of ethical knowledge and its actual use in clinical decision-making. The remaining problem was assessment. How do you assess clinical ethical reasoning and decision-making? In the preclinical years of medical education, knowledge-based assessment tools, like the modified essay question (MEQ), provide a means for assessing the sensitivity of students to ethical issues. However, such tools permit neither an appraisal of how students actually make clinical ethical decisions, nor which factors students perceive as important in making an actual clinical decision. In order to make this type of appraisal, we developed a format for a written case report that facilitated our assessing the process as well as the end-product, the decision. The results obtained from the use of the written case report in the annual assessment of our senior medical students in 1993, while encouraging, also identified a number of unexpected problems.     

Ethics and animal issues in US medical education

Increasing public and regulatory agency concern about a variety of animal protection issues that affect the field of medicine have made these issues increasingly relevant to medical school curricula. The purpose of this study was to assess the availability and forms of medical school training relating to ethical, conceptual, and societal concerns in the use of animals within the field of medicine and the perceived need for such training.
Questionnaire surveys were mailed to the Deans of the 125 accredited US medical schools, and completed by Deans or their designees within the same medical institution. Questionnaire recipients were informed that results would be compiled in a fashion that did not identify specific individuals or institutions.
Survey responses were obtained from 84 medical institutions (67% response). Sixty respondents (71%) indicated that their medical school offered or sponsored some type of activity related to ethical and conceptual concerns in the use of animals in medical research and training. Most schools (43) offered informal discussions/seminars relating to these issues, but nine schools offered full formal courses with up to 15 lectures on these topics. Programme content and perceived need for additional instruction varied greatly amongst respondents.
The results suggest a wide diversity amongst US medical schools in the availability and perceived importance of medical school training relating to ethical and conceptual concerns in the uses of animals in medicine. It is proposed that instruction in these areas be pursued with more concerted efforts to address the growing body of knowledge about non-human beings and the ethical implications of such knowledge.     

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.     

The role of psychology in the teaching of medical ethics: the example of informed consent

Summary: Over the past two decades, psychology has become well established in the medical curriculum. This paper argues that it has much to say about ethical issues, particularly informed consent. Because psychology addresses such areas as providing information, ensuring understanding of this information, identifying situations in which coercion occurs and assessing competence, its inclusion in the curriculum is justified on ethical as well as scientific grounds. This has several implications, including the allocation of resources, collaboration with health and clinical psychologists and the timing of the teaching.     

A community-based approach to the medical humanities

BACKGROUND: This paper discusses the rationale behind, and an approach to, the development of a graduate level interdisciplinary curriculum in literature and health care that incorporates community-based learning. Such an innovative approach emerges from the recognition that professional training in both health care and humanities programmes often does not model the kinds of collaborative relationships and professional values desired by contemporary health care students, providers and patients. METHOD: Recent trends in literary study and the medical humanities are described, along with the function (and benefits to students) of interdisciplinary classrooms and the role of community-based learning in higher education. The authors discuss their experiences teaching, and offer students' responses to medical humanities courses from which the concept for such a curriculum evolved. The paper offers advice on developing, evaluating and disseminating such a model curriculum for medical, nursing and graduate literature students. PROPOSAL: By linking health care with graduate English literature students, such a course would promote dialogue and understanding among health professionals, enhance student awareness of the effects of illness on patients, their caregivers and families, and encourage student activism and community service. A common set of literary works would provide a shared vocabulary and opportunities for ethical, critical and personal response. Working together in a community-based project, students from different programmes would learn to appreciate alternative professional and lay perspectives on common experiences.     

Teaching medical ethics: A review of the literature from North American medical schools with emphasis on education

Efforts to reform medical education have emphasized the need to formalize instruction in medical ethics. However, the discipline of medical ethics education is still searching for an acceptable identity among North American medical schools; in these schools, no real consensus exists on its definition. Medical educators are grappling with not only what to teach (content) in this regard, but also with how to teach (process) ethics to the physicians of tomorrow. A literature review focused on medical ethics education among North American medical schools reveals that instruction in ethics is considered to be vitally important for medical students. Agreement by medical educators on a possible “core curriculum” in ethics should be explored. To develop such a curriculum, “deliberative curriculum inquiry” by means of a targeted Delphi technique may be a useful methodology. However, the literature reveals that medical curricular change is notoriously slow. General implications for medical ethics education as a discipline are discussed. This revised version was published online in July 2006 with corrections to the Cover Date.     

A theoretical framework for human and veterinary medical ethics education

In their practice, physicians and veterinarians need to resort to an array of ethical competences. As a teaching topic, however, there is no accepted gold standard for human medical ethics, and veterinary medical ethics is not yet well established. This paper provides a reflection on the underlying aims of human and veterinary medical ethics education. Drawing from published literature on ethics education in the health professions a theoretical framework common to the teaching of human and veterinary medical ethics is proposed, based on three concepts: professional rules, moral virtues and ethical skills. The rules approach relies on the transmission of professional and social values by means of regulatory documents and depends intimately on the knowledge that students have of those documents. The virtues approach involves the inculcation of moral values and virtues that will stimulate students to develop desirable behaviours. The main focus of this approach to ethics is to develop students’ attitudinal competences. Finally, the skills approach is focused on equipping the students with the necessary moral reasoning abilities to recognise and respect the plurality of ethical views that make part of contemporary society. This framework can inform future curriculum development in human and veterinary medical ethics as well as in other health care professions.     

An innovative examination ending the medical curriculum

There has been increasing interest in curriculum innovation in many medical schools. The pedagogic principles for learning and for assessment should be congruent. Changing the curriculum and pedagogic principles for medical education implies that the examinations should also be adapted to the new principles. At the Faculty of Health Sciences, Linköping University, we use a student-oriented programme with problem-based learning, early patient contact, multiprofessional integrated education, and integration between basic science and clinical medicine and between traditional medical subjects. We also encourage the students to adopt a scientific attitude from the very beginning. To assess the students at the conclusion of the medical curriculum, we have developed a new form for the final examination containing measurements of clinical ability based on a videotaped patient consultation, an assessment of the student's performance and presentation of a scientific project, the student's analysis of a published scientific paper and an extensive oral examination based on the students' own scientific papers. Our experience, including results from questionnaires to students and teachers, is that the method is suitable for a final examination and assesses qualities that we previously were not able to assess.     

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.     

Extending community involvement in the medical curriculum: lessons from a case study

OBJECTIVES: Recent reports have stressed the importance of developing medical students' understanding of primary and community care and their ability to work in health-care teams. DESIGN: An innovative 3-year project aimed to achieve this understanding by broadening the range of health-care professionals and community organizations contributing to the medical curriculum. SETTING: King's College School of Medicine, London. SUBJECTS: Undergraduate medical students. RESULTS: Through partnerships with three local community health care trusts, non-medical health care disciplines in the teaching hospital and a range of voluntary and statutory services, students have been introduced to a broader spectrum of care. This has taken place both within the core curriculum and through the development of special study modules. CONCLUSIONS: Involving teachers and organizations which have not traditionally contributed to medical education raises philosophical issues around the aims and rationale of their involvement and practical issues such as gaining curriculum time, recruiting suitable teachers and gaining credibility for the courses. We analyse the benefits and difficulties inherent in broadening the curriculum in this way and assess the lessons our experience provides for the future expansion of such learning, both locally and nationally.