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Medical students’ perceptions of their ethics teaching
  1. Carolyn Johnston,
  2. Peter Haughton
  1. King’s College London, Department of General Practice and Primary Care, London, UK
  1. Correspondence to:
 MsC Johnston
 King’s College London, Department of General Practice and Primary Care, 5 Lambeth Walk, London SE11 6SP, UK; carolyn.johnston{at}kcl.ac.uk

Abstract

The teaching of ethics in UK medical schools has recently been reviewed, from the perspective of the teachers themselves. A questionnaire survey of medical undergraduates at King’s College London School of Medicine provides useful insight into the students’ perception of ethics education, what they consider to be the value of learning ethics and law, and how engaged they feel with the subject.

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There is no doubt that ethics teaching is now embedded in the UK medical schools’ curricula,1,2i and consideration of the delivery and assessment of medical ethics has now replaced the earlier discussion on content. The recent evaluation of teaching and assessment of ethics in the 28 UK medical schools,3 and the discussion at the Conference on Learning, Teaching and Assessing Medical Ethicsii emphasised the need for a clear focus on future perspectives.

Those involved in the delivery of undergraduate ethics teaching perhaps need no convincing of its value in the preparation of tomorrow’s doctors. But how is the subject viewed by the medical students themselves? While the curriculum should not necessarily be led by students, their views and insights are invaluable to ensure delivery of a curriculum that is of interest and relevance to them. One of the authors (CJ) joined King’s College London, School of Medicine (UK) last year and, having experienced one run-through of the curriculum, undertook the evaluation of the ethics and law teaching with a view to potential tinkering or an overhaul.

ETHICS AND LAW TEACHING AT KING’S COLLEGE LONDON SCHOOL OF MEDICINE

King’s College London, School of Medicineiii is one of the largest medical schools in the country with around 400 students enrolled on the medical undergraduate course (MBBS) in each year.,iv The initial ethics teaching, together with communication skills, takes place within the context of the Inter Professional Education Programme, and, in the first phase, medical students are taught alongside other healthcare students. Ethics teaching is integrated vertically throughout the five undergraduate years. At the end of 5 years undergraduate medical training, each student will have had the opportunity to engage in a minimum of 32 h of formal ethics and law teaching (box 1). In addition, special study modules are offered, which allow students to study ethics and law in greater depth. King’s has been running an intercalated BSc in Clinical Healthcare Ethics and Law since 2003. Teaching is undertaken by two dedicated advisersv in medical law and ethics, and small group sessions are facilitated by them and other medical school staff. The Centre of Medical Law and Ethics provides valuable support. A steering group has been set up to discuss and plan the teaching and research, and identify necessary resources for delivery.

Box 1: Exposure to law and ethics teaching (hours per student)

  • Year 1: 10 h (6 h lectures and 4 h break-out sessions—6 h as part of the Inter Professional Education Programme)

  • Year 2: 10 h (5 h lectures and 5 h break-out sessions)

  • Year 3: 2 h (introduction to Clinical Skills lecture)

  • Year 4: 7 h (3×morning symposia)

  • Year 5: 3 h (question and answer session)

ASKING THE STUDENTS

We wanted to find out the undergraduates’ attitudes to their experience of ethics teaching—their perception of the value of learning ethics, how engaged they feel with the subject, and their suggestions for improving the content and delivery of the course. A questionnaire was drafted for each year group, except for year 3.vi The format was similar for each of the years; some questions were identical and others reflected the different learning experiences of the students at the various stages of their studies (box 2).

Box 2: Questionnaire—questions common to all years:

  • How would you define medical ethics?

  • Is medical ethics and law a subject that you are interested in?

  • What do you consider to be the value of having an understanding of ethical and legal issues?

  • To what extent do you consider education in medical ethics important to help you to practise professionally?

  • Please indicate how far you agree with the following statements within a range:

–I found ethics and law teaching this year interesting.

–The teaching made me want to learn more about the subject.

–Medical ethics is just common sense.

–I can pass this subject without turning up to the teaching sessions.

–We do not cover the topic in enough detail to make a difference.

–This topic is not relevant to me.

–It made me more aware of the complexity of the practice of medicine.

–The teaching of this subject enables me to engage with contemporary ethical issues.

Rather than send out a questionnaire to all students by, for example, email, we decided to hand out the questionnaire during actual contact time to ensure a response within the limited time available. The questionnaires were handed out and completed, for years 1 and 2 during the last cycle of small group breakout sessions, for year 4 during a teaching symposium at the end of one rotation (of three), and for the final year students at a question and answer session (again, at the end of a rotation of three; table 1). Attendance is not compulsory for any session, and, as a result, not all of the students in the relevant year group were asked to complete the questionnaire, as they were not at the break-out session in which the questionnaires were handed out.

Table 1

 Response rate for the questions across the years

Table 2

 Percentages of response from the respondents (n = 238)

The emergent themes could not be said to represent authoritatively the views of the students in each cohort. However, the purpose of the questionnaire was for our own audit of students’ perceptions of ethics teaching at King’s, and we consider it a first step in identifying what is considered good and not so good, with an aim to implementing improvements.

Comment from a 5th year student:
 Sessions tend not to be compulsory/sign ups, hence the audience is self-selective—those that don’t turn up are likely to be the ones that need the sessions most, so I would recommend more attempts to involve these students, or give them more incentives to attend.

ANALYSIS OF THE DATA

Each completed questionnaire was considered individually, and comments and suggestions were recorded. We logged and compared the responses for each question against responses for each year group. We did notice some differences between responses from preclinical and clinical students, but as the numbers sampled were small, these trends cannot be considered to reflect the student population as a whole. Therefore, for the purpose of this paper, we have mainly analysed the data from a qualitative perspective, and have concentrated on comments and suggestions made by the students. We intend to continue to undertake an annual audit, and thereby generate more meaningful quantitative data.

KEY THEMES

We wanted to know the extent to which students felt engaged with medical ethics and how relevant they considered the teaching to be. Further, we wished to discover the extent to which the teaching equipped the medical students to deal with ethical dilemmas that they may face in clinical encounters. It is not possible in the length of this paper to analyse all the data produced by the questionnaire. Some themes, which we believe to be of wider interest, are considered below.

“Is medical ethics and law a subject you are interested in?” (yes, no, fairly interested)

In response to this question, we received 231 replies across all year groups. By far, the majority expressed some interest in the subject: 115 (50%) students said that they were interested, and 101 (44%) said that they were fairly interested.

Comment from a 2nd year student:
 It is interesting once you turn up to it and I believe it is informative. Therefore make it compulsory or take a register or something.

However, 15 (6.5%) students said that they were not interested. In giving reasons for their lack of interest, a number of students said they found it difficult and complicated.

Comment from a 1st year student:
 Just not interested in the law area.

Comment from a 2nd year student:
 In most times, medical professionals would just have to follow what is stated in the law and not what they think is ethically right.

Students do seem to recognise the importance of the subject, irrespective of their interest in it (and of course, the students who expressed that they were not interested in ethics and law did attend the session at which the questionnaire was handed out).

Not all of the 238 respondents answered every question, and there were some spoilt answers. Percentages shown below have been rounded to the nearest 0.5%.

“To what extent do you consider education in medical ethics important to help you to practise professionally?” (very important, important, quite important, not at all)

Out of the 235 responses, 122 (52%) thought that the subject was very important and 82 (35%) thought it was important. Of the 15 students who stated that they were not interested in medical ethics (previous question) 10 students, nevertheless considered education in medical ethics important to help them to practise professionally. This must be true of other aspects of medical education—knowing which antibiotic to prescribe may not be very interesting, but it is important!

Only one student stated that education in medical ethics was not at all important to help him/her to practise professionally, and it seems that this student only turned up to teaching sessions because he/she “was under the impression they were registered”.vii

Comment from a 4th year student:
 I think it’s important but it’s just too complicated.

Rather than indicating altruistic or virtuous motives, however, the recognition of the importance of ethics may indicate a concern about the potential for being sued for malpractice. We asked the students,

“What do you consider to be the value of having an understanding of ethical and legal issues?” (you can tick more than one)

The students seem to consider that an understanding of ethical and legal issues will enable them to be better doctors, almost by instilling an ethical code, without perhaps recognising that problem-solving skills, the ability to “make, defend, criticise and reflect” (Institute of Medical Ethics,1, p 13) will give them practical tools to deal with moral judgements required of them in medical practice.

STUDENTS’ PERCEPTION OF THE RELEVANCE OF ETHICS TEACHING

We asked all year groups to score within a range (0–5) how far they agreed with the following statements (5, I strongly agree with the statement; 0, I do not agree with the statement at all)

“This topic is not relevant to me.”

In all, 192 (81%) students strongly disagreed (score 0 or 1) with this statement. Only 6 (2.5%) students strongly agreed (score 4 or 5) with the statement.

Comment from a 1st year student:
 Don’t feel it applies too much to me at the moment.

Comment from a 2nd year student:
 The impression I get from many of my peers is that ethics is vaguely interesting but not relevant to their lives. This is CLEARLY WRONG (!) and needs to be addressed at the very beginning of the course.

Comment from a 4th year student:
 I used to dislike ethics and law in the first year, but over the years I have grown to understand it better and have developed (my own) views.

Comment from a 5th year student
 These topics are much more relevant to us during the clinical years, however, it was refreshing to discuss cases during the pre-clinicals.

“Medical ethics is just common sense” viii

Responses indicate that as students progress through their studies, there seems to be an increasing recognition that resolving ethical dilemmas requires more than an application of common sense: 25% of the preclinical students (years 1 and 2) strongly disagreed (score 0 or 1) with this statement compared with 34% of the students in their clinical years (years 4 and 5). “Not all problems have common sense solutions. Some must be examined with a more structured approach, by identifying the conflict of values and principles, analysing the risks and benefits of each alternative, and arriving at a solution that can withstand criticism, even if not everyone agrees with it”.5

Is the teaching of ethics necessary to equip medical students with ethical antennae?4,6ix We asked students in years 4 and 5 whether the teaching of medical law and ethics has helped their understanding and appreciation of difficult issues that will arise in practice. All students who responded to this question said that it had. We also asked them whether the teaching had helped their ability to resolve difficult issues that will arise in practice. Only one student in year 5 felt that the teaching had not helped his/her ability to resolve difficult issues, students in year 4 were more equivocal in their response.x

We wanted to know whether students want more focus on problem-solving skills and formal teaching of ethical theories. We asked the students,

“Would you have liked to have covered ethical theory and problem-solving skills in more detail?“

Of the students in year 4, 54 of 62 responded to this question (one spoilt paper and seven unanswered), of which 21 answered yes and 17 answered no. We received additional comments from 16 students which indicate that they do not want a formal study of ethical theory but rather want an opportunity to acquire relevant and practical problem-solving skills.

Comments from 4th year students:
 Problem solving—yes. Ethical theory no.
 I think we cover it in enough detail. SSMs may allow those who want to, to explore ethical theory further.

Cowley considers that “every medical student is familiar with ethical dilemmas in their own lives” and that they have deployed ordinary ethical concepts in experiencing and discussing ethical dilemmas (Cowley,7 p 739). He argues that “ethical jargon obscures the essential familiarity of ethics and drives a wedge between ethical concepts and ethical conduct”, and that “our ordinary ethical vocabularies are more than equipped to make sense of and deal with (though not necessarily solve) all ethical problems thrown up by medicine” (Cowley,7 p 741).

A number of students expressed frustration that ethics education does not provide an “answer” to clinical dilemmas, although some liked the challenge of ethical discourse.

Comment from a 4th year student:
 I find it quite frustrating…. Discussing questions in endless circles and never coming out with a firm resolution. I am a scientist and I like hard facts.

Comment from a 5th year student:
 It is a central part of medical practice—one will definitely have to deal with it. There isn’t always a defined answer, its important to discuss options.

If students have such an expectation, then we will be perceived to have failed if we cannot give an “answer” to an ethical dilemma. The Pond Report recognised that abstract theorising is unlikely to achieve greater understanding and awareness on the part of doctors and that “any form of ethics teaching which suggest either that ‘it is all too difficult’, or that there are known and incontrovertible ‘right answers’, is likely to be counterproductive” (Institute of Medical Ethics,1 p 3). We have to be clear therefore about the purpose of ethics in the curriculum; to help students to develop an awareness of ethical problems, to enable them to engage in the process of analysis and argument, to express their views and to be able to explain and justify their decisions to others.xi

ASSESSMENT

It is obviously important that the teaching of ethics not only provides the students with relevant tools to recognise and analyse ethical dilemmas arising in clinical practice (or at least to know where to go for assistance) but also that assessment is linked in a real way with delivery and content of the curriculum. Assessment of ethics by multiple choice questions, best matching answers and single best answers does of course require students to give an “answer”, and students consider that these forms of assessment are an inappropriate form of assessment.

Comments from 2nd year students:
 Doesn’t occupy enough of the exam so people feel it’s “common sense enough” to blag their way through the exam.


 Too many people seem to have the quite frightening perception that there are “right/wrong” T/F or single best answers to all aspects of medical ethics and this is all they are interested in.


 It is interesting, the only problem is that I feel I don’t benefit in the exam from going to the lectures.


 MCQ doesn’t seem adequate testing of understanding.


 How well I can write an essay—that has nothing to do with how good a doctor I would make.

Students indicate a strong preference for assessment by way of rolling case studies with short-written answers. In light of these comments, we are reverting back to in-course assessment at the end of year 2. Students will be required to provide short answers to case scenarios. The steering group is considering submission of an ethics portfolio as part of assessment of year 4.

FORMAT FOR TEACHING

Teaching of ethics and law at King’s College London in the first two years is undertaken by way of lectures and small group sessions.8xii We asked the first and second year students,

“What would you find the most beneficial format for learning this subject?”

The majority of students in these two years who answered this question prefer lectures and break-out sessions (77 out of 129 (60%)); 48 out of 129 (37%) prefer small-group sessions only, whereas 4 out of 129 (3%) would prefer individual problem-based learning with virtual campus support—that is, no formal teaching.xiii Students certainly prefer small group teaching as a way of promoting debate and discussion, and we noted that students in year 2 had a greater preference (70%) for the lecture/break-out session format than those in year 1 (48%). Many students commented that the ethics and law teaching could be improved by having more break-out sessions. One student in year 2 thought that break-out sessions should be compulsory.

Comment from a 2nd year student:
 Discussion is, after all, what it’s all about…

Comment from a 4th year student:
 Opportunity for more frequent small group discussion with particular contemporary cases.

This clearly would require more facilitators. We are looking into the possibility of students in year 4 and year 5, and/or those who have intercalated in ethics and law, to be facilitators.

Finally, we received some interesting suggestions in response to the question,

“How do you think the ethics and law teaching at GKT [Guy’s King’s and St Thomas’] could be improved?

Comment from a 1st year student:
 Greater involvement of students. Students asked to research areas.

Comment from a 5th year student:
 In clinical years (or solely 5th year) having access to an appointed medical ethics advisor to discuss certain unethical practices we may be already exposed to in our allocated District General Hospital placements.9xiv
 …. debates, role play, watching (relevant) films!

It seems that the key issue is to engage the students in the first place. This relates not only to curriculum content and delivery but also appropriate assessment. As one student so nicely put it, “it is interesting, once you turn up to it!”

REFERENCES

Footnotes

  • i “graduates must know about and understand the main ethical and legal issues they will come across” (General Medical Council,2 para 29).

  • ii Conference held at BMA House, London, 29 March 2006, convened by the British Medical Association’s Medical Ethics Department and cohosted with The Higher Education Academy and the Institute of Medical Ethics.

  • iii The medical schools of Guy’s and St Thomas’s merged with the School of Medicine, King’s College London, in August 1998.

  • iv King’s College also runs the Graduate Entry Programme and Extended Medical Degree Programme.

  • v One full time and the other part time.

  • vi Students in year 3 were not included, as there was no dedicated contact time with this group within the time parameters of the review. Some students intercalating in Clinical Health Care Ethics and Law gave valuable input in the drafting of the questionnaire.

  • vii The same student considered that the reason for having an understanding of ethical and legal issues was to “prevent me from being sued”. We wonder whether a lack of awareness of ethical issues might be taken into account when assessing the clinical competence of students (The Pond Report,1 p 22). “A (third) type of unethical doctor may be one who does not care about the ethical side of his practice” (Lowe et al,4 p 404).

  • viii “Among the reasons why [problems raised by the practice of medicine] are problems, is that normally they cannot be resolved simply by appealing to professional codes, or to science, religion, the law or even common sense” (Institute of Medical Ethics,1 p 2).

  • ix Lowe et al consider that there is “a paucity of evidence that undergraduate or postgraduate education may change or shape ethical practice in the long term” (Lowe et al,4 p 404). Evidence of a significant gain in the adoption of principled reasoning after a course in medical ethics.6

  • x Of the students responding in year 5, 18 students said “yes”—the teaching had helped their ability to resolve difficult issues; only 1 said “no”. By comparison, 47 students in year 4 agreed that the teaching had helped their ability to resolve difficult issues, 11 said that it had not.

  • xi “The initial aims of ethics teaching are to help students develop both an awareness of where and what ethical problems are, and an intellectual framework within which these problems can be examined” (Institute of Medical Ethics,1 p 12).

  • xii “The majority of schools used a combination of large and small group teaching” (Mattick and Bligh,8 p 183).

  • xiii Twenty-five students ticked more than one box, and these responses have not been included in this analysis.

  • xiv Nearly half (47%) of clinical students, one year from completing medical school, reported that they had felt pressure to act unethically in a clinical situation (Hicks et al,9 p 709).

  • Competing interests: None.

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