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.
Statistics from Altmetric.com
‘It is important to stimulate student thinking on ethical issues.’1
Over the past two decades, ethics education has become a fundamental component of medical programmes, both in medical schools in New Zealand and around the world2–5 This is also true of other health-related disciplines such as pharmacy and nursing. All medical students in New Zealand undertake ethics education throughout their medical training.
All medical students in the University of Auckland medical programme undertake formal ethics education in years 2–5. In years 2 and 3 (preclinical), formal instruction broadly encompasses teaching that is primarily centred around ethical approaches in the medical endeavour (both theoretical and applied). In years 4 and 5 (clinical), more emphasis is directed towards applied ethical issues arising in medicine. Less formal ethics teaching may occur in other disciplines, in which teaching and discussion may focus on different aspects of a clinical situation—the ethical dimension being just one of many to be considered (the legal dimension being another).
The focus of the ethics curriculum is to:
provide students with a solid framework and understanding of the central principles underpinning medical ethics
cultivate students' recognition of the ethical dimension in all medical interactions
foster students' critical thinking and reflective skills so that they can work through ethically challenging situations as they arise in practice, and
nurture and develop students' own ethical awareness and sensitivity (to become reflective practitioners).
The ethics teaching sits comfortably in the professional, clinical and communication skills component of the medical programme in years 2 and 3. The professional, clinical, and communication skills course guides the acquisition of skills that a student needs to become ‘an effective medical practitioner’.6 Ethics education is a fundamental part of this focus. Students do not ‘do ethics’, rather they are encouraged to see the ethical dimension of medicine permeating all the disciplines they study—a way of thinking about how they act and behave that will continue into their professional lives. The ethics teaching is thus integrated both vertically and horizontally throughout the medical programme.
In the clinical years (4 and 5) students spend a considerable time out of the classroom in the ‘real world’—the medical environment.
Although they continue to receive ethics teaching, much of their interaction and learning comes from those who are supervising the various attachments they alternate between (both in the hospital and general practice setting).
The purpose of the following discussion is to twofold: first, to outline some of the ethical issues raised by year 5 medical students in their ethics reports in 2010; and second, to reflect on what we, as educators and health professionals can learn from their experiences and insights. It should be noted that the ethics reports were set as part of the ethics assessment and not as a research project, thus the discussion here reflects the author's viewpoint on the cases discussed by students. As a result of the process in 2010, ethics committee approval has been granted to use the reports submitted in 2011 for research purposes.
Year 5 ethics education
In year 5 of the medical programme students spend most of the academic year rotating between various disciplines, returning to the School of Medicine for several weeks of on-campus learning throughout the year.
In January 2010 the ethics component of the teaching discussed a number of issues broadly centered around the ethics of ‘speaking up’.7 This topic was considered from several different perspectives: one's responsibilities as a medical student, the disclosure of medical error or an adverse event, boundary violations in the doctor–patient relationship, what to do when you witness a colleague whose performance is impaired in some way, and how to manage one's relationships with industry. Case studies, examples from the literature and professional organisations, and reports from the Health and Disability Commissioner's websitei were used to stimulate and steer debate on these issues. Students were also encouraged to discuss particular incidents they may have witnessed, heard about, or been involved in. The focus and direction of these lectures were thus situated around practical and ‘real life’ examples within various day-to-day medical settings.
Continuing with the theme of speaking up, coursework assessment of the ethics component (of the teaching) required all students to write a 1200-word report. This was compulsory. Reports of this kind are widely used in medical education, both in New Zealand and internationally. The purpose of the report was to get students to reflect critically on the ethical dimension of a clinical case or situation they had identified and been involved in during the past 2 years. An important component of this assignment was that students identified the ethical aspects of a situation themselves. It was not a matter of giving the students a number of scenarios with various compelling ethical dimensions and asking them to discuss them.
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. It may have related to a case or situation that a student felt troubled or uneasy about because aspects of it raised ethical concerns that had been poorly or inadequately addressed at the time. Conversely, it may have been a case or situation that had a compelling ethical dimension that raised ethical issues (or had the potential to), which were successfully addressed. Basically, students were asked to think about the ethical dimension of a situation that had stayed in their mind (for whatever reason)!
Students were asked not to identify any individual (staff, patient, or patient's family) or institution in their report. They were given reassurance verbally and in writing that their reports would not be read by anyone other than the author, and that their identity would not be disclosed to anyone. This was important as students had to submit their assignment with their name on it, thus confidentiality was essential if I expected them to be candid and honest in their reporting of a situationii. While confidentiality stands as a cornerstone of medical ethics and good medical practice, the upholding of it is not absolute. Therefore, had students disclosed actions that were illegal or likely to result in serious or imminent harms to others, they were advised the author would contact them in the first instance to discuss the situation further.
Many students reflected on their own actions or those of others, and wrote reports that were insightful and empathetic. For instance, some students had clearly learnt valuable lessons in how not to talk to patients, how not to talk to students (when they are in senior roles), and were more conscious of their own actions, attitudes and behaviours towards patients and medical staff.
Some students had been involved in ethically challenging situations that had been dealt with sensitively and professionally by senior clinicians who were portrayed as inspiring role models. For example, one student wrote:
‘I observed a follow-up appointment with an elderly woman (in her eighties) and a surgical consultant. Investigation had revealed that the woman had carcinoma of the breast. Despite the cancer, the woman was healthy; she had no on-going past medical history, was living independently, and on no medications. The consultant was of the opinion that the patient should have surgery plus adjunct therapy. This appointment was to discuss treatment options. The patient was adamant that she did not want surgery.’
The student then discussed the way in which the consultant had spoken with the woman, clearly telling her what he believed to be in her best medical interests as well as ensuring she understood the treatment options (including no treatment) available to her. He listened to her and encouraged her to ask questions. Although the consultant felt surgery was her best option, the patient's decision was respected at the end of the day. She made an informed decision about what she wanted.
Other students wrote about situations in which they were given the opportunity to take patient's histories, undertake examinations and participate in surgeries while under supervision. For many students these experiences were extremely positive and reinforced their desire to pursue a particular area of medicine in their careers.
Disappointingly, although perhaps unsurprisingly, a number of students discussed cases and situations that raised concerns about some of the attitudes, behaviours and actions of some senior medical staff in a variety of different environmentsiii (in hospitals and general practice settings in the greater Auckland region). A number of broad themes emerged from the reports. These included: issues around gaining consent from patients; general rudeness towards patients (often expressed as contempt for a patient's lifestyle); unprofessional attitudes towards patients from senior medical staff; humiliation of medical students and inadequate supervision of students. I will briefly comment on the first three themes as these issues were the ones most commonly discussed by students.
Many of the students’ reports concerned the issue of consent; in particular, when students had not gained consent from patients for them to participate in the patient's care. For instance, one student wrote about their experience of being asked to perform a rectal examination on an anaesthetised patient on whom they had not gained consent to do so. Similar experiences around intimate examinations were reported by other students in various settings. Another wrote:
‘over the past few years during clinical attachments, I have been invited a number of times by senior staff to witness or be involved in a procedure or operation but have declined the invitation because I was unable to gain consent. This has been met by scoffing remarks such as “when I was a medical student we used to do intimate exams on anesthetised patients without their consent”.’
The issue of medical students learning intimate examinations without a patient's consent was recently highlighted in a multicentre study carried out in medical schools in England, Wales and Australia.8 The authors note that despite comprehensive polices in place that require valid patient consent, ‘students are still being asked by senior clinicians to conduct intimate examinations without valid patient consent, sometimes in contexts in which multiple students examine one patient’.8
Attitudes towards patients by some senior medical staff were also a cause for concern for some students. Often this was described by students as contempt for a patient's lifestyle or current situation (for instance, their drug use, intoxication, obesity, or age). One student recounted her experience in a ward round when a morbidly obese patient was seen by a senior clinician and several medical students. As the team were leaving the ward, the clinician commented that obese patients like the one they had just seen were responsible for their weight ‘and that obesity could be prevented if the doors of fast-food restaurants only let slim people in’. The student was aware that the patient had overheard the conversation.
Some students discussed what they perceived to be an attitude among some staff that patients have a duty to allow medical students to learn on them. One woman recounted her experience of examining a young woman who had extensive pustular lesions covering most of her body. The patient was clearly distressed by her condition and the fact of having to be examined. The student later mentioned her own concerns about the woman's uneasiness to the specialist who said that it was the patient's duty to allow medical students to learn and that she (the patient) should not have been so difficult.
Several students wrote about their experiences of being humiliated in front of their peers and senior colleagues and of being yelled at by some senior medical staff.
As noted earlier, the ethics assignment was not undertaken as a research project. Furthermore, caution should be exercised in how reports such as these are viewed. They need to be seen in light of many factors: students may not fully understand a clinical situation and may misinterpret what they saw, or they may fail to consider fully or appreciate other compelling issues that arise within the context of the situation they are discussing (eg, mental health issues and emergencies). The pressure of time, long hours, tiredness and constant changes in staff may also have an effect on how students perceive a situation.
Furthermore, words spoken in haste, jest or frustration may be misinterpreted by students unused to the peculiarities of the medical environment. Yet as Reisman9 points out, there may be a fine line between a comment that is humorous and one that is insensitive.
There was no doubt that some of the attitudes, behaviours and actions of some medical staff were ethically and professionally troubling. Yet it was encouraging to read many students commenting that some of the unprofessional behaviour they witnessed reinforced (to them) the importance of looking at their own attitudes towards patients and what it means to act in an ethical and professional manner.
Many students wrote about the conflict they experienced between their educational needs (their understandably strong desire and enthusiasm to observe and participate in procedures) and the best medical interests of the patient. For instance, one student recounted how she had been asked to perform a sensitive examination without the patient's consent. She was apprehensive at the thought of questioning the clinician about the consent issue because he had a reputation for being abrupt and she knew he was formally assessing her skills and performance. She did not want to jeopardise her grades, yet was aware that she ought to have sought the patient's permission, and was troubled that she had not done so before examining him. Caldicott and colleagues10 speak of the fear students feel when making a trade-off between academic survival and patients' interests.
Yet this alleged trade-off obscures a more complex state of affairs. As Dwyer7 notes, ‘students need to consider exactly when and how they should speak up’. They need to take into account their own judgements about a situation, their role, any harm that may result to others and the efficacy of speaking up. In other words, students need to be encouraged to reflect critically on their own actions and behaviours. At times they may be required to act ‘in ways that sometimes include a cost or inconvenience to themselves’.7 Therefore, although students may feel a conflict between their own interests and those of their patients, they should be encouraged to think more widely about the context and particulars of the situation and their responsibilities. At times this may be demanding.
As part of their assignment, students were asked to reflect on the case they had discussed. What had they learnt from the situation; what might they do differently if confronted by a similar situation in the future; what had challenged them personally? The level of ethical awareness and professionalism exhibited by the students was encouraging and clearly illustrated the seriousness and responsibility with which they took their role. For instance, students said the following:
‘After reflecting on this case, I have learnt that although as medical professionals we generally have the best intentions in mind and may feel that we better understand the benefits and risks of the situation, we must never forget that our patients have the right to choose what they believe is best for them.’
‘The most important thing I've learnt in this case is that I should try to obtain consent where possible and if it isn't possible, ask for adequate supervision in everything that I do and document it.’
‘I think these ethical issues in the hospital allowed me to realise what a privilege it is to be a medical student.’
The ethics reports were an opportunity for students to reflect on the ethical aspects of a case or situation that had had an impact on them. It was encouraging to see that students took the assignment seriously and submitted reports that were insightful, honest and self-reflective. It was also a timely reminder to those of us involved in the teaching of ethics and professional skills to pay attention to the kinds of challenges facing medical students, to reflect on what we are teaching as well as how we model what is being taught, and to ensure that the pathways available to them to discuss the challenges they face as students are clearly outlined and transparent.
In a recent article reflecting on some of the insights gained from his time as New Zealand's Health and Disability Commissioner, Ron Paterson11 states, ‘how we teach may be as important as what we teach. Our behaviour as educators matters.’
As the person who was responsible for initiating the ethics report, I felt accountable to the students and to the patients (on whom many students had learnt invaluable lessons). It was not enough to read the reports, make comments and move on. It was important that the students were reminded of their ethical and professional duties towards their patients, to each other and to the profession. For example, that the welfare and interests of the patient are of paramount consideration, that patients have the right to decide whether they will be involved in a teaching situation, that patients have a right to refuse to participate in teaching, the importance of seeking the permission of the patient and of introducing oneself to the patient.
In light of this, several months after the reports had been submitted the students were spoken to about the issues they had discussed and what had happened in the meantime. Students were assured that their maturing ethical voices were being heard and taken seriously by management within the School of Medicine. They were told that some of the attitudes and behaviours exhibited by senior health practitioners were unprofessional and unacceptable, and they were encouraged to continue to speak up appropriately. Senior management within the School of Medicine are working with chief medical officers in the country's district health boards to address some of these issues. For instance, in June 2010, chief medical officers met in Wellington to discuss how consent is currently obtained from patients, and how the process can be improved.
Students across all years within the medical programme are encouraged to speak to the phase director of their year about any aspect of their training (clinical and/or academic) that causes them concern, especially in relation to the ethical and legal aspects. The Assistant Dean of Student Affairs is also available if students have particular concerns or issues about their clinical experiences in the medical setting.
The issue of speaking up as a medical student is a demanding one for ‘students have much less power and authority than practising physicians’,7 and they are not subject to the same obligations as their more qualified colleagues (although they share many duties with them). There are also the consequences that may come from speaking up: being ridiculed or poorly assessed by some senior colleagues, or being viewed as a disloyal team member. A student may justifiably question whether speaking out about a particular attitude, behaviour or action of a senior physician may jeopardise their future career advancement. Yet as Dwyer7 succinctly notes, students should not ‘keep quiet about a significant matter simply because speaking up may have some effect on their grades and careers’. It was disappointing that one student noted in his discussion that, ‘I have learnt to exercise silence.’
As noted earlier, the purpose of this discussion was to outline some of the ethical issues that concerned senior medical students within the medical programme at the University of Auckland, and to reflect on what we can learn from their experiences and insights. It was not to criticise or condemn doctors who work with and supervise medical students, nor to undermine public confidence and faith in the health system. In fact, it could reasonably be claimed that by raising these issues in a forum such as this, the public can be reassured that troubling attitudes and behaviours are not kept secret, and that efforts are being made to address concerns at the highest level. While many of the situations discussed by students are of immense concern, the public can be confident that medical students are speaking up and taking responsibility for their own professional behaviour.
Yet there is much demanding work to do. Many of the situations discussed by students are of immense concern, both ethically and professionally. In light of the 2010 ethics reports, ethics committee approval has been granted to undertake research on the student's reports in 2011. It is intended that professional bodies and colleges will be notified of the findings. It is hoped this will help effect positive change in the attitudes and behaviours exhibited by some health practitioners.
In fronting up to the challenge of speaking up, the students demonstrated their developing ethical and professional skills; the challenge for those of us who teach and supervise medical students is to reflect on our own attitudes, behaviour and actions towards patients, students and colleagues. I believe the ethics reports show we have a challenging road ahead.
The author would like to thank the fifth year medical students in the medical programme at the University of Auckland. She would also like to thank two reviewers from the Journal of Medical Ethics and Professor Robert Kydd, Associate Professor Warwick Bagg and Dr Sue Hawken for their critical and insightful comments.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.