Background There is little evidence of junior trainee perspectives in the design and implementation of medical ethics and law (MEL) curriculum in UK medical schools.
Aim To determine the ethical issues the foundation year 1 (FY1) doctors (first year after graduation) encountered during clinical practice and the skills and knowledge of MEL, which were useful in informing MEL curriculum development.
Method The National Research Ethics Service gave ethical approval. Eighteen one-to-one interviews were conducted in each school with FY1 doctors.
Analysis Interviews were recorded and transcribed verbatim; a thematic analysis was undertaken with the transcriptions and saturation of themes was achieved.
Key findings Themes closely overlapped between the two study sites. (1) Knowing my place as an FY1 (this theme consisted of four subthemes: challenging the hierarchy, being honest when the team is titrating the truth, taking consent for unfamiliar procedures and personal safety vs competing considerations); (2) Do not attempt resuscitation)/end-of-life pathway and its implications; (3) ‘You have to be there’ (contextualising ethics and law teaching through cases or role plays to allow students to explore future work situations); and (4) advanced interpersonal skills competency for ethical clinical practice.
Conclusions The data provide a snapshot of the real challenges faced by MEL FY1 doctors in early clinical practice: they may feel ill-prepared and sometimes unsupported by senior members of the team. The key themes suggest areas for development of undergraduate and postgraduate MEL curricula. We will work to develop our own curriculum accordingly. We intend to further investigate the applicability of our findings to UK medical ethics and law curriculum.
- Clinical Ethics
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Ethics teaching is integral to the development of both professionalism and clinicians’ decision-making capability, and this is recognised by the General Medical Council.1
The Institute of Medical Ethics (IME) consensus statement2 recommends the key learning outcomes for undergraduate medical ethics and law (MEL) training, thereby providing a unified outcome-based approach for training future doctors. However, this document does not incorporate a consensus of view of the foundation year 1 (FY1) trainees. A literature review to identify the work incorporating systematic data of recent graduate doctor's ethical dilemmas into curriculum development in ethics and law found few examples and these are discussed next.
A US study argued that graduating physicians do not always meet the expected ethical standards because of the power of the ‘informal curriculum’.3 Marcoux et al4 used group interviews with family physicians in Canada in developing the curriculum, ensuring that current practitioner concerns are a focus. This resulted in better learner engagement. Parker et al5 used survey responses from clinical students and teachers and their observations of clinical teaching sessions in designing an integrated ethics programme in Australia. However, no evaluation data accompanied these studies to measure the programme's fitness for the purpose. Other studies have identified little opportunity in the curriculum to apply and integrate the knowledge and skills to clinical practice.6–8
Ethical dilemmas that medical students face in clinical practice were investigated previously.9 ,10 Cordingley et al11 investigated the challenges that the final year medical students in three UK medical schools encountered during clinical placements. Students regularly experienced challenges to their ethical values in clinical teaching. Students’ self-reports indicate confidence in their knowledge of ethical principles, but they also indicate low confidence in addressing ethical challenges and a need for additional support from clinical teachers.
In this study, we aim to determine what are the ethically challenging experiences that FY1 doctors have encountered in their first year of clinical practice and how prepared they were to respond to these challenges. We expected the data (1) to facilitate an understanding of how the undergraduate MEL curriculum could be further developed; (2) to use the qualitative data to develop a questionnaire survey to gather consensus views from the UK FY1 doctors about undergraduate MEL curriculum; (3) and to improve the local curriculum in the participating institutions.
Since there was little previous work to inform this project, we chose a qualitative exploratory method of semistructured interviewing; a key advantage is promoting frank discussion in a safe atmosphere while protecting confidentiality and allowing exploration of new areas of interest that arises during the interview process.12 ,13 The key aim is not obtaining the consensus of views but the opportunity for further investigation and gaining deeper insight13 in the issue of the ethicolegal challenges that FY1 doctors face.
FY1 doctors at each site with 6–8 months of experience attending mandatory teaching were invited to participate.
In one site, 19 participants signed a contact sheet to arrange a research interview and 9 completed, whereas in the other site, 10 participants signed a contact sheet and 9 completed the research interview. The interview addressed the ethicolegal challenges the participants had experienced in their first year of clinical practice (see Box 1).
The interview schedule was developed from the aims and objectives of the project and reflected the evidence gaps in the literature. It was piloted with colleagues at the Academic Unit of Medical Education at a medical school. All interviews were audiotaped and transcribed with the interviewee's permission. The transcriber signed a confidentiality agreement.
The interview process was iterative, that is, any new themes that emerged in an interview were incorporated into the schedule for the subsequent interview(s). The interviews were carried out by the researchers until consistent themes started to emerge and saturation was achieved (ie, the interviews were stopped when no new themes emerged and there was repetition of previously identified themes).
Identify an ethical issue which that you or your teams have faced in the last month. On a scale of 1–10, how prepared did you feel to handle this issue effectively?
What components of your medical curriculum helped you to handle this issue effectively? Can you be specific? (eg, a particular placement or non-placement-based learning experience)
What additional components or teaching methods (curricular or non-curricular) would have helped you handle this issue more effectively?
MEL curriculum at the participating schools
One school follows an integrated curriculum. In year 1, there are ethics lectures and seminars mostly delivered by non-clinical ethics teaching staff. End-of-life issues would be covered when death and bereavement are being taught and confidentiality to coincide with early patient contact. In phase II, students are in separate units, which teach common learning outcomes. Although there is specific teaching on abortion, mental capacity and issues in child health, much clinician-led ethics teaching is opportunistic. In the past 2 years, FY1 doctors have led discussions on ethical problems they have encountered as part of a Preparation for Practice course for final year students. In their final year, students wrote a 2000-word essay on a case they have encountered, which raises ethical issues.
The participants of the study at the other site followed the pre-2009 programme. The programme aimed to give students the opportunity to reflect on ethicolegal issues taking into account philosophical, professional and practical aspects of MEL. Teaching was largely lecture based with an emphasis on identifying ethicolegal issues in clinical practice as they arise and this was largely through opportunistic learning at clinical placements; this was a key weakness. Since 2009, there is increased emphasis on using a range of methods, such as through symposia, structured patient case write-up and master classes, to facilitate the development of sensitivity and reasoning all through the 5 years of study. Students now also have structured opportunities to consider speciality-related clinical ethical dilemmas, and these sessions are mostly delivered during the appropriate speciality placements.
Neither medical school had incorporated the IME Core Content of Learning outcomes when these interviewees were undergraduates.
Following initial familiarisation with the transcribed data, a thematic analysis was undertaken using a contestant comparative method: data were systematically reviewed for supportive/conflicting evidence for emergent themes, coded and themes and subthemes were generated from the data set. Then the authors analysed one another's transcripts to verify the key themes and to ensure inter-rater agreement.13 Agreement was reached on all key themes. The analysis was verified by presentation to colleagues at an academic meeting at site 2.
Nine interviews were conducted in each site. Saturation of themes was reached at both sites with saturations at sites 1 and 2 after the sixth and fifth interview, respectively. In order to improve the credibility and dependability of the data14 and to maximise the variety of FY1 participants, interviews were continued even though no new themes were emerging.
Most of the interviewees addressed the first question as reflected in the themes.
Box 1 provides the case synopses addressed in the interviews.
Box 1 Case synopses
The 18 interviewees identified 29 ethical issues which they had faced in the previous month as summarised below. These issues are all covered by the learning outcomes in the IME MEL Core Content of Learning.
Active management of a patient with do not attempt resuscitation (DNAR) order.
HIV testing an unconscious patient after a needlestick injury.
Relatives wanting to prolong a patient's life for inheritance reasons.
Involving coroner against family wishes.
Disclosure of HIV status to a patient's sexual partner.
Honesty in communicating diagnosis.
How aggressively to treat a patient with terminal cancer.
Using antibiotics for patients on Liverpool Care Pathway.
Treating patients who vacillate over treatment options when they are probably terminal.
Value of treating an alcoholic patient on liver ward.
Completing DSS forms as FY1.
When to refer a case to the coroner.
Taking consent for procedures beyond competence of FY1.
Withdrawing life-sustaining treatment.
Best treatment for a vacillating patient.
Assessing capacity effectively.
Use of Liverpool Care Pathway.
Patient refusing nutrition.
Withholding diagnosis from a patient requested by a person with lasting power of attorney.
Negotiating DNAR with family.
Effect of FY1's 33-week pregnancy on patient seeking termination of pregnancy.
Taking consent from patients when they are unfamiliar with the procedure.
Provision of rehabilitation for patients with alcohol dependency.
Wife challenging the patient's capacity to avoid; difficult husband being discharged home.
Use of end-of-life pathway.
Patient with total parenteral nutrition living on acute surgical ward declining move to palliative care.
29. Discharging people with alcohol dependency without treating the underlying causes.
Four key themes emerged from the interviews at both study sites from the interview discourse. They do not conveniently link to the themes of the IME consensus statement as this structure had not been imposed on the participants. To impose this, structure would have limited the voices of the interviewees. The themes are presented below with supporting quotes.
Knowing my place
The FY1 doctors reported tensions between their perception of the right thing to do and what they perceived as clinical norms.
Challenging the hierarchy
Questioning hierarchy and challenging the practice of seniors and colleagues was seen as a key but uncomfortable element of maintaining ethical-clinical practice.
what really is the law of the jungle is that whatever your senior says goes and that evidence and best practice (...) is never completely realised (...) that's quite challenging. (N3)
Taking consent when unable to do the procedure
Participants describe the potential for conflict with other health professionals where the cultural ‘norm’ of hospital practice and values clashes with the ‘ideal world’ of ethics as taught.
Well, with regard to taking consent there are issues around the fact that FY1 doctors aren't supposed to take consent for issues that we can't do, and that is very well explained to us at medical school but then again the minute you get on the ward you then say you can't take consent and it's very much looked down upon by seniors. (S9)
Yes I've always said no but I think that's my personality (...) whereas I think other people can be easily pushed into it, signing things when they're not supposed to. (...) [what] we're not really equipped with is how to deal with bullying, bullying from seniors and bullying from nursing staff. (S10)
Being honest when the team is titrating the truth
The following quote illustrates a participant's dilemma of how much truthfulness is ethical.
they (the team) often put it in terms of shadows on the scans and the word cancer hadn't been told to her (the patient) though we had said you know it could be something serious but it was all implied (...) (the patient) was telling me how she likes to know things straight down the line and likes to be told things kind of upfront I knew the team had decided not to tell her or use the word cancer (N12)
Personal safety versus competing considerations
In the process of trying to put a cannula into him he's obviously jerking around quite a lot (...) as I turned it stabbed me in the hand so it's been into him and it's been into you. (...) this was at night I had to wait for the morning until someone was around so sort of eight hours later I went to see the team and this man is not in any position to give any consent to have his blood taken because he's unconscious and he's unlikely to regain consciousness at any time soon. There is obviously a window of opportunity in terms of prophylaxis (...) He never said to me that I could cannulate and then of course he could never say to anybody that he permitted to his blood being tested which leaves me in a position of an unknown inoculation essentially which is difficult because (...) ideally you would start with prophylaxis but prophylaxis for HIV has a lot of side effects and a lot of nasty stuff and almost nobody manages to complete the course (N8).
Improving the utility of do not attempt resuscitation (DNAR)/end-of-life teaching
This is a core learning outcome for undergraduate MEL curriculum.2 Two key issues were raised from the data: (1) need for better understanding the purpose of the care pathways and their flexibility and (2) difficulties in communicating their nature to other members of the healthcare team.
one of the nurses had said to me, he's DNAR you know why are we giving him fluids, why are we doing all this stuff and I would kind of been a bit like well yes DNAR means they're going to die so you know I agree with you, you know you've been working for twenty five years and I've only been working for two months. But now being on more medically acute wards it kind of gives you a bit more confidence to (explain what is happening to the patient) (N7)
You have to be there
Some interviewees said that no amount of undergraduate teaching could fully prepare them for clinical practice when a decision was their responsibility.
Gap between MEL teaching and clinical practice
MEL teaching needed to be contextualised to be useful: the following quote describes a participant explaining how, even though she was familiar with the capacity assessment, she was unprepared to carry this out in practice.
I knew the basics of how to assess whether somebody had capacity (...) whether they could understand the information, retain the information and way up the pros and cons and sort of say it back to you and remember it and retain it. I could do that but I don't think I could say yes he definitely or he doesn't (have capacity). (...) Also I wasn't really aware of the procedure afterwards on who could help the team make that decision (N6).
In this instance (below), a participant describes a lack of understanding about how MEL undergraduate knowledge would need to be translated and applied in clinical practice.
lots of stuff that happens at med school is knowledge but it's not, you don't give it relevance so you learn it because it's a fact and you have to learn it but until you kind of encounter it in real life that that's when you kind of see the point of it if you see what I mean. (N7)
Useful aspects of undergraduate teaching
Most of the data addressed the first and the third question as reflected in the themes and very little data addressed what was useful in the curriculum; the data for the second question indicated that maximum utility is obtained when teaching is situated in the appropriate clinical context and accompanied by the opportunity for application in practice.
In site 1, final year ethics case essays were cited as a practice, which successfully focused the learner to apply the ethicolegal principles in context.
The ethics essay I wrote in fifth year helped me to become familiar (with ethics and law) because of the reading I had to do. I am a reductionist black and white person. They (the essays) contextualise the event. They give you a framework for thinking about these things. (N4)
Scenario-based teaching in site 2 focusing on directing the student to use the decision-making process in a safe environment helps develop their skills for justifying those decisions.
Practical, yes, you had a scenario: you know this is the patient what are you going to do? Who has responsibility for making decisions about the patient; is it the relative or the doctors; just actually kind of working through the scenarios and making some decisions; then they told us what the law said and talking through the ethical issues involved with each of those cases and that was really good. (...) they actually got us to start thinking about the issues and make our own decisions before they said what would be actually acceptable decisions and that was really useful. But until you start doing things for yourself you don't really ground it. (S6)
Ways to improve the undergraduate MEL curriculum and delivery
Participants reported that delivery could be improved through cases, role plays and by giving students the opportunity to take responsibility enabling them to practise for future work scenarios. Junior doctors’ engagement in the undergraduate curriculum was perceived to be potentially useful by one participant.
I think it would be useful to get junior doctors in to discuss the issues (...) that you encounter daily and these are the certain issues that you will come across because a lot of the things that we talked about were often big ethical issues that were kind of in the media and they're the things that often come to more specialist and it's kind of up there and it's a bit different when you're going into FY1. (N12)
Encouraging medical students to take responsibility was deemed to give the opportunities to develop the skills needed to uphold ethical practice during interactions with colleagues, patients and carers.
Unless you explain to the patients especially when you're on call a lot you literally are the first on the scene, you do the assessments and then you make the decisions and that's where you do a lot of the learning. (S2)
A contrary view was also expressed.
I was on the accelerated programme so it might be different to the undergrads but the accelerated we did just get kind of odd days I remember dotted around. I don't know if it's just for me but I like having things in a block. I like thinking about them and having like two weeks for example I don't know if I would benefit more from that but people would like it either way really but for me I would prefer it more as a block. (N12).
Advanced interpersonal skills
Developing interpersonal skills to discuss and clarify care protocols with family was seen as necessary for ethically sound practice.
I had some awkward conversations where they were dissatisfied with the care; they were saying they didn't know why we wouldn't give him fluids or oxygen. My personal opinion is that far too often we pander to patients and relatives. We actually should be more proactive in explaining to them the care should be more around keeping the relative comfortable than having an O2. We need to explain the needle would cause more discomfort than good. (...) It was all a bit of a mess. (N7).
Two of the key themes such as ‘knowing my place’ and advanced interpersonal skills (see below) are about the necessary skills needed for implementing ethicolegal competencies than ethicolegal competencies per se. This illustrates the importance of equipping graduates with the necessary skills required to apply and implement what is taught in the MEL curriculum.
Teaching MEL by facilitating its application in clinical practice is not new and is advocated by educational principles15 and previous work.7 ,8 ,16 Currently it is unclear whether all aspects of ethics and law teaching are successful in becoming applied. Ensuring ethically sound clinical practice is only possible if the practitioner has the appropriate interpersonal skills, such as communication skills, leadership, assertiveness, etc, during interactions with peers and seniors. The emphasis given to the development of communication skills has significantly increased in the last decade.16 ,17 Our study indicates that FY1 doctors may not always be adequately supported (see examples in results section: Yes, I have always said No, S10; in the process of putting a cannula, N8) and can at times struggle to put themselves first or to act in a manner in which they feel is right. These snapshots also emphasize the importance of developing advanced interpersonal skills such as assertiveness and leadership skills to ensure that young doctors feel able to practise ethically and can safeguard patient safety and welfare. The key strength of the study is its attempt to elicit the views of end users of the UK curriculum for the first time. The exploratory semistructured interview process ensured that the emerging themes are derived without the researchers being directive.
The key issues addressed by the case synposes can be used to develop the MEL teaching. However, several of the key issues raised by the case synposes (box 1) are addressed in key guidance for practice in the BMAs Medical Ethics Today.18 Also each of these key issues are addressed by the IME's consensus statement outlining the key learning outcomes for the MEL curriculum for undergraduate medicine.2 However, despite these issues being addressed by the core curriculum and key professional guidance, these are identified by participants as issues which they found inadequately prepared to apply in professional practice. A number of outcomes are identified that are relevant in refining the current delivery of the MEL programme including ensuring that what is addressed is of immediate relevance (I think it would be useful to get junior doctors in to discuss..., N12) for the foundation programme; and better integration and contextualised teaching of the ethics at the end-of-life care. Pre-2009 truth telling was not covered as part of core MEL teaching at site 2, but the post-2009 curriculum offers structured teaching opportunity in this area. At site 2, the findings were shared with the end-of-life care team to better signpost and integrate the ethics of end-of-life care teaching. Themes such as ‘challenging hierarchy’ or ‘putting personal safety first’ indicate the need to refine not only the local curriculum but also the importance of bigger changes at organisational and cultural levels.
The study only focused on two institutions. Participant responses may have been restricted due to confidentiality concerns, although the researchers aimed to minimise this factor by providing the participants appropriate confidentiality and anonymity guarantees. Both interviewers had taught the FY1 doctors and this may have biased the recruitment and made it harder for participants to criticise undergraduate teaching. Furthermore, the timing of the project and limited resources did not permit the respondent validation of the emergent themes.
Conclusions and recommendations for further work
Even though further work is required to test the generalisability of our findings, our study gives a first insight into how purposeful the current MEL programme may be to graduating doctors. The key outcomes here can also be used to inform postgraduate MEL teaching. Our study also poses the challenge of how to develop opportunities for application of MEL to clinical practice (identified as a key requirement by participants for developing ethically competent clinical practice). Case scenarios in teaching, role plays and writing up patient cases were all identified as effective opportunities for this. This study points towards the need to ensure MEL is seamlessly integrated to classroom-based and workplace-based teaching about all aspects of patient care. The effectiveness of MEL training is demonstrated in a clinician's practice. To practise ethically in future, clinicians need to possess appropriate behavioural skills. Communication skills have received significant attention in medical education but our data indicate a more complex picture of the soft skills such as assertiveness, leadership and self-confidence to act when necessary. We need to consider how to develop safe opportunities to develop these advanced interpersonal skills in our future doctors. The American Board of Pediatrics recognised the importance of advanced interpersonal skills for ethical decision making in the 1980s,19 but 20 years later explicit recognition of this link in the UK undergraduate medical assessment is rare. Also, the challenges of predicting future ethical practice by assessing attitudes, values and behaviour remain.
Planned student assistantships in undergraduate medical education1 may be a key opportunity to demonstrate that in practice MEL should be integral in patient management.
This study provides a snapshot summary of the collective experiences of 18 FY1 doctors in two sites in 2010. We plan to further develop this work by focusing on the following key issues: (1) the generalisability of our findings to other medical schools using a nationwide questionnaire survey; (2) the perceived gap between the classroom-based MEL taught to undergraduates and that practised by senior hospital colleagues; (3) the ethicolegal challenges experienced by FY2 doctors in primary and secondary care.
What this paper adds
What is already known on this subject
Tomorrow's doctors and the Institute of Medical Ethics consensus statement drive the undergraduate medical ethics and law curriculum in the UK.
What this study adds
It identifies the professional ethicolegal challenges FY1 doctors experience using a small group of interviewees at two sites.
The data indicate possible areas for development of the medical ethics and law curriculum.
To the participants of the study and to Dr Caroline Mitchell for the informal peer review.
Contributors Both authors had full access to all of the data (including the tables in the study) and take responsibility for the integrity of the data and the accuracy of the data analysis. Participants provided informed consent for sharing the anonymised data.
Competing interests None.
Ethics approval The study obtained ethical approval from the National Research Ethics Committee (Anonymised, STH15432) and written consent was obtained from all FY1 doctors who participated in the study.
Provenance and peer review Not commissioned; externally peer reviewed.
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