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The clinical years of medical student education are an ideal time for students to practise and refine ethical thinking and behaviour. We piloted a new clinical ethics teaching activity this year with undergraduate medical students within the Rural Clinical School at the University of New South Wales. We used a modified teaching ward round model, with students bringing deidentified cases of ethical interest for round-table discussion. We found that students were more engaged in the subject of clinical ethics after attending the teaching sessions and particularly appreciated having structured time to listen to and learn from their peers. Despite this, we found no change in student involvement in managing or planning action in situations that they find ethically challenging. A key challenge for educators in clinical ethics is to address the barriers that prevent students taking action.
- Clinical ethics
- education for healthcare professionals
- education/
- allocation of organs/tissues, history of health ethics/bioethics
- informed consent
- codes of/position statements on professional ethics
- professional misconduct
- education
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- Clinical ethics
- education for healthcare professionals
- education/
- allocation of organs/tissues, history of health ethics/bioethics
- informed consent
- codes of/position statements on professional ethics
- professional misconduct
- education
Introduction
The goals of ethics education in medicine include the development of professional virtues and skills so that students emerge as thoughtful and reflective ethical practitioners.1–4 The clinical years of medical student education are an ideal time for students to practise and refine these important graduate attributes under the supervision and guidance of teaching staff. Based on a review of the ethics teaching within our undergraduate medicine curriculum and anecdotal reports from staff and students in the Rural Clinical School, we identified a need to extend formal ethics teaching to senior medical students in their clinical training years. The literature indicates that some medical students suffer from erosion of ethical values5 and empathy6 as they progress through medical school, and suggests that ongoing formal teaching in clinical ethics, including practical skill development, can help to ameliorate this trend.7–9 We therefore piloted a new teaching programme within the four campuses of the Rural Clinical School at our university.
The current ethics teaching programme for our undergraduate medical students includes a comprehensive set of lectures and tutorials during the first four years of the undergraduate programme covering important issues such as consent, confidentiality, beginning/end of life issues, and allocation of scarce resources. Our aim was to pilot an ethics teaching programme that built on this core curriculum, offering a particular focus on ethical issues that students are likely to encounter as they progress into the senior years of their clinical education. Such topics include day-to-day ‘ward’ ethics, student ethics, rural ethics, and the ongoing maturation of skills necessary to deal with such situations.10–12 In this way we hoped to expose and unpick the negative messages being received in the so-called ‘hidden curriculum’, the influential set of institutional practices and informal collegial interactions that impact on students' professional development,13 thus turning difficult and challenging clinical encounters into positive learning experiences. While it was beyond the scope of our study to investigate the impact of our teaching on the ethical values of students, we did set out to assess its effect on their development of ethics skills including personal engagement in the process of ethical debate and decision making.
Method
Informed by the literature,5 ,9 ,14 ,15 we used a modified teaching ward round model, with students bringing deidentified cases for presentation to their peers. The so-called ‘clinical ethics ward rounds’ were facilitated by a clinician, and students were encouraged to discuss the case and ask questions, rather than assume that there were fixed answers to be learnt. We know that maturation of ethical thinking is enhanced by discussion with others, and we hoped to provide a forum for students to learn from, and with, their peers in this way.9 ,16 Importantly, there was no formal assessment attached to these sessions; this was deliberate and was aimed at encouraging students to discuss their concerns without fear of academic penalty or reprisal, and reinforcing the message that clinical ethics is a discipline for which personal reflection and group discussion are more important elements than the individual tutor's mark. Although not expressly compulsory, attendance was expected, and was encouraged by advising students that they would receive a certificate of attendance at the conclusion of the sessions, which could be included in their final year portfolio as evidence of learning in ethics.
We ran four 1 h sessions for year 5 students in each of our Rural Clinical School campuses using video-conferencing technology for the facilitator to attend. Four year 6 students requested to attend the sessions. Our teaching included 60 students in total, with approximately 15 in each of the four campuses. Timetable clashes and technical difficulties with video-conferencing hardware meant that some students were unable to attend all sessions, but most students were able to attend at least three sessions.
After ethics approval, we evaluated our clinical ethics ward rounds using a questionnaire that students were asked to complete at the beginning of the first ethics ward round and at the end of the fourth ward round. The pre-ward round questionnaire included nine items with Likert scale choices and one open-ended question. The post-ward round questionnaire repeated the previous questions and included three new Likert scale items and two new open-ended questions (box 1).
Example questionnaire items
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‘I contribute to discussions and debates about clinical ethics with my peers and other clinical colleagues’ (never, rarely, sometimes, frequently, very frequently; for the purposes of data analysis, we scored the Likert responses in the following manner: never = 1; rarely = 2; sometimes = 3; frequently = 4; very frequently = 5.)
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‘How well prepared are you to deal with ethical challenges you face as a medical student?’
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‘The best features of the ethics ward rounds are…’
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‘The features of the ethics ward rounds that need improvement are … ’
We used data from the 47 students who had attended three or more ward rounds and completed both pre- and post-ward round questionnaires. We analysed the data using Predictive Analytics Software (PASW—V.18). T-Tests for paired samples were used to investigate the differences between students' responses before and after the ethics ward round. p Values of <0.05 were considered significant.
Results and discussion
Students face a range of ethically challenging situations, as indicated by the number and variety of cases presented in our ward round sessions. Student presentations encompassed both the ‘big’ topics in most core ethics curricula and the more practical issues relevant to students and junior medical professionals. There were a number of cases relating to apparently unethical behaviour in others (table 1).
Subject of student case presentations
Data from the pre-ward round questionnaire indicated that many students feel a lack of experience and confidence in clinical ethics, reinforcing our initial hypothesis about the need to build on the current core curriculum by adding a teaching programme focusing particularly on clinical ethics. Students reported that they ‘sometimes’ get involved in ethics discussions, are ‘sometimes’ able to determine action in ethically challenging situations, and ‘rarely’ help patients make decisions on ethical issues. More disturbingly, students do not appear to see clinical supervisors as a natural source of ready assistance in this aspect of their learning: students report that they are only ‘sometimes’ confident enough to raise concerns with supervisors and ‘sometimes’ feel powerless when facing their own ethical dilemmas (figure 1). These results suggest that students would benefit from ongoing teaching and support in clinical ethics including facilitation in the development of skills required to act confidently in the face of ethical challenges.
Student confidence and experiences in clinical ethics. Horizontal striped bar, pre-ethics ward round; vertical striped bar, post-ethics ward round. *Significantly different, p<0.05.
Students valued the learning opportunities provided within our teaching programme and a number of key themes emerged from their free-hand comments on the programme. Students liked the ‘real-life’ curriculum and appeared ready for the authentic learning that comes from discussion of cases personally experienced by themselves or their peers:
“I really enjoyed being able to talk about relevant clinical situations which we encountered and were relevant to us as students.”
Students reported favourably on being able to raise their own, specific concerns, and applauded the,
“opportunity to … raise issues which have concerned us and to realise others have the same concerns.”
Students were grateful for the opportunity to speak openly without fear of academic or other penalty:
“Open and comfortable atmosphere [allowed] us to speak up.”
Students particularly appreciated having structured time to listen to and learn from their peers:
“It was helpful to hear everybody's opinions to broaden my understanding of ethical issues.”
“…wide range of cases discussed with different viewpoints covered and conclusions being drawn—not just being held in suspense.”
Such a format proved particularly useful with cases such as the apparently unethical colleague. There were a variety of benefits for the student with regard to these difficult situations. Several students had often been present at any one clinical encounter brought up for discussion and the class was therefore able to hear different interpretations of the same scenario. Importantly, peer discussions also allowed students to receive “feedback on how others felt” thus exposing the group to a variety of ideas and considerations. In some cases, the round-table format led the presenting student to consider that perhaps the medical treatment suggested was reasonable after all, or the apparently disrespectful comment may not, in fact, have caused any harm. That is, exposure to the variable experiences and opinions of peers can promote greater understanding of the different expectations and interpretations of a clinical encounter and encourage the student to ask questions before making judgements. In other cases, the presenting student's concerns were echoed by the class group. Students noted on the pre-ward round questionnaire that, “there is no body or watchdog with whom we can voice our concerns”, and, without an outlet to discuss such cases, students may perceive that the medical profession turns a ‘blind eye’ towards unethical conduct. A supposed lack of interest or concern belies our exhortations for professional virtue and sends mixed messages to the students. Feeling unable to express confusion or disappointment or even ask questions, students may disengage from clinical ethics. By providing a forum for students to share “situations we have personally experienced”, the ward rounds “enabled concerns to be raised” and validated student interest in the ethical dimension of clinical encounters. Students benefited from discussing the disparity between idealised, virtuous behaviour in the healthcare profession, and the reality of complex, challenging clinical practice. They were able to explore the personal values of themselves and others and learn from difficult patient encounters.
We found that students were more engaged in the subject of clinical ethics after attending the teaching sessions, with a statistically significant increase in self-reported contributions to ethics discussions and debates with peers and clinical colleagues, and a non-significant trend towards increasing confidence in discussing concerns with their supervisors (figures 1 and 2). Students reported that attending the ward round teaching sessions,
“Makes me more likely to think and discuss these issues with my peers making me more likely to make better ethical decisions.”
Student contributions in discussions about clinical ethics. Dark grey bar, never and rarely; black bar, sometimes; light grey bar, frequently and very frequently.
“Pushed me to use my critical thinking skills and with time develop a definite answer as to the way I would approach these situations.”
These results suggest that even a short intervention similar to this pilot study assists student development and maturation of skills in clinical ethics, resulting in improved engagement, both cognitively and verbally. The ward rounds build on previous knowledge of clinical ethics, assisting the student with the application of that knowledge to the real clinical encounter. Arguably the ward rounds work most successfully when students already have a strong theoretical foundation in medical ethics.
Despite this, we found no change in student involvement in managing or planning action in ethically challenging situations. That is, although students were more involved in ethical considerations and debates after attending the short teaching programme, this did not translate into increased action. There was no significant change in self-reported decision making in or management of clinical ethical problems (figure 1). Using student answers to our open questions, we identified three barriers to student action in such situations.
Some students are unsure of their role, effectively being unable to progress beyond the question, ‘should I act?’
“Although we often face ethical challenges it is often unclear as to what our role is, especially when it comes to advising patients.”
Many students feel they lack training or experience to act (‘how should I act?’):
“In practice I am comfortable talking about it but unsure how it would be in reality.”
A significant minority of students feel powerless to act (‘I cannot act’):
“As a medical student I feel powerless to change unethical situations that I witness at hospital.”
Feelings of powerlessness among students were identified in our initial pre-ward round questionnaire, and these were not altered by attendance at our short teaching programme (figures 1 and 3). We felt that identification of student barriers to action was an important issue: lack of confident action in the face of ethical challenges may be a mechanism for ethical erosion. That is, students who have ethical concerns (and there are many, as identified in our study) but lack the skills or confidence to discuss these concerns with supervisors may disengage from ethical issues. They may become morally cynical, and normal maturation of moral thinking may come to a halt or even regress.12 ,17
Student powerlessness in clinical situations. Dark grey bar, never and rarely; black bar, sometimes; light grey bar, frequently and very frequently.
A key challenge for educators in clinical ethics is to address the barriers that prevent students taking action. We are hopeful that an expanded ethics teaching programme in the clinical years will assist with this. Further teaching and peer discussion can assist students who are unsure of their role in identifying what is needed. With respect to the apparently unethical colleague, such discussion can explore the normal range of behaviour in others, helping to clarify situations where the student ‘role’ is simply to listen and learn from the normal challenges of clinical practice. That is, student perceptions of unethical behaviour in others may not be anything more than recognition of a difficult clinical situation. Discussion of such situations becomes a useful curriculum for the senior medical student and junior doctor.
For those who have concerns but do not know how to act, ongoing teaching with a particular focus on tips and strategies for action can assist the student to develop action skills in ethically challenging situations. Students themselves identified this, suggesting that:
“More practical teaching would be useful.”
‘Solutions’ to ethical problems in clinical practice are often not enacted immediately, but progress slowly over weeks or months. Ongoing discussion of cases over time can broaden the exposure of students to such cases ensuring that they receive not just a ‘snapshot’ model of ethics dilemmas, but grow to understand that management of such cases is often a step-by-step process, enacted slowly by healthcare professional teams. It is hoped that students will follow the progress of these ‘too hard’ cases, and learn ways to continue clinical practice in the face of dilemma and uncertainty. Owing to the often sensitive nature of many ethical dilemmas, students may be excluded from direct discussions with patients and therefore miss out on this aspect of clinical management. If, however, students are able to bring evidence of mature ethical understanding of situations to the attention of their clinical supervisors, the value of their contributions and involvement may be increasingly recognised and welcomed.18
Feelings of powerlessness may be more difficult to address. Students were somewhat disillusioned about the oppressive effect of medical hierarchy and the inability of our ethics teaching to make an impact:
“I think that, despite the interesting cases brought up during the ethics ward rounds, the underlying problems that make medical students powerless in ethically charged clinical settings remain unchanged.”
Such comments expose the pervasive, negative influence of the hidden curriculum. This is a difficult problem to tackle, and, while changing the attitudes and behaviours of senior staff may be an important long-term aim, the contribution of empowering students to withstand its effect should not be overlooked. Although students did not identify any change to their feelings of powerlessness after this short teaching course in clinical ethics, a more substantial programme might be of greater value. We would hope that, by improving the student skill set in clinical ethics, providing ongoing experience in talking through ethical matters, and exposing students to strategies used by their peers when raising concerns with colleagues, students would begin to explore ways of overcoming power imbalances.11 ,17 We aim to build upon the tentative beginnings suggested by one student who noted after attending our ward rounds that,
“In some situations it's ok to bring up ethical issues with seniors.”
Dwyer has suggested that students be encouraged to practise the difficult skill of ‘speaking out’. He writes, ‘[Students should] try to voice important concerns and disagreements in a way that does not alienate the people they are working with. This is a task that requires a lot of practice. Now is the time to begin’.19 The ethics ward rounds provide a forum for students to explore and improve upon this skill.
It is possible that ethics teaching such as suggested in our ward round model will uncover areas of need for institutional change.9 It would be wise to anticipate this, and have a programme in place for managing such issues, should they arise. This might include localised interventions such as the use of hospital grand rounds discussions to disseminate updated guidelines relating to students performing intimate examinations20 or a chain of communication as described by Malpas,21 involving senior academic management and chief medical officers and the need to improve practices of obtaining consent from patients. Such methods can successfully impact on the target audience without transgressing issues of student or staff confidentiality. It may be sensible to reassure clinical staff on this point, explicitly stating that ethics ward rounds are a teaching programme aimed at developing mature ethical thinking and exploring ways of managing challenging situations in clinical ethics, not a forum for identifying or condemning individual staff members.
Conclusion
The senior years of medical student training are a time for maturing ethical skills and thought. Our clinical ethics ward round model engages student attention on ethically challenging cases and provides opportunities for students to discuss relevant issues in a safe environment. It provides an excellent bridge between introductory courses based around high-profile ethics topics and the real-life ward experience of the junior doctor. During the ethics ward rounds, students can gain experience in identifying the ethical dimension of clinical encounters, listening to and debating ethical values, and considering management plans for ethical dilemmas. Students are able to benefit from the greater understanding that exposure to a wider peer group can give them, with enriched awareness of the complexity of clinical ethics. Ongoing teaching in clinical ethics with more emphasis on the range of normal behaviours and peer discussion of practical tips and strategies may assist students to become more confident with managing the ethical challenges that they face and can promote the development of ethical practice.
Acknowledgments
We thank Dr Lesley Forster and staff of the Rural Clinical School of the Faculty of Medicine, University of New South Wales, for their assistance with this project.
References
Footnotes
Funding Internal Learning and Teaching Seed Grant Fund at the University of New South Wales.
Competing interests None.
Ethics approval Human Research Ethics Advisory Panel, Medical/Community, of the University of New South Wales.
Provenance and peer review Not commissioned; externally peer reviewed.
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