• Law
• Ethics

‘What is important is to keep learning, to enjoy challenge, and to tolerate ambiguity. In the end there are no certain answers.’1

Martina Horner Radcliffe College, Cambridge Massachusetts

Assessing students’ learning on medical ethics to fully understand how they interpret, react and behave when faced with the uncertain, often ambiguous, challenges of real clinical encounters remains an educational conundrum. The authors of this guide are to be congratulated on their comprehensive summary of current practice. They provide an excellent platform from which to reflect and think forward. Are our assessment practices fit for purpose? Do they effectively relay the appropriate and necessary educational messages to our future doctors? I believe, although the range of assessment tools we have to date are welcome, there are pitfalls that remain unresolved.

A strong foundation knowledge of ethical principles and law is important. A robust moral framework is essential. The Guide confirms that we have the tools to assess students’ learning at the ‘knows how’ and ‘shows how’ level of Miller's pyramid.2 The context in which this knowledge is integrated into actual ethical practice, that is, ‘the does’, still presents many challenges perhaps more pertinent to ethics and professionalism than to other curriculum themes. We should acknowledge that, for a future clinician, we assess at a level distant from the ideal educational endpoint for graduation. Pelligrino3 highlights that, in the clinical encounter, there is ‘a peculiar constellation of urgency, intimacy, unavoidability, unpredictability, and extraordinary vulnerability’. The recent Francis report4 emphasises this ‘vulnerability’ only too well. Assessing students on how they ‘should’ apply ethical frameworks to clinical scenarios cannot validly address the realities of medical practice. We know that transition into the Foundation years remains difficult as students meet the clinical intensity of the workplace.5 Herein lies a genuine danger. We ‘train’ students for a theoretical ‘medical school world’ that students interpret as ‘what they should do’; a view reinforced by our assessments. They then divorce this from the reality of the clinical world and ‘what they would do’: a divide we are increasingly aware of.6

The clinical environment does not always mirror what students are taught and assessed on.7 The authors of the Guide acknowledge the forceful, as yet poorly explored, ‘hidden curriculum’. They argue there is evidence that teaching and assessing ethics can help overcome these forces. This may be true. I suspect the evidence to support this claim remains weak. The different and conflicting role models and interactions students experience in the workplace cannot be ignored.8 Our assessments risk confusing students if they encourage responses that support attitudinal behaviours that fail to connect with the uncertainty and ambiguity of the real world. Unfortunately health professionals do not always work within the framework of their theoretical learning. Educational researchers exploring the hidden curriculum are increasingly demonstrating this.7 ,9 Professional behaviours that are embedded, as Pelligrino states, in the complexity of the clinical encounter may fail to match the theoretical frameworks students hold. In the presence of significant external constraints, attitudes and behaviour are not necessarily strongly related.10 We do not know the extent to which inner virtues and outer conduct differ.11 This leads to the possible conclusion that ethical understanding can be stage-managed; students demonstrate the professional behaviour required to graduate but hold within themselves unprofessional attitudes. In addition, there is a genuine fear that the current focus on ‘competency’ encourages a tick box ‘can do’ culture that detracts from a desire to continue to understand, improve and strive for excellence.12

Should we accept this? I believe not. To this end the Guide might have taken a step further and explored the direction of travel postulated by van der Vleuten and Schuwirth.13 They argue cogently for assessment programmes that intertwine with the curriculum, sample widely across authentic contexts and address ‘complex competencies that cannot be broken down into simple parts’.13 Much of the ethical framework as outlined in the Guide requires Tomorrow's Doctors' competencies14 that centre on professional values such as honesty integrity confidentiality and trust. A recent international review on the assessment of professionalism15 concludes that not only is professionalism contextually bound it should be assessed at three levels of interaction: individual, inter-personal (team) and societal–institutional. We need a multidimensional, multiparadigmatic approach to assessing ethical behaviours at these different levels. More attention to enabling students to develop and understand their personal identity and their interpersonal interactions is essential. To achieve this, we should encourage more formative assessments designed to enable students to address the significance of their internal cultural values and prejudices. They should understand how these impact on their decision making when faced with difficult clinical challenges. We are increasingly aware of how difficult sharing these thoughts can be.16 The competency based culture must not be allowed to foster complacency. The Francis report4 has highlighted the need to build our medical training to enable doctors to demonstrate ethical behaviour embedded in the complexity of the clinical workplace. In the end there are no certain answers and our future doctors need to come to terms with this. Our assessments can change to ensure we enable students to keep learning, enjoy challenge and tolerate ambiguity. This Guide provides a useful platform to this next step.