Emergency medicine trainees lack ethics knowledge, found a recent study.

• Residents had the most trouble with assessing decision-making capacity.

• Residents with knowledge gaps perceived themselves to be prepared.

• Having an ethics module in place was not linked to higher scores.

Gaps in clinical ethics knowledge appear prevalent among emergency medicine trainees, and few programs feature dedicated ethics modules, found a recent study.1

“We are hoping that program directors take note of this gap in knowledge,” says Aasim I. Padela, MD, MSc, the study’s lead author. The researchers wanted to know the baseline level of ethics knowledge that trainees have currently. Their conclusion: “Their knowledge is generally poor,” says Padela.

The researchers asked these questions:

• Are emergency medicine residents prepared to deal with common ethical challenges?

• Do they perceive themselves to be prepared when they actually are not?

• Does having an ethics module in place really improve knowledge, or just the perception of how much the resident knows?

“The residents didn’t score well in terms of identifying the correct issue or the correct action,” says Padela. However well-prepared the residents felt they were to handle ethical challenges, it had little bearing on their knowledge.

“The main finding is that residents’ knowledge is not very good in terms of identifying what the ethical issue is or how to deal with it,” says Padela.

The researchers assessed knowledge and perceived preparedness for 302 residents for five ethics areas: informed consent and decisional-capacity assessment, surrogate decision-making, interpretation of advanced directives, withdrawing and/or withholding life support, and presumed consent for emergency treatment. Two significant findings:

• About one-third reported having a dedicated ethics module within their residency curriculum.

These residents perceived themselves as better prepared, but this was not borne out in the findings. There was no link between a dedicated ethics module and knowledge scores.

This suggests that residents became somewhat familiar with the topics but not enough to handle the issue in actual practice. “This is a significant challenge, and we wanted to draw attention to it,” says Padela.

• Assessing decisional capacity was the most difficult topic for respondents.

Just 1% correctly addressed the general issue and identified the correct plan of action. This finding was particularly concerning to Padela. In the ED setting, the issue comes up frequently when patients leave against medical advice, or an inebriated patient is consenting to treatment.

“Every clinical case we have has an ethical wrinkle in it,” says Padela. “This is part and parcel of emergency medicine. It is germane to our practice.”

Techniques Vary Widely

For more than a decade, the Society for Academic Emergency Medicine (SAEM) has produced a case-based ethics curriculum for trainees. “We had hoped that residency program directors incorporate those into their teaching,” says Padela, who chairs SAEM’s ethics committee. Padela would like to see more focus on didactics and case-based discussions.

“Ten years ago, it was a PowerPoint presentation and description of learning points,” says Padela. “Maybe we need something more interactive.”

The Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine (ABEM) both require clinical ethics education in residency training. Although most programs do include ethics in the curriculum, “teaching techniques vary widely,” says Catherine A. Marco, MD, FACEP, professor in the department of emergency medicine at Wright State University in Dayton, OH.

Ethics is included in the Model of the Clinical Practice of Emergency Medicine, which serves as the basis for the content specifications for ABEM exams. This includes areas such as professionalism, conflicts of interest, diversity awareness, electronic communications, medical ethics, end-of-life and palliative care, regulatory and legal issues, and stewardship of resources.

“Personally, I advocate for case-based discussions to highlight the importance of the practical application of principles of bioethics to the bedside,” says Marco.

Padela says just as residents learn clinical pathways through actual cases, “that’s how we should also treat ethics, so it sticks in people’s heads and [they] can respond to it when they see it in real life.”

If trainees want to supplement their clinical expertise, such as cardiovascular knowledge, there are appropriate courses to provide it. The same cannot be said of ethics. “There are no dedicated emergency medicine ethics conferences or training programs,” notes Padela. Residents find themselves overwhelmed with coursework focused on patient care and clinical sciences.

“They don’t appreciate the ethical challenges, sometimes, until in clinical practice — when they are the person who has to deal with these issues,” says Padela.


1. Padela AI, Davis J, Hall S, et al. Are emergency medicine residents prepared to meet the ethical challenges of clinical practice? Findings from an exploratory national survey. AEM Educ Train 2018; 2(4):301-309.


• Catherine A. Marco, MD, FACEP, Professor, Department of Emergency Medicine, Wright State University, Dayton, OH. Phone: (937) 395-8839. E-mail: catherine.marco@wright.edu.

• Aasim I. Padela, MD, MSc, Associate Professor, Section of Emergency Medicine/Faculty, MacLean Center for Clinical Medical Ethics, University of Chicago. Phone: (773) 702-6081. Email: apadela@uchicago.edu.