A group of students at The Medical College of Georgia at Augusta University perceived a need for more bioethics education. They asked the ethics committee for assistance, leading to the creation of a new grassroots Leadership through Ethics program for medical students.
“The student leaders created some founding documents, and had a vision for their work to become a graduate certificate program,” says Richard Sams, MD, MA, associate professor in the department of family medicine and the Center for Bioethics and Health Policy at Augusta University.
The novel program includes lunch-and-learn sessions, ethics presentations, faculty-student mentorship sessions, student ethics committee discussions, and an ethics capstone scholarly project. Students learn to recognize ethical issues in everyday medical decisions as they transition to providing direct patient care on clinical wards, Sams says.1
Before expanding the program to graduate-level certification, students were surveyed to gauge demand for it.2
“We wanted to see what an interprofessional cohort of graduate students in healthcare thought was the need for and value of additional bioethics education,” Sams says. Of 562 students surveyed:
- 47% had received no medical ethics training;
- 60% desired more bioethics education;
- 92% said bioethics education was important for their future careers.
Also, another one-quarter of respondents were interested in graduate-level training in medical ethics. “This bolstered our work in starting a graduate certificate in bioethics, which is thriving,” Sams reports. “We have a long-term vision of offering an MA in bioethics.”
Shadowing pastoral care is an important part of the Leadership through Ethics program. Students accompany chaplains to see how they talk to families about various topics. “I do not change one thing about the patients we see or my approach. They simply go with me,” says W. Jeffrey Flowers, DMin, BCC, director of pastoral care.
Chaplains and students spend about 90 minutes visiting patients and checking in with family in intensive care unit (ICU) waiting areas. The next half-hour is spent reflecting on what the students observed. “The natural day of a chaplain is we’re going to have difficult conversations,” Flowers notes.
The program is entirely voluntary. “It’s not for credit or graded in any way. It’s just an opportunity that is offered to them,” Flowers reports. Only 16 first-year medical students are accepted each academic year. Students who are not selected may ask chaplains if they still can participate in the shadowing aspect of the program, and they are never turned down. “We take all comers,” Flowers adds.
During patient encounters, it is understood that students are to respond only if patients speak to them directly. Since they are not physicians yet, they should not be offering clinical information. “We worked out a signal so that if I feel they are interfering or things go awry, they will back away,” Flowers explains.
It has never become necessary during three years of shadowing. “Students have been very respectful, and have asked wonderful questions,” Flowers observes.
Students soon realize communication is not just about test results or diagnoses. “We are also communicating hope and empathy,” Flowers says.
Most students have no personal experience with family members’ end-of-life issues. “They are getting exposure earlier, in a controlled environment, with immediate feedback,” Flowers says.
Sometimes, students receive advice from patients directly. Chaplains sometimes asks patients, “This is your chance to be a medical educator. What would you say to this first-year medical student about what makes a good physician?”
“Families and patients take a moment to teach,” Flowers says. Almost always, patients tell students something along the lines of: Bedside manner matters much more than physicians realize.
“Students learn that there’s a way to deliver difficult news but still be kind. There’s a way to be in a hurry but still give patients the attention they need,” Flowers says.
During the shadowing, Flowers also makes a point of stopping by the nurses station to ask, “What would you tell this student about how they can they work with you better in the day-to-day care of patients?” Most say they wish physicians would take time to listen to what nurses have to say. One nurse told a student, “Physicians spend 15 minutes with the patient, and we spend 12 hours. We can help you understand family dynamics and the patient’s desires, needs, and fears. We are more than happy to do that if you will take the time.”
The COVID-19 pandemic has put the shadowing program on hold for now while everyone involved figures out a way to do it safely. Students may be able to safely observe by staying outside a certain radius, but near enough to see and hear what goes on. This might allow students to use only mask and gloves, which are not currently in short supply, as opposed to more extensive personal protective equipment. “We’re going to work out something,” Flowers promises.
Medical students saw firsthand the ethical challenges of virtual communication between patients and families, usually handled with tablet computers. Sometimes, it is just updates and encouragement conveyed. In other cases, end-of-life decisions are made this way. “It’s one of the most heart-wrenching things to witness,” Flowers laments.
Collectively, all the students’ observations teach the importance of building relationships. Even after the program is completed, some students make arrangements to check in on certain patients on their own time. Patients ask chaplains how the medical student is doing, and express the hope that the student will come by again.
Students also learn about the unique role of the chaplain. “We don’t go in with an agenda. We go in, and the person takes it down the path they choose,” Flowers notes.
Students see how critically ill patients appreciate a chance to talk about what is on their mind. “[Patients] need to know, first of all, that you are a human being who cares about them. It’s the joy of what we get to do,” Flowers says.
Flowers tells students, “Ten years from now, I hope you will remember your conversation with Mrs. Smith. In the midst of not feeling very healthy, she wanted you to know that your ability to comfort her meant a great deal.”
Sometimes, the discussion is not about anything clinical. Instead, patients talk about their grandchildren. Students express surprise the chaplain did not discuss the patient’s condition at all. In reality, Flowers explains, the chaplain was conducting a spiritual assessment the entire time. “The patient was talking about what’s meaningful to them — their grandchildren — and their fears, that they won’t be able to spend time with [grandchildren],” Flowers says.
There is nothing high-tech about the shadowing program. Yet it succeeds in teaching one of the most crucial skills in healthcare. “We teach people how to go into a room, pull up a chair, and have a meaningful conversation with people who are in [difficult] times [in] their life,” Flowers says.
- Sullivan BT, DeFoor MT, Hwang B, et al. A novel peer-directed curriculum to enhance medical ethics training for medical students: A single-institution experience. J Med Educ Curric Dev 2020;7:2382120519899148.
- DeFoor, Chung Y, Zadinsky JK, et al. An interprofessional cohort analysis of student interest in medical ethics education: A survey-based quantitative study. BMC Med Ethics 2020;21:26.