Graduates of a clinical ethics fellowship would have liked better preparation for their first job in some areas, according to a recent survey.1
“The idea for this study arose when a couple of the authors were sitting in a meeting talking about whether clinical bioethics fellowship programs should be accredited,” says Douglas S. Diekema, MD, MPH, one of the study’s authors.
The group disagreed on what accreditation should include, largely because of how different their programs were from one another. “We really didn’t have a good idea of how diverse the various programs were, and whether they were meeting the needs of their graduates,” says Diekema, an attending physician and director of education for the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Hospital.
Diekema and colleagues surveyed 45 graduating fellows. For some programs, ethical theory was not a focus because the authors assumed fellows already underwent that training. Other fellowships did an excellent job teaching applied ethics, but general theory was not covered much. “I was surprised at just how little standardization and similarity there is from one program to another,” Diekema observes.
Medical residency programs differ in small ways, but are fairly consistent from one institution to the next. “By and large, they follow the same basic template in terms of learning experiences,” Diekema notes. “That did not seem to be the case in clinical bioethics training programs.”
Clinical bioethics training programs serve a wide variety of individuals, some with clinical backgrounds, others with PhDs. “Most graduates indicated that their basic training in ethics was adequate,” Diekema says. Still, many wanted more training in quality improvement skills, including some exposure to quality improvement methodology. They also wanted to learn how to negotiate for resources and how to communicate with hospital leadership.
Yale New Haven (CT) Hospital’s ethics committee surveyed 22 of its members recently about their top priorities. Most (78%) said creating a packet of key ethics readings was a top priority, and 56% named ethics training as a top priority. “We’ve been particularly focused on education in ethics theory and clinical ethics best practices, including frameworks for approaching common consult questions,” says Benjamin Tolchin, MD, MS, co-chair of the adult ethics committee at Yale New Haven Hospital and assistant professor of neurology at the Yale School of Medicine.
The overarching goal is to ensure consistent, high-quality practices are used by all of the health system’s ethics consultants. “We have also been working with the healthcare system administration much more closely during the pandemic,” Tolchin reports.
Ethicists have developed and implemented system policies, including crisis standards of care triage. “This has definitely been a learning experience for us as we’ve become involved in organizational ethics,” Tolchin says.
Ethicists had to achieve consensus with a much broader range of stakeholders than they normally do during traditional clinical ethics consults. Building on these new relationships, ethicists began collaborating with health disparity researchers. “We wanted to assess the outcomes of new hospital policies — in particular, to ensure that they do not propagate or exacerbate racial or socioeconomic health disparities,” Tolchin explains. The ethics committee made these other changes to improve member training:
• Members are encouraged to obtain the American Society for Bioethics and Humanities Healthcare Ethics Consultant-Certification (HEC-C). Two committee co-chairs recently completed the exam, and a third member is preparing. The goal is for at least one ethicist participating in every consultation to earn the HEC-C.
“The idea is for this team leader to mentor junior team members, and to ensure that consultations meet national guidelines and best practices,” Tolchin says.
• Ethicists participate in short, focused sessions based on topics from previous cases. Recent topics included standards for surrogate decision-making, medical care for underrepresented patients, and accommodating religious faiths and the hope for miracles among patients and families.
• The committee started engaging in ethics case simulations. “We intend to simulate very standard ‘bread-and-butter’ clinical ethics cases,” Tolchin says.
One example is a family meeting during which some (but not all) adult children of an intubated patient ask for life-prolonging care the clinical team believes to be extremely unlikely to benefit the patient. “The goal here is not to introduce complex ethical topics, but to give newer committee members a chance to practice basic clinical ethics and communication skills,” Tolchin says.
Training of individuals performing clinical ethics consults depends in large part on available resources. Consult services that can hire full- or part-time clinical ethicists likely will employ individuals formally trained in bioethics.
“These individuals are going to have at least a masters-level education; often, a degree in bioethics or a field related to bioethics; and will have engaged in coursework, practica, or fellowships that directly relate to the knowledge and skills needed for consults,” says Erica K. Salter, PhD, HEC-C, associate professor and PhD program director of healthcare ethics at Saint Louis (MO) University.
Graduate-level training in bioethics ideally includes common clinical ethics topics and the steps of an ethics consult, mediation, and communication. Clinical ethics practica and fellowships offer the chance to observe and participate in actual ethics consults. “A majority of ethics consult services do not have a significant budget,” Salter notes.
Most are staffed by volunteer members, likely without any formal training in how to handle consults. “Most training of these individuals will, by necessity, be on-the-job training,” Salter explains.
Many committees offer short workshops or training sessions to cover the basic steps of how to complete a consult, what to document, and how to follow up, or an apprenticeship model, with new consultants shadowing experienced consultants.
“Some institutions will have the budget to send new consultants to conferences, workshops, or certificate programs for additional intensive training,” Salter says. Two other areas are overlooked frequently:
• The skills of effective literature review. Ethicists need the ability to find and apply the most recent and relevant scholarly literature to analyze cases and justify recommendations. “These skills are typically a strength of formal ethics education, and a weakness of on-the-job ethics training,” Salter says.
• Mediation skills, which emphasize the importance of conflict resolution and interpersonal communication. “So much of an effective consult depends on relationship-building and good communication,” Salter observes. “We often forget that these skills can be learned and practiced.”
Ethicists and skilled communicators engage in simulated mediations, playing the roles of clinicians or family members. The session ends with a debriefing during which the mediator’s choices and tactics are discussed. “Trainees practice the skills of bioethics mediation, and view dilemmas from various perspectives and moral positions,” Salter adds.
- Guerin RM, Diekema DS, Hizlan S, Weise KL. Do clinical ethics fellowships prepare trainees for their first jobs? A national survey of former clinical ethics fellows. J Clin Ethics 2020;31:372-380.