Clinical medical students given “booster shot” in ethics education

The majority of third-year medical students were able to recall the four ethical principles, appreciated the relevance of preclinical ethics education, and had positive self-assessments of their clinical-ethical reasoning abilities, according to a recent study.1

However, they were less able to recall other sources of ethical value and infrequently used ethical terms spontaneously in written reflections about ethically or professionally challenging issues.

“We were interested in trying to understand how much of what we teach in preclinical course work actually ‘sticks’ when students go into the clinical terrain,” says Lauris C. Kaldjian, MD, PhD, the study’s lead author and director of the Program in Bioethics and Humanities at the University of Iowa Carver College of Medicine in Iowa City. Kaldjian is medical director for clinical ethics at University of Iowa Hospitals and Clinics.

For the past few years, Kaldjian and his colleagues have asked students to write about patient-based experiences that raised some type of ethical or professional concern. “We give minimal directions for this assignment, intentionally. We don’t prompt them to make references to formal ethical principles,” he says. The researchers analyzed the students’ writings to see whether they used the language of ethics that they had been taught previously, and also surveyed the students to see whether they could recall certain ethical principles when directly asked.

“By their responses to explicit prompts, we know that most of them remember at least the four ethical principles. But when they are writing about ethical and professional issues, they are not frequently using the language of principles and other sources of moral value,” he says.

As a result of these findings, Kaldjian and his colleagues now use Medical Professionalism in the New Millenium: A Physical Charter, jointly authored in 2002 by the ABIM Foundation, the American College of Physicians foundation, and the European Federation of Internal Medicine,2 to guide fourth-year students in writing about a patient-based experience they have during a professionalism seminar run for sub-interns doing rotations in internal medicine and pediatrics.

“We ask them explicitly to consider which of the Charter’s ethical principles or commitments is most relevant to what they are writing about,” he says. “What we have found, not surprisingly, is that the frequency with which they make reference to such principles and values is much higher.”

Kaldjian says this approach works as a kind of “booster shot” to remind students of ethical principles while they are actually involved in clinical experiences. “Rarely is it enough to present things to someone once,” he says. “One of the great things about teaching in the clinical environment is you do not have to persuade students that this is serious business. Students have already wrestled with these issues and come to group discussions prepared for dialogue.”

During group discussions during each rotation, faculty facilitators select some of the students’ writing for group discussion, keeping the name of the author anonymous unless the student chooses to disclose his or her identity. “This becomes a very powerful experience,” says Kaldjian. “It’s one thing to present hypothetical situations in a lecture hall. It is a very different thing when students come to a discussion with their own cases in hand that they have already written about themselves.”

Kaldjian says it’s important for students to learn the language of medical ethics and to use the terms appropriately. “Like in other areas of life, if you don’t have a language to describe things, you cannot identify or understand those things as well,” he says. “The language of ethics is an important issue. How we communicate about moral matters in health care has implications for how we interact with our patients and colleagues, especially when differences of moral judgment arise.”


1. Kaldjian LC, Shinkunas LA, Forman-Hoffman VL, et al. Do medical students recall and use the language of ethics they are taught preclinically once they are in the clinical training environment? An empirical study in ethics education. AJOB Primary Research 2013;4(2):23-30.

2. ABIM Foundation. American Board of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243-246.


• Lauris C. Kaldjian, MD, PhD, Director, Program in Bioethics and Humanities/Medical Director for Clinical Ethics, University of Iowa Hospitals and Clinics/University of Iowa Carver College of Medicine, Iowa City. Phone: (319) 335-6706. E-mail: