Early, Integrated Education May Prevent ‘Ethical Erosion’
Ethics education often occurs early in medical school, with a focus on theory and hypothetical case studies.
“As the trainee’s plate fills up, ethics education competes with an ever-increasing workload. However, when trainees start to see patients, ethics education and reflection become more important, not less,” asserts Joelle Marie Robertson-Preidler, PhD, assistant professor in the McGovern Center for Humanities and Ethics at the University of Texas Health Science Center at Houston.
To address this, faculty can ask trainees to discuss the ethical elements of each clinical encounter. “Modalities such as ethics rounds or clinical ethics shadowing could help make ethical considerations a part of everyday practice,” Robertson-Preidler offers.
Ideally, trainees could work alongside a clinical ethicist for a day. “However, many hospitals where medical students train may not have a formal clinical ethics service,” Robertson-Preidler notes.
Faculty at Creighton University School of Medicine in Omaha, NE, sought to integrate ethics and humanities into the medical curriculum.
“The largest issue was not having the dedicated time in the curriculum,” says Cassie Eno, PhD, assistant professor of medical education at Creighton University.
The existing curriculum did include some group discussions of medical ethics cases. Those sessions covered topics such as informed consent and end-of-life decision-making. However, the ethics education was presented separately from the clinical sciences and foundational courses the students attended.
“It is certainly easier to plan single sessions or sporadic sessions. But the longitudinal integration of ethics and humanities is critical,” Eno argues.
Eno and colleagues implemented a revised curriculum called New ERA (Experience, Reflection, Action) in fall 2019. The new curriculum covers basic sciences in a “Blue Track,” clinical skills in a “Green Track,” and the social contexts of care and development of the future physician in a “Gold Track.” The Gold Track includes group sessions in clinical ethics, leadership, and personal and professional development. The faculty wanted data on how the first cohort of medical students perceived the New ERA program.
“Based on other literature and our own experiences, we knew the intentional inclusion of ethical and humanities training is important and impactful for medical students. Our motivation was to find a way to empirically assess what that impact entailed, which has been a gap in this literature,” Eno says.
Researchers assessed first-year medical students’ perceptions and behavioral intentions after experiencing the new curriculum, based in part on interviews with 27 students.1 Investigators also examined student essays on professional development and what it means to be a physician, along with end-of-year survey responses that asked students how their identity as a physician changed over time in medical school.
Many students described how the ethics and humanities sessions had opened their minds to others’ perspectives. Students explained the sessions caused them to see a bigger picture, that patients exist within a larger social context that influences behavior and decision-making.
Such insights suggest the New ERA model could prevent the “ethical erosion” and empathy deficit that can occur during clinical training, the authors concluded.
Topics covered during ethics sessions mirror the clinical content students are currently learning about. For example, when students practice cardiovascular exams and heart sounds during the “Green Track,” end-of-life decision-making that arises during those cases is covered during the corresponding “Gold Track.” Students examine an ethically complex case involving the decision to turn off an automated implantable cardioverter-defibrillator in a patient dying of heart failure.
“Students in the preclerkship curriculum often have limited experience in clinical settings,” Eno notes.
This can lead to challenges with understanding the nuances of ethically complex cases. For example, students may struggle with the need to weigh patient preferences against the best clinical care decision. “Students noted the value of having faculty available to help facilitate discussion and to provide guidance on unfamiliar situations,” Eno says.
- Eno C, Piemonte N, Michalec B, et al. Forming physicians: Evaluating the opportunities and benefits of structured integration of humanities and ethics into medical education. J Med Humanit 2023; Aug 1. doi: 10.1007/s10912-023-09812. [Online ahead of print].
Modalities such as ethics rounds or shadowing could help make these considerations a part of everyday practice.
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