Annual Feature: in Progress: Reports of New Approaches in Medical Education: Professionalism
Objective: Ethical dilemmas often arise in routine clinical practice under managed care. Relevant clinical examples, together with a process that focuses on attitudes and behaviors, are necessary to educate medical students about such dilemmas. In 1995, we developed a required two-day, third-year course in managed care, covering such topics as health care financing, use of guidelines and formularies, disease management, capitated managed care for special populations, physician workforce considerations, and ethics.1 We were particularly concerned that ethical issues related to managed care practice receive full attention and that students actively participate in the learning process.
Description: We used a case-based, small-group discussion format, with trained faculty facilitators. Cases were drawn from actual faculty patient encounters that highlighted routine ethical issues that are seen in managed care. These include conflicts between the patient's interest and the physician's self-interest, the autonomy of the patient and the physician, beneficence, and social justice. The cases explored the use of a pharmaceutical formulary, the “gatekeeper” role, limiting specialty referrals, and participation in a “for-profit” HMO. The cases were reviewed and modified by a working group of physicians drawn from our academic practice, a group-model HMO, and private practice.
Many ethical dilemmas in managed care practice are associated with strong emotional reactions. To overcome “knee-jerk” responses and ensure thorough discussion and consideration of all sides of the issues, we assigned students specific points of view to argue without consideration of their own personal opinion—an approach patterned on the adult party game “A Question of Scruples.”2 “Scruples” was first adapted to the teaching of ethics by Nancy Eklund, MD, at the University of Miami School of Medicine and was later enhanced for use with larger groups by Chip Celestino, MD, at Wake Forest University School of Medicine. For each case, three students are selected. One is randomly assigned to the “yes” position, another to the “no” position, and the third to a “maybe” position. This forces each student to develop an argument to support the assigned position, regardless of personal viewpoint. After the group has read the case, each of the presenters argues for the assigned position. The group then identifies the type of ethical conflicts at issue. After the case is discussed, the group must vote, with no abstentions, on what should be done, thus approximating the realities of clinical decision making.
Discussion: We present a framework for structuring a dialog that allows students to analyze the ethical conflicts that can arise under managed care, using examples drawn from actual practice. In addition to dialog, these small-group exercises provide an opportunity to role-play potentially difficult doctor-patient encounters. Our students have embraced this method for teaching managed care ethics. Almost all the students have agreed that the “game” was an effective way to learn about managed care ethics. Finally, we thought assigning a “pro or con” stance would allow for a richer discussion than having students express their own opinions. The majority of students agreed that such assignments allowed for expressions of more diverse opinions, but almost half would have preferred to express their own opinions. We have pilot tested this teaching method with primary care residents, and they have also received it well. Such an approach can be adapted easily to any number of educational settings.
1. Field TS, Baldor RA, Casey LM, et al. Introducing managed care to the medical school curriculum: effect on student attitudes. Am J Managed Care. 1998;4:1015–21.
2. A Question of Scruples.™ High Care Enterprises.™ Canada.
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