Fryer-Edwards, Kelly PhD; Wilkins, M Davis MD; Baernstein, Amy MD; Braddock, Clarence H. III MD, MPH
Medical educators have recently focused more attention on the professional development of medical students.1 The current system of medical education has been criticized for creating technically competent physicians, yet neglecting issues that arise in medical practice such as abuse of power, conflicts of interest, truthfulness with patients, and abrogating patient autonomy.2 The current system of medical education itself may be part of the problem, as other authors have documented that medical students undergo “ethical erosion” during their clinical training, a phenomenon of decreased ability to recognize and respond appropriately to ethically problematic behavior.3,4
Current strategies in ethics education have focused on the students’ abilities to analyze particular ethical situations, such as pregnancy termination, physician-assisted suicide, and decisions around genetic counseling and end-of-life care, with teaching usually consisting of didactics or small group discussions during the first two years of training.5 Although effective at highlighting the importance of these topics, these interventions do not adequately prepare students with a range of ethical skills needed to approach work on the wards or clinics.
The unique ethical and professional conflicts that medical students experience have been documented by other authors.6,7 These conflicts include needing to practice new skills while trying to act in patients’ best interests; hiding their level of inexperience from patients; witnessing supervisors’ unethical behavior, yet feeling hostage to fears of poor evaluations; and wanting to acculturate and be a team player in spite of the negative behaviors that assimilation may require. How students address these conflicts early on influences how they will behave in ethical and professional domains as they progress toward independent practice.8,9 Patterns of behavior are set early, and striking a balance between attainment and attrition is one of the key tasks of professional development.10 When students’ ideals are not met or modeled by faculty teachers in clinical practice, or when students act in a way that they would previously have judged as unprofessional, they may develop cynicism and apathy.11,12
Several ethics educators have suggested that such issues are best addressed in the context of real clinical work, not as abstract case studies.13,14 In this report, we describe one such effort and provide two years (1999–2001) of evaluation data from participating students and faculty.
Motivated by the negative effects of the informal curriculum on students’ ethical and professional development,15,16 we developed a series of peer discussion sessions with trained faculty facilitators during the third year required clerkships. Entitled “Ward Ethics,” these sessions were designed to foster reflection about critical incidents in the students’ clinical experience, with the goal to identify ethical and professional issues, clarify norms, and develop strategies for future situations. We based the design of our program on the four components of ethics education identified by Rest and colleagues,17 which focus on developing ethical sensitivity, ethical reasoning, professional motivation, and the ability to act. The program therefore focused not only on issue identification and discussion but also on role modeling, identifying norms, problem solving, and strategy development. With these combined elements, students in the program could develop the ability to recognize issues, apply a framework for reasoning through them, clarify professional responsibility, and identify specific actions for facing future conflicts.
In 1998, we piloted this program with third-year medical students during their medicine rotations at one hospital teaching site for the University of Washington School of Medicine. Collaborating with clerkship directors, we later expanded the program to four hospital-based clerkship sites in Seattle (University of Washington Medical Center, VA Medical Center, Providence Medical Center, and Harborview Medical Center) for students rotating in both medicine and surgery. The program continued from January through June each of the four years (1999–2003) following the pilot. Although 82 of our medical students (45%) completed their surgery clerkships elsewhere, all students completed at least six out of 12 weeks of the medicine clerkship in Seattle. By offering the sessions during a six-month period, we had the potential to reach, at most, an estimated 89 out of the 183 third-year students (49%) enrolled per year.
We received recommendations from clerkship coordinators and invited those faculty members known to be respected clinicians and teachers. Over the four years of the program, we recruited 30 faculty members from the departments of medicine and surgery. These volunteers participated in multifaceted facilitator training that included readings on strategies for leading small group discussions, the objectives of and the structure for the Ward Ethics sessions, and evaluation materials. In addition, a faculty development expert conducted training sessions at our institution, during which the trainer and the faculty conferred about the nuances of facilitating small-group discussions. At the beginning of each year, we offered training for newly selected faculty and debriefing for experienced faculty, which provided us an opportunity to discuss and solve teaching dilemmas with peers. As a result of these discussions, further tips for small-group facilitation were developed and circulated to all Ward Ethics faculty. Approximately 12 of the volunteer faculty (40%) attended at least one of these annual meetings during the program period; their participation was dependent on time availability. The range of sessions any one faculty volunteer facilitated was zero to five. All faculty members were with the program for more than one year.
Session structure and objectives
We held 24 sessions at four hospital sites for all 89 third-year students on medicine or surgery clerkships during the first week of the six-week clerkship or rotation between 1999 and 2001. We chose the first week because these students were not yet fully integrated into a new clinical rotation, often still attending orientation lectures and meetings during that time. Meeting during the first week also allowed students to reflect on fresh experiences from prior clerkships, rather than their current clerkship. Our goal was to preserve students’ sense of safety by disassociating the discussions from any evaluation of the clerkship itself. Ward Ethics sessions were scheduled for 90 minutes at the end of the workday. Based on clerkship director preferences, attendance was required for surgery students, but only recommended for medicine students. As designed, groups consisted of approximately ten third-year students and two faculty members, one from medicine and one from surgery. Whenever possible, we placed surgery faculty with students on the medicine rotation, and vice versa, to further preserve student safety and confidentiality.
Facilitators opened sessions with a discussion of the objectives and ground rules for the session, including an explicit statement that the session would be confidential. The stated objectives for the students were
▪ to discuss with their peers the challenging experiences occurring during third-year clinical rotations;
▪ to describe ways to address difficult issues with superiors and manage risks, mistakes, and perceived failures on future rotations;
▪ to identify strategies to maintain integrity throughout medical training and practice, particularly in respect to one’s role in the hierarchy; and
▪ to improve awareness of personal values and beliefs, strengths and weaknesses, and interests and aversions.
Facilitators followed this discussion by eliciting from students ethically challenging situations that they had encountered during their previous clerkships. To encourage students to identify a range of critical incidents for reflection and discussion, facilitators had the option of asking them to write their responses first. For the remainder of the session, the faculty facilitator fostered a student-directed discussion, encouraging students to solicit from and share with their peers real or anticipated coping strategies relevant to the incident at hand. If needed, faculty facilitators could offer to help students identify problematic elements within an incident or offer a professional perspective; the sessions were explicitly designed to foster student-led problem solving.
Both students and faculty completed written evaluations at the conclusion of each session. Evaluations were one page long, including a combination of Likert-scale queries regarding the session’s success at meeting the goals (five-point scale for each of the four goals with anchors of “Very Unsuccessful” to “Very Successful”); overall usefulness of the session (five-point scale from “Not Useful at All” to “Very Useful”); and how valuable the facilitator was (five-point scale from “Not Valuable at All” to “Very Valuable”). Open-ended questions regarded successful or problematic aspects of and key take-home points from the session. We also asked the faculty what types of issues and general themes had been discussed, and stripped specific incidents of identifiable details before reporting them. Additionally, in 2001, we conducted one-hour interviews with 15 of the Ward Ethics faculty (50%) for a qualitative assessment of the sessions from a faculty perspective. Our goal with these interviews was to understand more fully the faculty members’ experiences in the sessions, knowing that the project’s success relied on voluntary time commitments from busy clinician teachers.
We received a Certificate of Exemption from the University of Washington institutional review board for the faculty interview portion of the project only: The interviews were not audio-recorded, and no other identifying information was kept. The Ward Ethics evaluations were done as part of ongoing program evaluations and were not considered research.
After the 24 sessions, we obtained comments from 102 student-written and 22 faculty-written evaluations (92%) and from 15 faculty interviews (50%). Sign-up sheets were not used, so we do not have a total number of students who attended the sessions although 178 would have been the most possible participants (for a low estimate of response rate from students at 57%). A sampling of ethical and professional conflicts discussed most frequently is given in Table 1. The concerns identified were similar to student concerns reported in the literature from other institutions.6,18
Between 1999 and 2001, 96 students (94%) rated the sessions as valuable, useful, or successful. They saw the sessions as being the most successful way to facilitate discussions of challenging experiences among peers (97 [98%]). Many students noted that learning from their current issues was better than learning from generic ones. Open-ended comments on exit evaluations showed that students had overwhelmingly positive comments about the sessions, such as “it brought out a lot of emotions and dialogue that I had repressed and not even realized it,” “I am reminded that my colleagues are generally exceptionally thoughtful people,” and “a safe forum to discuss issues that often go undiscussed with others who can understand the challenging circumstances.”
The majority of students (85 [83%]) felt the sessions helped them to outline how to manage risks, mistakes, or failures. Students cited a diverse group of skills and ideas that they took away from the sessions, including “To hang on to my intuition and gut feelings, even if I can’t always act on them”; “Including RNs, LPNs, and considering them as part of the team is essential in patient care”; “I feel better about the contributions I make to the care of my patients”; “When in doubt, ask questions until you are satisfied”; “My little white coat shouldn’t suspend my own common sense.” Ninety-eight students (96%) valued faculty presence, specifically, for creating a collegial, safe climate for discussion and for giving their perspective on challenging issues.
According to the faculty, students universally reported it was helpful to hear that other students had similar experiences and readily shared strategies for coping with difficult situations. “Unbelievable openness/honesty from the students: insightful, thoughtful, caring, supportive of one another,” and “they took cues from one another, very little direction needed from me ninety percent of the problem solving came from the students themselves,” are representative comments. Most (20 [91%]) of the faculty rated the sessions as either “very” or “somewhat” successful at meeting all session goals, with the exception of two (10%) without an opinion and one (5%) reporting “somewhat unsuccessful” at the goal of improving student awareness of values.
During in-depth interviews, faculty cited multiple reasons for participating in Ward Ethics sessions, describing a diverse set of personal and professional benefits (Table 2). In addition, faculty appreciated the chance to work with colleagues: “I like talking with colleagues about difficult situations even though it can be challenging facilitating with peers when we have very different styles.” Faculty also endorsed the importance of the session focus: “If you frame things in an ethical context, it tends to raise the level of conversation and I like to take time to talk with students on that higher level.”
The topics students discussed during Ward Ethics sessions were similar to those noted by others documenting medical student-level ethical concerns.19 Students’ ethical challenges included situations that are inherent in professional training, such as performing procedures that carry risk to patients, as well as situations in which students witnessed superiors behaving unethically. Through supported discussions of issues, students could refine their own moral compass and intuition about appropriate training behaviors and practices. An example of an important skill for inexperienced medical students is the ability to judge whether a specific situation is a suitably challenging learning environment or if the situation’s challenge is professionally unsuitable. Ward Ethics discussions allowed students to identify issues, develop a response to a dilemma, recognize their own responsibility to act in certain situations, and begin to identify skills that they could use to carry out the appropriate actions.
Student feedback reinforced the notion that clinical years are a fruitful time for discussions of professionalism and ethics. As students first observe ward etiquette and routine, they are “imprinting” and learning the appropriate behaviors and interaction styles of doctors with colleagues, patients, and staff.20,21
In contrast to their first two years spent as a cohort in the classroom, students on clerkships are relatively isolated from their peers, which decreases their opportunity to use their peers as sounding boards on the appropriateness of behaviors. Several students commented on how rare it was to find the time or opportunity to talk about many of these difficult issues with peers other than during Ward Ethics sessions. Without time for reflection and discussion, there may be lasting consequences to professional development if issues, actions, and feelings go unquestioned and students remain isolated. From other moral development work, we know that people make better moral judgments if they have a peer group and support rather than working alone. A future longitudinal study would explore in more detail whether a forum such as Ward Ethics helps students maintain and augment their understanding of appropriate professional behavior.
The students’ enthusiasm and engagement in the sessions is encouraging. Ethics educators commonly lament that students resist discussions of values and behavior in the abstract, no matter how realistic the scenarios. Here, in contrast, students commented, “we are finally talking about some very real issues—our truth in this experience,” and “it’s good to hear our own stories instead of generic cases.” During the Ward Ethics discussions it seemed important for students to have faculty present who not only listen to their stories with compassion but who also can offer various responses and perspectives. Since students often report feeling disempowered in their third year, it is a boon to have a student-run session, yet equally helpful to have it witnessed by their volunteer faculty members.
One unexpected finding was how much the faculty facilitators seemed to appreciate participating in the sessions as well. When serving as attendings, faculty noted they rarely have an opportunity for reflective discussions with students. Several commented on the rare opportunity to discuss teaching strategies as well as the climate of medical training with faculty colleagues during the annual Ward Ethics faculty meetings.
These preliminary findings suggest that more opportunities should be given to faculty for discussion and reflection, and that there are rewards such as opportunities for self-reflection, role modeling, peer conversations, and professional development that come from participating in small group discussions. These rewards could be emphasized when recruiting additional faculty to the program. This type of program self-selects for faculty who enjoy discussing difficult issues, so it is no surprise that the facilitators were unanimously enthusiastic about participating in the sessions. That we were able to recruit 30 faculty members from two clinical departments who had little or no previous ethics training was encouraging.
Several challenges emerged in conducting this activity. One of the most significant for faculty was uncertainty about how to most appropriately respond to reports of unprofessional or unethical behaviors. Although these sessions were not intended to serve as a reporting mechanism to the institution, faculty felt that some stories needed to be reported to someone with the power to take further action. Students perceive themselves to be in the worst position to make complaints about the individuals or facilities providing them with training, and faculty members were unsure how they, as third parties, could influence events outside their own domain. This tension underscores the importance of developing effective and safe venues for reporting unprofessional incidents.22,23
Getting students to attend sessions was a significant logistical challenge. We found that when relationships with clerkship staff and chief residents were formed, the students got a just-in-time message to attend sessions and participate. Successful implementation depended on buy-in from the clinical departments. As attendance at this activity was not required across the board and was not monitored, it is likely that students disinterested or hostile to such exercises did not participate. Arguably, these are the students who might most benefit from external feedback about behaviors and attitudes. Further work should be done to recruit all students to such sessions; however, in the short-term, Ward Ethics sessions created a much-needed opportunity to support a majority of the participating students in their professional development.
We operated these sessions on a minimal budget, with funding only for a part-time research assistant, who coordinated the sessions. The University of Washington School of Medicine is currently developing a plan for a larger roll-out of Ward Ethics sessions across more clerkship sites as part of a renewed effort to integrate ethics and professionalism throughout the four years of training.
Medical students in the clinical years face ethically challenging situations. Ward Ethics sessions can be an effective way to address issues of professionalism and to counteract the ethical erosion that can result from isolation and a lack of reflection on challenging experiences during early clinical training. Students who participated in this activity with peers and faculty role models agreed that it served as a way to fight isolation, share stories, and exchange concrete ideas for future problem solving, and faculty found personal and professional satisfaction from participating. We thus offer up Ward Ethics sessions as a method to engage students as witnesses to their own complex experiences when entering clinical practice, a method that may foster a deeper personal and interpersonal dialogue about professional dilemmas encountered along the way.
This project was supported in part by a Robert Wood Johnson Faculty Development award. The authors thank Dr. Susan Marshall and the University of Washington School of Medicine for institutional support. Dr. Anthony Back contributed to the training of facilitators, and Drs. Doug Paauw and Lorrie Langdale, clerkship directors in medicine and surgery, made the sessions possible. The authors also thank all of the faculty facilitators and students who participated in this program.
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