Ethics education in the clinical setting.

Abstract

To integrate ethics education for medical students into the clinical setting, the University of California, Irvine College of Medicine is piloting an ethics liaison program. Building on a study that demonstrated the benefit of ethics consultation in the intensive care setting, ethics committee members work with specific clinical units to offer instruction in the identification and resolution of ethical issues. Goals of the liaison program include creating a dynamic environment for integrated ethics education and the development of ethics role models.

Introduction

Ethics education in medical schools has grown over the past 30 years in response to school accreditation and professional licensure requirements. Ethics education reflects a perceived need in society to address ethical shortcomings among health care professionals, ethical dilemmas raised by new or controversial technologies, and health policy implications of events reported in the media. Every medical school in the United States claims to require ethics education, [1] but the requirements diverge greatly. The number of formal classroom hours, the existence of an independent ethics course, the course objectives, the topics taught, and the methods used vary among each school.

What does appear to be consistent is the prevalence of classroom teaching. Common methods include discussions/debates, readings, writing exercises, and lectures. [2] Students have the opportunity to discuss particular topics, reflect on and analyze their behavior and that of their colleagues and teachers, learn communication skills, and practice critical thinking, but are not actively and formally engaged in ethical practice in the clinical setting. This contrasts with the general model of medical education in which what is learned in the classroom and from the textbook is practiced during clinical rotations, translating the knowledge attained into practicable skills. While role plays, standardized patients, and computer simulations are utilized, ethics does not appear to be explicitly integrated into the clinical setting.

At the University of California, Irvine College of Medicine (UC1 COM), the ethics curriculum is integrated longitudinally into other courses throughout the four years of medical school, including sessions or content in the patient-doctor course, problem-based learning modules, anatomy, genetics, and the didactic portions of several clinical clerkships. Curricular goals include developing understanding of key ethics concepts, critical thinking and case analysis, issue identification, self-reflection, communication, and interpersonal skills. The interactive sessions are designed to supplement self-discovery with practical resources for identifying, analyzing, and resolving issues of ethics and professionalism. Development is ongoing and faculty and students have been receptive.

To advance through UCI COM, medical students must demonstrate both technical competence and ethical and professional behavior, assessed by exams, standardized patients, and faculty and resident evaluations. These assessments are announced and the requirements for success are well known. Based on these assessments, student behavior is consistent with classroom education regarding professionalism and ethics. Anecdotal experience and student report, however, suggest that the performance during assessment does not reflect reality or usual practice. The students admit to a duality in practice behavior: 1) performing according to classroom instruction in evaluation settings, and 2) performing in emulation of the behavior and expectations of their resident/faculty role models in the clinical setting. Often these behaviors are contrary. For example, during classroom instruction during the first and second years, students are taught to take complete patient histories using open-ended questions, but the use of close-ended questions is modeled and often the use of open-ended questions is actively discouraged by supervising physicians.

The Need for Integrated Ethics Education

Research suggests that this discrepancy between evaluation behavior and real practice is not unique to UCI COM students. [3,4] In the clinical setting, where evaluation is conducted in part by faculty and residents--who may not be familiar with the formal curriculum--the students' behavior appears to reflect the expectations and actions of their physician role models. Yet, the students express beliefs that what they are taught in the classroom may be "ideal" or ethically preferable to practice styles as they exist in reality. Observations suggest that the "informal" or "hidden" curricula blunt the impact of the formal curricula, resulting in students trained to practice according to what they see rather than what they are taught.

This is not to suggest that the faculty and residents who perpetuate this hidden curriculum are necessarily unethical or unprofessional. Rather, they may not be aware of the specific content of the ethics curriculum, may have other priorities in clinical teaching, or may not recognize that they are professional role models. Regardless of the reasons, ethical and professional role modeling appears to be largely neglected leaving students to learn positive behaviors despite the formal teaching or resulting in the perpetuation of ethically neglectful behaviors. Medical education has focused on increasing knowledge and developing clinical skills while the values, attitudes, and professional behaviors were at best implicit. Ethical acculturation has received little attention in the drive to improve test scores and residency placement.

Yet, becoming a doctor requires more than technical competence. The ability to recognize and address difficult or controversial issues, to develop appropriate relationships with patients/families and colleagues, to communicate informatively and compassionately, and to handle personal discomfort or distress comprise the crucial art of medicine. This art can be described in the classroom, but must be learned in practice from role models. Students will emulate the behaviors of their supervisors (and evaluators) to excel in or at least survive their training programs. This may be true even of behaviors with which they find fault, which if not emulated are not openly criticized. The result is students habituated into ethically questionable or troublesome practice styles, sometimes despite the explicit curriculum and even the best intentions of the clinical role models. Role modeling is often unintentional, but nonetheless makes strong impressions. The medical education literature has identified the importance of role modeling, but has not yet offered strategies for assuring or maximizing positive impact. [5]

Ethics has been incorporated into medical education with a focus on conceptual knowledge and management of moral dilemmas. While perhaps a good starting point, understanding the key tenets of the abortion debate or being able to explain to a patient why physician-assisted suicide is not a legal option do not necessarily result in better patient care, at least from the patient's perspective. Patients may well assume that their physicians possess such knowledge, but judge the care they receive based on how the physician explains their illness and treatment options or how responsive the physician is to their individual needs and preferences. Ethics, professionalism, and humanities courses address such behaviors and may offer role plays or standardized patients for practice, but leave the inculcation of those behaviors to the practice setting. The practitioners, however, may be unprepared or unwilling to reinforce those behaviors and in fact may behave, knowingly or unknowingly, in ways that may weaken or otherwise modify those behaviors.

Integrating Ethics Education into Clinical Practice

To address the educational dissonance created by the formal and informal curricula and to create role models in ethical practices, the UCI Medical Center Ethics Committee has developed an innovative approach to integrating ethics into the clinical setting. While education is often among their explicit mission, [6] ethics committees appear to be an underutilized resource in health professional education. Ethics committee members frequently are employed as medical educators, but no existing literature documents a consistent role for ethics committees in medical education. To create a more dynamic teaching environment, the Ethics Committee is actively inserting itself into the educational process by developing a liaison program.

In the pilot phase of this program development, ethics committee members are working throughout the medical center to identify proactively, address, and resolve ethical conflicts and professionalism issues. The Committee elected to focus on units which had generated the majority of ethics consultation requests, primarily intensive and specialty care units. The liaisons are long-term members of the ethics committee who possess the most clinical ethics experience. They function to provide educational content; model clinical communication skills; demonstrate the identification and management of ethical and professional issues; conduct ethics case analysis; and serve as ethics mentors by providing feedback to clinicians. The Ethics Committee regularly reviews the experiences of the individual liaisons to develop supplemental teaching modules available for in-service training or independent study.

In a second phase, the liaisons will initiate a train the trainer approach, identifying, recruiting, and training interested clinicians to assume the liaison functions. Training will consist of case analysis skills and paradigm ethics cases in the classroom and clinical setting. The liaisons will then be able to expand the program to other units. With the pilot underway in select units, an evaluation method is being developed. The goals of evaluation include assessing changes in awareness of the ethics committee and ethical issues, behavioral responses to ethical questions, ethical decision making process, and self-awareness. The evaluation will consist of a pre- and post-test survey of participants in each unit, including medical students and residents.

Impact of Ethics Consultations

The liaison program builds on UCI's experience with "The Impact of Ethics Consultation in the ICU" study, a prospective randomized controlled intervention trial of the impact of ethics consultations on patients, families/friends, health care professionals, treatments, and charges in the medical intensive care units. The study, coordinated by the University of California, San Diego, and conducted in seven sites across the United States, was designed to identify the benefits (or harms) of ethics consultations in treating seriously ill patients in the intensive care setting. In participating, Ethics Committee members regularly attended rounds (1-3/week) to identify potential ethical conflicts, randomize patients into the trial, and initiate ethics consultations on intervention-arm patients. Data was collected on the patients and clinicians involved. Between January 2000 and December 2002, 551 patients were enrolled; 278 were assigned to the intervention arm and were offered ethics consultation and 273 were enrolled as controls for whom usual care was provided (including ethics consultation if requested). The study results demonstrated no differences in overall mortality between the control patients and intervention patients. However, ethics consultations were associated with reductions in hospital and ICU days and life-sustaining treatments in those patients who ultimately failed to survive to discharge. The majority of clinicians and patients/surrogates agreed that ethics consultations in the ICU were helpful in addressing treatment conflicts. [7]

While the study was designed to assess effects on health care utilization and cost, the educational implications were overwhelming. The clinicians involved consistently reported that the consultations provided a significant learning opportunity for themselves as well as for patients. During the study period, Ethics Committee consultation requests throughout the hospital increased fourfold and informal requests for information about ethical and professional issues became frequent among all members of the ICU team, including medical students and residents.. The health care professionals and trainees involved appear to have improved their ability to identify ethical conflicts, were more open to addressing ethical issues with patients and colleagues, and more readily included the Ethics Committee in their deliberations. Findings from the ethics consultation study provide support for the belief that ethics consultation provides assists health care professionals dealing with end-of-life consultations. A large majority of the health care professionals interviewed believed that ethics consultations are beneficial in educating both clinicians and family (80.3%), helping identify ethical issues (87.7%), analyze ethical issues (86.5%) and resolve ethical issues (80.3%). Further, 95% of the clinicians noted they would seek out further ethics consultations given similar circumstances and 98.7% would recommend ethics consultation to other clinicians. Finally, the vast majority of clinicians believed that by better identifying the issues, ethics consultations are beneficial in helping to articulate or present their views (80.9%).

In addition to benefiting clinicians, the ethics consultation appeared to create an environment where family members were able to better understand ethical concerns and become more involved in the decision making process. Similar to the responses of the clinicians', family members believed that ethics consultations were helpful in identifying (86.7%), analyzing (84.6%) and resolving (71.2%) ethical issues. Furthermore, family members would seek future ethics consultations given similar circumstances (80.4%) and recommend ethics consultations to others (80.4%). Most family members reported that ethics consultations are beneficial in helping to present their views (84.9%). In an editorial accompanying the published study, ethicist Bernard Lo noted:

   ethics consultations can help improve the quality of medical
   education ... an active ethics consultation service can offer
   hands-on training for residents and faculty members. Such training
   would likely engage learners actively, through addressing dilemmas
   in real cases. Also ethics consultations can teach physicians how
   to integrate different skills, including clarifying the clinical
   issues, analyzing bioethics issues, and communicating
   effectively.... additional research can foster more effective
   education. [8]

Continuing to involve ethics committee members in the day-to-day patient management through the ethics liaison program may similutaneously facilitate student, resident, and faculty education on communication with patients/families about difficult issues; role model intervention on ethical and professional issues with patients and team members; and encourage teamwork by partnering a member of the multi-disciplinary Ethics Committee with the clinicians.

The consultation model employed during the study was particularly helpful in creating educational opportunities. Usually, consultations are triggered by a situation of conflict and are more reactive in nature. A member of the health care team, the patient, or family member requests an ethics consult at that point to help resolve whatever dispute has emerged. During the study, however, a proactive model of consultations was utilized. Previous work suggests that proactive ethics consultation can improve decision-making, communication, and patient care. [9] To facilitate proactive identification of potential ethical issues, nurses, case managers, and social workers were employed as "spotters" during the study. These spotters would notify the ethics committee of any potential ethical questions or issues, situations in which conflict could be reasonably anticipated or were burgeoning. During rounds or other patient care meetings, the ethics committee members would review the cases identified by the spotters with the health care team to determine qualification for the study. Potential ethics conflicts were defined to include situations involving value-based treatment conflicts in which two or more parties would form fixed opinions about treatments plans that would lead to incompatible courses of action. That is, the patient, the patient's family/friends, and/or members of the health care team may have disagreed about the course of patient care. Categories of potential conflict appropriate for the study included conflicts among health care team members, among the patient/family/friends, or between health care providers and the patient/family/friends regarding the pursuit of aggressive life-sustaining treatment or comfort care, the patient's best interests, futility of treatment, or the identify of a surrogate decision maker. For example, the patient or family may indicate a preference for cardiopulmonary resuscitation under any circumstances, but the treating physician may believe it to be medically inappropriate, or a nurse may perceive a physician's order for artificial nutrition and hydration to be inappropriate in light of his/her understanding of the patient's preferences.

The proactive model provides openings to work with health care team members to prevent or lessen likely conflicts. Identifying ethical questions and potential conflicts early offers "teachable moments," or opportunities to help health care team members recognize and analyze value-laden issues in patient care; learn about paradigm cases, debates in the ethics literature, and relevant hospital policies or laws; and develop strategies for addressing questions or conflicts in a timely manner. In addition, the successful use of spotters during the study suggests an ability to increase the utlization and role of the ethics committee in other units throughout the hospital. Ethics Committee members, limited in number and serving as volunteers, cannot monitor the entire hospital for potential ethical issues. Training members of each unit to work with the ethics committee can enhance the educational and consultative functions of the committee.

Conclusion

During and since the study, ethics committee members and unit attendings reported perceptions of a change in culture. Those involved, including residents and students, report being more comfortable with requesting consults, including Ethics Committee members in team and family meetings, anticipating ethical issues, and applying hospital policies to patient care situations. With support from the hospital administration, the Ethics Committee has been able to capitalize on the positive lessons from the study experience and findings in initiating a liaison program. Evaluation methods in development will confirm if the program is also beneficial to medical education, achieving the goals of helping medical students and professionals recognize and address ethical issues, work with ethics committees, and role model ethical medical practice. Exams and standardized patients experiences of UCI COM students indicate that students "know" and "show how" to practice as they have been taught, i.e. demonstrate knowledge and skills in a controlled setting. Through role modeling and feedback, the goal of this proactive model is to encourage students to "do" what they have been taught in a real care setting so that they may foster ethical and professional practice habits. [10]

References

[1] American Association of Medical Colleges. Curriculum Directory 1998-1999, Washington, DC: Association of American Medical Colleges, 1998.

[2] DuBois JM, Burkemper J. Ethics education in US medical schools: A study of syllabi. Academic Medicine. 2002;77(5):432-437.

[3] Pieters HM, Touw-Otten FW, DeMelker RA. Simulated patients in assessing consultation skills of trainees in general practice vocational training: a validity study. Medical Education. 1994;28:226-233.

[4] Tamblyn RM, Abrahamowicz M, Berkson L, et al. First-visit bias in the measurement of clinical competence with standardized patients. Academic Medicine. 1992;67(suppl):S22-S24.

[5] Kenny NP, Man KV, MacLeod H. Role Modeling in Physicians' Professional Formation: Reconsidering an Essential but Untapped Educational Strategy. Academic Medicine 2003;78(12):1203-1210.

[6] Fletcher JC, Siegler M, What are the goals of ethics consultation? A consensus statement. J Clin Ethics. 1996 Summer;7(2):122-6.

[7] Schneiderman LJ, Gilmer T, Teetzel HD, Dugan DO, Young EWD, Goodman-Crews P, Cranford R, Briggs KB, Blustein J, Cohn F, Komatsu GI, Effect of Ethics Consultations on Non-Beneficial Life-Sustaining Treatments in the Intensive Care Setting: A Multi-Center, Prospective, Randomized, Controlled Trial, JAMA 290 (2003) 1166-1172.

[8] Lo, B. Answers and Questions about Ethics Consultations. JAMA 2003;290(9): 1209

[9] Dowdy MD, Robertson C, Bander JA. A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Crit Care Med 1998;26(2):252-259.

[10] Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine 1990;65(suppl): S63-S67.

Cohn, PhD is Director of Medical Ethics. Rudman, PhD, is Professor of Health Information Management.