As a medical student on a rotation, Divya Yerramilli, MD, watched as an attending physician convinced a hesitant patient that surgery was the best option to treat her abdominal pain. Privately, Yerramilli and the residents in the room felt that the surgeon overstated the benefits of the surgery and did not inform the patient of the risks.
The patient underwent the surgery, suffered a bowel perforation requiring a colostomy, and died at the hospital. The residents who had observed the case were unsettled and angry, said Yerramilli, now a second-year resident in the Harvard Radiation Oncology Program. They hadn’t spoken up during rounds because the attending was dismissive of residents and questions were not welcomed.
“The attending physician can create a climate that either supports or impedes ethical dialogue,” wrote Yerramilli in the 2014–2015 Hastings Center Report series on teaching bioethics that was developed collaboratively with the Presidential Commission for the Study of Bioethical Issues. She titled the essay: “On Cultivating the Courage to Speak Up: The Critical Role of Attendings in the Moral Development of Physicians in Training.”
“Too often, leaders of academic medicine assume that physicians in training will develop ethical skills and sensitivities simply by existing within the walls of the hospital and observing attendings and residents,” Yerramilli wrote. “That conclusion places the responsibility for improvement on the students rather than on their teachers.”
Physicians make decisions every day that have an ethical or moral component. Today, the Liaison Committee on Medical Education requires medical schools to cover bioethics in their curricula. The Accreditation Council for Graduate Medical Education addresses ethics by including adherence to professionalism as a core competency in training. In addition, many admissions committees are trying to preselect students who demonstrate the qualities needed to make tough ethical decisions, including compassion, empathy, reasoning, and the ability to listen and communicate, noted John Prescott, MD, AAMC chief academic officer.
“Ethics education is teaching about principles, virtues, knowledge, attitudes, and skills we want all doctors to have. [Ethics] are central to a physician’s identity,” said Joseph A. Carrese MD, MPH, who is on the faculty of the Johns Hopkins Berman Institute of Bioethics and a professor at Johns Hopkins School of Medicine.
“Ethics education is teaching about principles, virtues, knowledge, attitudes, and skills we want all doctors to have. [Ethics] are central to a physician’s identity.”
Joseph A. Carrese MD, MPH
Johns Hopkins Berman Institute of Bioethics
Ethical issues and quandaries are just below the surface in so many doctor-patient interactions, echoed Elaine C. Meyer, PhD, RN, cofounder and director of the Institute for Professionalism & Ethical Practice (IPEP) at Boston Children’s Hospital. Does the physician listen to the patient’s views about medication side effects? Use the term “fetus” or “baby” selectively? Express regret or make an apology about an adverse medical outcome? “Learning how to recognize and address these everyday ethical issues requires training and practice,” she said.
Traditionally, difficult questions were delegated to ethics experts to debate and resolve. Meyer noted that this approach has its place, but ideally, all doctors and health care professionals should have a working knowledge of ethics so they can flag potential conflicts early on. Otherwise, physicians resort to calling an ethics committee for a consult at the 11th hour when there is little time to reflect and make a thoughtful choice, she said.
Everyday ethics
Some would say that morality can’t be taught, but given the high stakes in medical care, educators do all they can to prepare students and residents to negotiate complex decisions in an ethical, humane way.
The best ethics education establishes the connection between ethical actions and better patient outcomes. “What resonates with learners are everyday, relevant clinical situations that they could encounter that afternoon,” said Meyer.
Some educators favor weaving bioethical case studies into other courses, as opposed to a stand-alone medical ethics course. But not so much that the integrated curriculum is invisible or ethics is treated like a peripheral issue, Carrese explained. “Students need to be able to identify the discipline of medical ethics and be familiar with its literature.”
Developing a bioethics curriculum is challenging, though. Researchers from the Cleveland Clinic and Case Western Reserve University found a significant “mismatch” between what bioethicists wanted to see in an ethics curriculum in OB/GYN, for example, and the issues that came up most often in practice according to OB/GYN clinicians. While the bioethicists identified assisted reproductive technology and preconception genetic testing as priorities in the education of bioethics trainees, the clinicians pointed to abortion, childbirth, contraception, infectious diseases, and sexuality as the areas that most frequently generated ethical questions.
“Create continuing opportunities for residents to bring real-life cases into the classroom and to talk about moments when they were not sure about what the right thing was to do. It is hard for residents to talk about what is distressing them, but it’s important for them to know that their mentors are open to hearing about moral distress and uncertainty.”
Mildred Solomon, EdD
The Hastings Center
Yerramilli described a “disconnect” between her ethics education in medical school and the more subtle day-to-day issues she encountered during her clerkship. “[In medical school], you learn about grand conflicts. Should a Jehovah’s Witness get a blood transfusion?” As a trainee, though, she faced more ordinary dilemmas, such as when a patient asked her about her experience with a procedure. “[Residents] often debate how best to disclose our level of comfort with a procedure, when we have done it many times in simulation, but it may be our first time performing it on a patient.”
“Another gray area is ‘capacity,’” she continued. Medical students learn that children and delirious patients can’t make treatment decisions. “In the clinics,” she said, “determining capacity is often so subtle that we reflexively consult psychiatry when we don’t necessarily agree with the decision a patient makes.” Ethics course work should not be divorced from clinical training “when residents feel the most tension on how to apply the principles they’ve learned,” she said.
Ethics is complicated today with complex issues like health equity, data privacy, and emerging debates about gene editing. Bioethicists have moved beyond “a naïve focus on principle-based analysis,” to an understanding that context and barriers to morality also need to be studied, said Mildred Solomon, EdD, president of The Hastings Center in New York and director of a fellowship in medical ethics at Harvard Medical School, where she is on the faculty.
Teaching approaches
Ideally, methods for teaching ethics and evaluating an ethics curriculum should be informed by research, said Carrese. “The use of simulated patients and role playing have proven effective and moves [trainees] beyond simple skills, but we need more data.” He acknowledged the difficulty of measuring a resident’s competency in ethics, too. “It may require faculty to observe residents in clinical settings to assess them for traits like humility and compassion or whether they are respectful of family members.”
Yerramilli believes that ethical training has to start with a learning environment that is “emotionally safe”—without discomfort during discussions or fear of repercussions. In a traditional hierarchical setting, she said, “Residents are afraid to ask questions [about values and choices] and insult the people they are trying to impress.”
Faculty must be modeling behavior that they want residents and students to adopt, Carrese added. “There are important implications for all faculty, whether they are explicitly teaching ethics or not. The ‘hidden curriculum’ can undermine moral development in the learning environment.”
Ethics educators see the need for professional development programs to teach faculty how to incorporate ethics lessons at the bedside and how to lead group discussions that encourage multiple viewpoints. “Create continuing opportunities for residents to bring real-life cases into the classroom and to talk about moments when they were not sure about what the right thing was to do,” Solomon advises educators. “It is hard for residents to talk about what is distressing them, but it’s important for them to know that their mentors are open to hearing about moral distress and uncertainty.”
Moralistic or politically correct stances should not be part of the conversation, Solomon added. “The best teachers probe for consensus, where possible, but they uphold minority views, too, and try to bring them into the room.”
With the advantage of an onsite institute dedicated to relational learning and ethical education, the staff at Boston Children’s Hospital have regular access to educational rounds and workshops on critical topics. Ethics “champions” are assigned throughout the units. To enliven the learning, actors are engaged to portray patients and provide feedback to residents about their communication and relational skills. Family members co-teach workshops and provide meaningful firsthand insight and feedback. Meyer describes the teaching approach as “interprofessional and preventive.”
An interprofessional approach means that physicians learn about ethics alongside nurses, chaplains, and interpreters, as well as other members of the medical team who may be sharing in the decision making about patients’ care. “Working across boundaries, [team members] identify moral choices that would not have been apparent if they had not worked together,” said Solomon.
Other schools have drawn on literature and the humanities to teach ethics. Georgetown University School of Medicine asked students to read Middlesex, a novel about an intersex man who was raised as female. Students attended an interdisciplinary panel discussion, which included an ethicist, to explore the complex gender and sexuality questions—both medical and personal—that the character encountered.
Barron Lerner, MD, a professor of medicine at New York University Langone Medical Center, wrote in Forbes about taking 17 medical students to a theater performance of Informed Consent. The play is based on actual events involving medical research conducted on Native Americans who could not read the consent forms they were asked to sign. Later, the students discussed the conflicts of interest raised in the story.
“Often everyone is acting morally, but they may not be sure which decision or policy will be wisest or offer the most good,” Solomon summed up about the quandaries that surface in the academic medicine setting. “Bioethics has tools to help us make those kinds of judgments.”
This article originally appeared in print in the April 2016 issue of the AAMC Reporter.