Informed consent learning: Needs and preferences in medical clerkship environments

Purpose

Limited information exists regarding students’ routine educational needs in support of ethics and professionalism practices faced in real clinical practice. As such the authors aimed to explore medical students learning needs and preferences for informed consent and relevant ethical issues in the clerkship environments.

Materials and methods

A cross-sectional study using a self-administered, printed survey distributed to final year clinical clerks.

Results

84% completed the survey. Students indicated the need for more attention to all topics related to informed consent (mean = 7.1 on a scale of 0 to 9; ±1.2). Most additional instructional attention was requested for topics raised in discussions with patients concerning the risks, benefits and alternatives to recommended treatments (7.3 ±1.4). The cohort expressed the need for education in the care of vulnerable patients (7.2 ±1.2) with a maximum score for the care of abused children. Women perceived greater need for education concerning informed consent than male respondents (p>0.05). There were significant differences between students who scored high or low on the item “being treated in professional manner” and “endorsement of educational needs for care of adolescents” (p = 0.05).

Conclusion

There was heightened perception among final year medical students of the need for greater attention to be paid to informed consent education.

Psychosocial issues discovered through reflective group dialogue between medical students

BACKGROUND

The biopsychosocial model is a comprehensive approach emphasizing holistic medical care. However, medical curricula that incorporate narrative reflective writing and group dynamic discussion of psychosocial issues among patients and their family members in reflective dialogue groups are currently underutilized. The aim of this study was to determine psychosocial issues among patients and their family members through medical students' reflective dialogue groups.

METHODS

This study was completed as part of a pediatric clerkship. Fifty medical students were rotated to the department of Pediatrics. They completed a narrative writing assignment concerning patients' psychosocial issues and participated in a reflective group discussion during the rotation. The recordings of the six reflective group sessions were transcribed for thematic analysis. A six-step theme generation process was conducted in the first reading stage of all transcripts by four researchers. Subsequently, initial codes were generated and potential themes sought before possible themes were reviewed and thematic maps generated. Names for each theme were defined and a scholarly report of the analysis was presented through a consensus-based approach.

RESULTS

A total of 108 psychosocial issues were coded and categorized as the following six main themes: medical communication, the intricate medical ecological system, role and function of a family, development of medical professionalism, ethical dilemmas, and various patient perspectives from diverse cultural backgrounds. All these themes underlie the complexity of clinical encounters.

CONCLUSIONS

Clinical care is an extremely complex interactive ecological network involving human behavior, family, and public health care systems. The discovery of psychosocial problems by medical students as narrators in this study illustrates that medical care should focus not only on illnesses but also patients' psychosocial narratives.

Medical Students Analyze Complex Ethical Issues Observed in Clinical Rotations

[Full article available at http://rimed.org/rimedicaljournal-2017-10.asp].

Understanding and addressing missed care in clinical placements - Implications for nursing students and nurse educators

This paper addresses the issue of substandard care and its effects on healthcare practice. It explores some recent concerns about the problem in nursing, its potential effects on students, how it can be conceptualised and what action needs to be, by both nurses and educators to prevent it. Recent healthcare scandals have tarnished the public image of nursing, and are also likely to influence nursing students' images, expectations and experiences of nursing. While much attention has been paid to the examination of such lapses in care, and potential corrective actions, little attention has been paid to the potential or actual effect on nursing students in practice. While good resources and staffing levels are crucial to ensuring optimal nursing care, developing and encouraging nursing students' awareness of and openness about personal behaviours, reflecting critically on practice reflection and strengthening nurse educators' collaborative links with healthcare practice can all serve to positively influence care deficits.

Caring to Care: Applying Noddings' Philosophy to Medical Education

The authors argue that Nel Noddings' philosophy, "an ethic of caring," may illuminate how students learn to be caring physicians from their experience of being in a caring, reciprocal relationship with teaching faculty. In her philosophy, Noddings acknowledges two important contextual continuities: duration and space, which the authors speculate exist within longitudinal integrated clerkships. In this Perspective, the authors highlight core features of Noddings' philosophy and explore its applicability to medical education. They apply Noddings' philosophy to a subset of data from a previously published longitudinal case study to explore its "goodness of fit" with the experience of eight students in the 2012 cohort of the Columbia-Bassett longitudinal integrated clerkship. In line with Noddings' philosophy, the authors' supplementary analysis suggests that students (1) recognized caring when they talked about "being known" by teaching faculty who "cared for" and "trusted" them; (2) responded to caring by demonstrating enthusiasm, action, and responsibility toward patients; and (3) acknowledged that duration and space facilitated caring relations with teaching faculty. The authors discuss how Noddings' philosophy provides a useful conceptual framework to apply to medical education design and to future research on caring-oriented clinical training, such as longitudinal integrated clerkships.

Offshore Medical Schools Are Buying Clinical Clerkships in U.S. Hospitals: The Problem and Potential Solutions

U.S. medical education faces a threat from for-profit Caribbean medical schools which purchase clinical rotation slots for their students at U.S. hospitals. These offshore schools are monetizing a system that was previously characterized as a duty-the duty of the current generation of physicians to educate their successors. Offshore schools purchase clinical rotation slots using funds largely derived from federally subsidized student loans. This leads to pressure on U.S. schools to pay for clinical clerkships and is forcing some of them to find new clinical training sites.For-profit Caribbean schools largely escape the type of scrutiny that U.S. schools face from U.S. national accreditation organizations. They also enroll large classes of students with lower undergraduate GPAs and Medical College Admission Test scores than those of students at U.S. medical schools; their students take and pass Step 1 of the United States Medical Licensing Examination at a substantially lower rate than that of U.S. medical students; and their students match for residencies at a fraction of the rate of U.S. medical school graduates.Among the potential solutions proposed by the authors are passing laws to hold for-profit Caribbean schools to standards for board passage rates, placing restrictions on federal student loans, monitoring attrition rates, and denying offshore schools access to U.S. clinical training sites unless they meet accreditation standards equivalent to those of U.S. medical schools.

Ethical dilemmas in clerkship rotations

A sound clinical education should include the opportunity for medical students to engage in a spirited and informed discussion with faculty about the ethical challenges they will undoubtedly face. Unfortunately, in many medical schools today this goal is thwarted by many factors, including denial that a problem exists, relentless system overload, unprofessional behavior, breakdown in communication, and inertia. What is worse is that this problem is not new, and the fallout is not insignificant. Another potential contributing factor is burnout, which is well documented in a high percentage of medical students, residents, and faculty, and two of its most serious consequences are patient dissatisfaction and medical error.The authors draw on hundreds of student reflections on ethical dilemmas submitted during classroom exercises to examine persistent themes. They posit that classroom and didactic teaching is not enough to enable students to face ethical dilemmas. The authors call for a major culture change in medical education: "buy in" from top administration, especially the dean (and associate/assistant deans), chairs of all departments, and clerkship and residency training directors; the appointing of an ombudsperson and/or ethicist to oversee and resolve issues as they arise; instructional workshops and materials to enhance and impart skills for all teachers; remediation or retiring of errant faculty; and ongoing research and dialogue between and among medical centers about novel solutions.

Should trainee doctors use the developing world to gain clinical experience? The annual Varsity Medical Debate - London, Friday 20th January, 2012

The 2012 Varsity Medical Debate between Oxford University and Cambridge University provided a stage for representatives from these famous institutions to debate the motion "This house believes that trainee doctors should be able to use the developing world to gain clinical experience." This article brings together many of the arguments put forward during the debate, centring around three major points of contention: the potential intrinsic wrong of 'using' patients in developing countries; the effects on the elective participant; and the effects on the host community. The article goes on to critically appraise overseas elective programmes, offering a number of solutions that would help optimise their effectiveness in the developing world.

Through students' eyes: ethical and professional issues identified by third-year medical students during clerkships

BACKGROUND

Education in ethics and professionalism should reflect the realities medical students encounter in the hospital and clinic.

METHOD

We performed content analyses on Case Observation and Assessments (COAs) written by third-year medical students about ethical and professional issues encountered during their internal medicine and paediatrics clinical clerkships.

RESULTS

A cohort of 141 third-year medical students wrote 272 COAs. Content analyses identified 35 subcategories of ethical and professional issues within 7 major domains: decisions regarding treatment (31.4%), communication (21.4%), professional duties (18.4%), justice (9.8%), student-specific issues (5.4%), quality of care (3.8%), and miscellaneous (9.8%).

CONCLUSIONS

Students encountered a wide variety of ethical and professional issues that can be used to guide pre-clinical and clinical education. Comparison of our findings with results from similar studies suggests that the wording of an assignment (specifying "ethical" issues, "professional" issues, or both) may influence the kinds of issues students identify in their experience-based clinical narratives.

Relationships between drug company representatives and medical students: medical school policies and attitudes of student affairs deans and third-year medical students

OBJECTIVES

The authors sought to ascertain the details of medical school policies about relationships between drug companies and medical students as well as student affairs deans' attitudes about these interactions.

METHODS

In 2005, the authors surveyed deans and student affairs deans at all U.S. medical schools and asked whether their schools had a policy about relationships between drug companies and medical students. They asked deans at schools with policies to summarize them, queried student affairs deans regarding their attitudes about gifts, and compared their attitudes with those of students who were studied previously.

RESULTS

Independently of each other, 114 out of 126 deans (90.5%) and 114 out of 126 student affairs deans (90.5%) responded (identical numbers are not misprints). Ten schools had a policy regarding relationships between medical students and drug company representatives. Student affairs deans were much more likely than students to perceive that gifts were inappropriate.

CONCLUSION

These 2005 policies show trends meriting review by current medical schools in considering how to comply with the 2008 Association of American Medical Colleges recommendations about relationships between drug companies and medical students or physicians.

Proximity morality in medical school--medical students forming physician morality "on the job": grounded theory analysis of a student survey

BACKGROUND

The value of ethics education have been questioned. Therefore we did a student survey on attitudes about the teaching of ethics in Swedish medical schools.

METHODS

Questionnaire survey on attitudes to ethics education with 409 Swedish medical students participating. We analyzed > 8000 words of open-ended responses and multiple-choice questions using classic grounded theory procedures.

RESULTS

In this paper we suggest that medical students take a proximity morality stance towards their ethics education meaning that they want to form physician morality "on the job". This involves comprehensive ethics courses in which quality lectures provide "ethics grammar" and together with attitude exercises and vignette reflections nurture tutored group discussions. Goals of forming physician morality are to develop a professional identity, handling diversity of religious and existential worldviews, training students described as ethically naive, processing difficult clinical experiences, and desisting negative role modeling from physicians in clinical or teaching situations, some engaging in "ethics suppression" by controlling sensitive topic discussions and serving students politically correct attitudes.

CONCLUSION

We found that medical students have a proximity morality attitude towards ethics education. Rather than being taught ethics they want to form their own physician morality through tutored group discussions in comprehensive ethics courses.

A window of opportunity: ethics and professionalism in the obstetrics and gynecology clerkship

Educational experiences of short duration may have substantial educational impact if they occur when the learner is at an appropriate maturational level. Medical educators agree that students rapidly internalize professional values and attitudes during clinical clerkships, thus making clerkships the ideal time to teach ethics and professionalism in medicine. At Stony Brook School of Medicine, we utilize these concepts by incorporating a structured ethics and professionalism exercise into the 3rd-year obstetrics-gynecology clerkship. Students utilize a team approach in a Medicine in Contemporary Society exercise that requires them to work up and present a patient case from an ethical, social, cultural, legal, and/or economic perspective in an interactive setting. In this report, we describe our 12 years of experience with this program including nearly 1,300 medical students.

Deception, discrimination, and fear of reprisal: lessons in ethics from third-year medical students

PURPOSE

To systematically examine ethical conflicts reported by all State University of New York Upstate Medical University third-year students, compare them with conflicts reported in the literature, and identify content areas that compel new or renewed emphasis in national educational objectives, standard curricula, and texts.

METHOD

From 1999 to 2002, all third-year students submitted papers for a required bioethics course. These papers depicted ethical issues arising during clinical clerkships. The authors devised a checklist of ethical issues; after analyzing the students' papers, the authors applied the checklist to the papers to create a taxonomy.

RESULTS

Three hundred twenty-seven students submitted 688 cases involving 40 ethical issues. The most common issues were deliberate lies or deceptions (n = 68), patients' right to refuse recommended treatment (n = 48), and insistence on futile treatment (n = 46). Students perceived overt and subtle discrimination toward patients, reflected in substandard or excessive treatment. In 81 cases (12%), students expressed reluctance to speak up about moral conflict for fear of reprisal. This fear was expressed in 18 (45%) of the 40 issues-particularly student-specific (36 [52% of 69]) and quality of care (7 [24% of 29])-and most frequently in cases involving surgery (p < .025) and obstetrics-gynecology patients (p < .01).

CONCLUSIONS

Students discerned ethical dilemmas in both "usual and customary" and seemingly incidental situations. Students who described fear of speaking up perceived a tradeoff between academic survival and patients' interests. The cases demonstrated that students still lacked the tools to navigate ethical dilemmas effectively. The authors propose that moral courage is within the realm of professional expectations for medical students; its cultivation is an appropriate formal objective for medical education.

Reflective practice and palliative care education: a clerkship responds to the informal and hidden curricula

The authors discuss the damaging influence of informal and hidden curricula on medical students and describe a two-week clerkship in palliative care and clinical ethics at their school (Weill Medical College of Cornell University). This required clerkship, begun in 1999, uses reflective practice and a special pedagogic technique, participant observation, to counteract the influences of the informal and hidden curricula. This technique seeks to immerse the participant observer in the context of care. In their role as participant observers, students are relieved of any direct clinical responsibilities for two weeks so they have time for the careful observation and reflection required and also can consider the humanistic dimensions of practice, which are often displaced by the need to master diagnostic and therapeutic skills. Course objectives include identifying psychosocial and contextual factors that influence care, principles of pain and symptom management, and ethical and legal issues at the end of life. Students are expected to learn how to apply ethical norms to patient care, describe methods of pain and symptom management, communicate in an effective and humanistic manner, and articulate models of patient-centered advocacy. The clerkship fosters professionalism in patient care, appreciation of cultural diversity, and the student's ability to assume responsibility for developing competency in these areas. Although it is too early to know whether this clerkship will ultimately affect the practice patterns of students who experience it, short-term evaluation has been very favorable.