Building reflective spaces for junior doctors to promote ethical, legal and professional learning relating to clinical practice

BACKGROUND

Concerns have been raised surrounding the training of Foundation Doctors on the ethical, legal and professionalism (ELP) aspects of clinical practice, leading to some to claim a degree of educational neglect. Foundation Doctors are junior doctors in the United Kingdom within the first 2 years of their medical career since graduating from medical school.

APPROACH

Lancaster University and Health Education England North West (HEE NW) introduced a series of training materials specially created to meet the ELP training needs of Foundation Doctors, which were piloted by Foundation Schools.

EVALUATION

The training was delivered to Foundation Doctors in first and second year of their training either online or in person. The facilitators were clinical senior doctors and did not have an academic qualification in ELP. Some large Foundation Schools used two training packs to provide an optional ELP day for their Foundation Doctors, while individual hospitals within a Foundation School used the training packs to provide training as part of their mandatory weekly training for Foundation Doctors. Feedback was gathered from Foundation Doctors and training facilitators when a training pack was piloted.

IMPLICATIONS

Foundation Doctors were able to make links between the messages delivered in the training to their own clinical practice. Foundation Schools have incorporated the training packs into the 2-year Foundation Programme, which creates the possibility for ELP training to become standardised across Foundation Schools.

Engaging Tomorrow's Doctors in Clinical Ethics: Implications for Healthcare Organisations

Clinical ethics can be viewed as a practical discipline that provides a structured approach to assist healthcare practitioners in identifying, analysing and resolving ethical issues that arise in practice. Clinical ethics can therefore promote ethically sound clinical and organisational practices and decision-making, thereby contributing to health organisation and system quality improvement. In order to develop students’ decision-making skills, as well as prepare them for practice, we decided to introduce a clinical ethics strand within an undergraduate medical curriculum. We designed a programme of clinical ethics activities for teaching and assessment purposes that involved using ethical frameworks to analyse hypothetical and real-life cases in uni- and inter- professional groups. In this paper, we draw on medical student feedback collected over 6 years to illustrate the appeal to students of learning clinical ethics. We also outline the range of benefits for students, healthcare organisations, and the field of clinical ethics arising from tomorrow’s doctors experiencing clinical ethics early in their training. We conclude by briefly reflecting on how including clinical ethics within tomorrow’s doctors curricular can secure and continue future engagement in clinical ethics support services in the UK, alongside the dangers of preparing students for organisational cultures that might not (yet) exist. We anticipate the findings presented in the paper will contribute to wider debates examining the impact of ethics teaching, and its ability to inform future doctors’ practice.

Exploring the perceived medical ethics and law training needs of UK foundation doctors

Foundation doctors (FDs) encounter a wide range of ethical and legal issues during their first two years of work. Despite ethics being a key part of most modern undergraduate curricula, FDs can struggle with the issues they see. This study is based on results from an on-line survey answered by 479 UK FDs regarding their medical law and ethics learning needs, and their undergraduate training in this area. Over two-thirds stated they would wish to receive MEL training as an FD on self-discharge against medical advice (∼71%), sedating patients (∼70%), decision making in emergency medicine (∼67%), and withholding and withdrawing treatment (∼66%). Over half of all respondents want MEL training during their Foundation Programme on DNACPR orders (∼63%), dealing with patients with suicidal intent (∼59%), Mental Health Act (∼55%), Deprivation of Liberty Safeguards (∼54%), and end of life care (∼53%). We therefore propose a minimum curriculum for ethics and law training for FDs based on these topics, as well as cases brought by the FDs themselves.

Rethinking gamete donor care: A satisfaction survey of egg and sperm donors in the UK

OBJECTIVE

Despite poor clinic communication and staff treatment being reported by donors, high rates of overall satisfaction are still reported in surveys. This study will evaluate the importance of communication and interaction between donors and fertility clinic staff in gamete donor care.

METHODS

We report on 120 egg and sperm donors' responses to a UK-wide online satisfaction survey. The survey focused on donors' interactions with fertility clinic staff pre-, during, and post- donation. Basic cross-tabulation was performed on the data using online survey software. Textual data was read and extracts identified, which illustrated and expanded on the findings from the numerical data. Diagrammatic modeling was also utilised to analyse the textual data, with particular focus to relationships between the donors and clinic staff, the main activities within the gamete donation process, and how these activities may affect donor satisfaction with the gamete donation process.

RESULTS

Donors expressed concern for the infertile couple and the resulting child; conveyed frustration at not receiving information on the expenses they could claim; felt lost in the system regarding the ease of making clinic appointments, and once made they were routinely not seen on time for these appointments. Donors also negatively commented on aftercare, the location and condition of the donation room, and information on contraception. In addition, Ovarian Hyperstimulation Syndrome was frequently reported, with these egg donors believing that clinic staff were not concerned with their physical or emotional well-being, but were instead disproportionately focused on extracting the eggs.

CONCLUSIONS

The multifaceted notion of donors highlights the complexity inherent to the gamete donation process, which comprises various aspects of uncertainty in the donation system, and ambiguity in the donation process. Categorising donors as Altruist, Customer, and Patient, conveys the particular importance of staff communication and treatment in donor care. These categories are not mutually exclusive however, in that an individual donor may experience more than one of these perspectives during the course of their gamete donation journey. Finally, there were a number of exemplar cases, where donors reported high satisfaction throughout, and these correlated with them being given a single point of contact at the clinic. Subject to resource constraints, we suggest that this practice should be implemented throughout clinics in the UK, so that donors have access to dedicated clinic staff who not only support them emotionally and physically throughout the gamete donation process, but also ensure that communication is open, clear, timely, and consistent.

An Alternative View of Self-Discharge Against Medical Advice: An Opportunity to Demonstrate Empathy, Empowerment, and Care

In this article, we present the experiences of discharging against medical advice from the perspectives of 17 hospital and community-based health care practitioners, and 16 patients, and relatives from a range of medical and surgical wards. Semistructured, in-depth interviews were conducted and thematically analyzed. We identified that practitioners, patients, and relatives frequently expressed empathy for each other during the interviews, and discharge against medical advice was presented as a way for patients to have control over their health. Contrary to predominantly negative framings that highlight increased mortality and morbidity, and portray people who discharge against medical advice as poor decision makers, we conclude discharge against medical advice can be framed positively. It can be an opportunity to empathize, empower, and care. We recommend that the vocabulary used in hospital discharge against medical advice policies and documents should be updated to reflect a culture of medicine that values patient autonomy, patient centeredness, and shared decision making.

Interprofessional spanning and building boundaries when supporting potential embryo donors to stem cell research

When patients undergo fertility treatment, it is likely that a surplus of embryos will be created. The existence of these surplus embryos creates responsibilities for the clinics where they are stored and for the people who own them. Since 2001, the owners of the surplus embryos in the UK have the option to donate them to be used in stem cell research (SCR). This development has generated a new population-potential embryo donors to SCR-who have unique support needs as they are neither fertility patients nor donors. However, little is known how lay and professional stakeholders associated with fertility treatment and SCR have conceptualised the support needs of potential embryo donors to SCR or have responded to the additional task once the option became available. In this article, we draw on Gieryn's concept of boundary-work to explore how the emergence of donating embryos to SCR has provided opportunities for embryologists, counsellors, and scientists to shift, adapt, or confirm their roles, knowledge base, and areas of expertise. We present a thematic analysis of 21 in-depth, semi-structured interviews conducted with UK lay and professional stakeholders associated with fertility treatment and SCR. We conclude with reflections on the implications this boundary-work has for those contemplating donating embryos to SCR and the care they receive when making their decision. Such insights are pertinent given the current policy and practice discussions led by the National Donation Strategy Group to improve the care of donors in the UK.

Giving to receive? The right to donate in umbilical cord blood banking for stem cell therapies

OBJECTIVES

To explore the views of lay and professional stakeholders about the donation of cord blood to public banks in England and the policies surrounding it.

METHODS

Qualitative in-depth interviews were undertaken between April 2009 and August 2010 with 62 participants based in England who play a key role in cord blood banking and therapy. All interviews were recorded, transcribed in full, and coded and analysed thematically.

RESULTS

Participants claimed pregnant women had a right to know of the value of cord blood. This highlighted the flaws of the existing donation infrastructure, which was portrayed as playing a significant role in determining public health. Participants called for a right to donate cord blood to readdress the inequity in healthcare services for pregnant women and transplant recipients. Donors maintained a sense of right over their donation when they discussed cord blood donation as potentially benefiting their family as well as society.

CONCLUSION

In order to keep receiving donated body parts, tissue and blood, there is a need to take into account the way in which donation operates within a prevalent 'rights' discourse.