John Goldie

Review of ethics curricula in undergraduate medical education

Medical ethics education, it has been said, has ‘come of age’ in recent years in terms of its formal inclusion in undergraduate medical curricula. This review article examines the background to its inclusion in undergraduate curricula and goes on to examine the consensus that has arisen on the design of ethics curricula, using Harden’s curriculum and S.P.I.C.E.S models as templates. While there is consensus on content for undergraduate medical ethics education, there is still significant debate on learning and teaching methods. Despite the broad agreement on the need to apply adult education principles to ethics teaching, there would appear to be some tension between balancing the need for experiential learning and achieving the ‘core curriculum’. There are also as yet unresolved difficulties with regards to resources for delivery, academic expertise, curriculum integration and consolidation of learning. Assessment methods also remain contentious. Although there is consensus that the ultimate goal of medical ethics, and indeed of medical education as a whole, is to create ‘good doctors’, the influence of the ‘hidden curriculum’ on students’ development is only beginning to be recognized, and strategies to counteract its effects are in their infancy. The need for proper evaluation studies is recognized. It is suggested that the areas of debate appearing in the literature could be used as a starting point for evaluation studies, which would form the empirical basis of future curriculum development.

The formation of professional identity in medical students: Considerations for educators

Context: Medical education is about more than acquiring an appropriate level of knowledge and developing relevant skills. To practice medicine students need to develop a professional identity – ways of being and relating in professional contexts. Objectives: This article conceptualises the processes underlying the formation and maintenance of medical students’ professional identity drawing on concepts from social psychology. Implications: A multi-dimensional model of identity and identity formation, along with the concepts of identity capital and multiple identities, are presented. The implications for educators are discussed. Conclusions: Identity formation is mainly social and relational in nature. Educators, and the wider medical society, need to utilise and maximise the opportunities that exist in the various relational settings students experience. Education in its broadest sense is about the transformation of the self into new ways of thinking and relating. Helping students form, and successfully integrate their professional selves into their multiple identities, is a fundamental of medical education.

Teaching professionalism in the early years of a medical curriculum: a qualitative study

Context  Despite the growing literature on professionalism in undergraduate medical curricula, few studies have examined its delivery.

Impact of a new course on students' potential behaviour on encountering ethical dilemmas

To evaluate the effectiveness of small‐group ethics teaching in an integrated medical curriculum.

AMEE Education Guide no. 29: Evaluating educational programmes

Evaluation has become an applied science in its own right in the last 40 years. This guide reviews the history of programme evaluation through its initial concern with methodology, giving way to concern with the context of evaluation practice and into the challenge of fitting evaluation results into highly politicized and decentralized systems. It provides a framework for potential evaluators considering undertaking evaluation. The role of the evaluator; the ethics of evaluation; choosing the questions to be asked; evaluation design, including the dimensions of evaluation and the range of evaluation approaches available to guide evaluators; interpreting and disseminating the findings; and influencing decision making are covered.

A process evaluation of medical ethics education in the first year of a new medical curriculum.

Despite the recent increase in activity in the field of medical ethics education, few evaluative studies have been carried out. Most studies have taken place in North America, in curricula where teaching is discipline‐based, and have concentrated on outcome rather than on the curricular processes adopted.

Assessment of professionalism: A consolidation of current thinking

Context: Professionalism has become a hot topic in medical education. Professionalism needs to be assessed if it is to be viewed as both positive and relevant. Objectives: The assessment of professionalism is an evolving field. This review aims to consolidate current thinking. Implications: Assessment of professionalism has progressed from an initial focus on the development and attainment of professional identity, through identifying areas of deficiency, to the attainment of a set of identifiable positive attributes and behaviours. It is now beginning to recognise the challenge of assessing a multi-dimensional construct, looking beyond the measurement of behaviour to embrace a diversity of approaches. Conclusions: Professionalism should be assessed longitudinally. It requires combinations of different approaches, assessing professionalism at individual, interpersonal and societal/institutional levels. Increasing the depth and the quality of reliability and validity of existing programmes in various contexts may be more appropriate than concentrating on developing new instruments. Increasing the number of tests and the number of relevant contexts will increase the reliability of the result. Similarly increasing the number of observers increases reliability. Feedback, encouraging reflection, can promote change in behaviour and identity formation.

Can students’ reasons for choosing set answers to ethical vignettes be reliably rated? Development and testing of a method

Although ethics is an important part of modern curricula, measures of students’ ethical disposition have not been easy to develop. A potential method is to assess students’ written justifications for selecting one option from a preset range of answers to vignettes and compare these justifications with predetermined ‘expert’ consensus. We describe the development of and reliability estimation for such a method – the Ethics in Health Care Instrument (EHCI). Seven raters classified the responses of ten subjects to nine vignettes, on two occasions. The first stage of analysis involved raters’ judging how consistent with consensus were subjects’ justifications using generalizability theory, and then rating consensus responses on the action justification and values recognition hierarchies. The inter-rater reliability was 0.39 for the initial rating. Differential performance on questions was identified as the largest source of variance. Hence reliability was investigated also for students’ total scores over the nine consensus vignettes. Rater effects were the largest source of variance identified. Examination of rater performance showed lack of rater consistency. D-studies were performed which showed acceptable reliability could nevertheless be obtained using four raters per EHCI. This study suggests that the EHCI has potential as an assessment instrument although further testing is required of all components of the methodology.

Whose information is it anyway? Informing a 12-year-old patient of her terminal prognosis

Objective: To examine students’ attitudes and potential behaviour towards informing a 12-year-old patient of her terminal prognosis in a situation in which her parents do not wish her to be told, as they pass through a modern medical curriculum. Design: A cohort study of students entering Glasgow University’s new medical curriculum in October 1996. Methods: Students’ responses obtained before year 1 and at the end of years 1, 3, and 5 to the “childhood leukaemia” vignette of the Ethics in Health Care Survey Instrument (EHCI) were examined quantitatively and qualitatively. Analysis of the students’ multichoice answers enabled measurement of the movement towards professional consensus opinion. An analysis of their written justifications for their answers helped to determine whether their reasoning was consistent with professional consensus and enabled measurement of changes in knowledge content and recognition of the values inherent in the vignette. Themes on the students’ reasoning behind their decision to tell the patient or not were also identified. Results: Unlike other vignettes of the EHCI in which autonomy was a main theme, few students chose the consensus answer before year 1 and there was no significant movement towards consensus at any point during the course. In defence of their decision to withhold information, the students expressed strong paternalistic opinions. The patient’s age was seen as a barrier to respecting her autonomy. Conclusions: It is important to identify students’ perceptions on entry to medical school. Transformative learning theory may provide the basis for an approach to foster doctors who consider the rights of young people. Small-group teaching is most conducive to this approach. The importance of positive role modelling is also emphasised.

Students’ attitudes and potential behaviour to a competent patient’s request for withdrawal of treatment as they pass through a modern medical curriculum

Objective: To examine students’ attitudes and potential behaviour to a competent patient’s request for withdrawal of treatment as they pass through a modern medical curriculum. Design: Cohort design. Setting: University of Glasgow Medical School, United Kingdom. Subjects: A cohort of students entering Glasgow University’s new learner centred, integrated medical curriculum in October 1996. Methods: Students’ responses before and after year 1, after year 3, and after year 5 to the assisted suicide vignette of the Ethics in Health Care Survey instrument, were examined quantitatively and qualitatively. Analysis of students’ multichoice answers enabled measurement of the movement towards professional consensus opinion. Analysis of written justifications helped determine whether their reasoning was consistent with professional consensus and enabled measurement of change in knowledge content and recognition of the values inherent in the vignette. Themes on students’ reasoning behind their decision to withdraw treatment or not were also identified. Results: Students’ answers were found to be consistent with professional consensus opinion precurriculum and remained so throughout the curriculum. There was an improvement in the knowledge content of the written responses following the first year of the curriculum, which was sustained postcurriculum. However, students were found to analyse the section mainly in terms of autonomy, with few responses considering the other main ethical principles or the wider ethical perspective. Students were unclear on their legal responsibilities. Conclusions: Students should be encouraged to consider all relevant ethical principles and the wider ethical perspective when deliberating ethical dilemmas. Students should have a clear understanding of their legal responsibilities.