Margaret M. Gaffney

Medical ethics education: where are we? Where should we be going? A review.

Purpose The authors’ primary goal was to provide a comprehensive and current review of the literature surrounding ethics education for medical students. Following this review, the authors summarize the deficits in the current literature and provide recommendations for future inquiries on medical ethics education. Method In 2004, the authors searched MEDLINE and PubMed using the following search terms: ethics, ethics education, medical ethics education, curriculum, undergraduate medical education, virtue, role model, philosophy of medicine, and outcomes research. No limit was placed on dates for this literature search. Articles whose primary focus was professionalism were excluded because the professionalism literature tends to focus on competencies and postgraduate education, whereas the primary focus of this study was on undergraduate education. Literature on physicians as role models to medical students as a form of teaching medical ethical ethics was excluded as well because the current discussion examines the formal undergraduate medical ethics curricula. Also excluded were reports from foreign countries (unless there were no equivalent studies in the United States). The authors found almost no literature exploring students’ backgrounds (cultural, religious, socioeconomic, etc.) and the teaching of medical ethics in medical schools. Otherwise, the authors reviewed everything they could find, regardless of imperfections in individual reports such as small sample size or poor research methodology. Results The review, which encompassed articles from 1978 to 2004, revealed that deep shortcomings exist in the literature on medical ethics education. Deficits exist in all areas of the literature: (1) theoretical work done on the overall goals of medical ethics education; (2) empirical studies that attempt to examine outcomes for students; (3) studies examining teaching methods in medical ethics education, and (4) studies evaluating the effectiveness of various teaching methods. Conclusions There are substantial opportunities for contribution to the literature on medical ethics education in all of the areas where deficits exist. The literature suggests that two points of view exist regarding the purpose of teaching medical ethics: (1) that it is a means of creating virtuous physicians; and (2) that it is a means of providing physicians with a skill set for analyzing and resolving ethical dilemmas. This dichotomy made it difficult to arrive at a consensus regarding the goals of medical ethics education. The field would benefit from further theoretical work aimed at better delineating the core content, core processes, and core skills relevant to the ethical practice of medicine. The time has come to organize an effort to improve and validate medical ethics education. In the end, effective medical ethics education will further the goals of medicine in dramatic and tangible ways.

Developing an OSTE to address lapses in learners' professional behavior and an instrument to code educators' responses

Purpose. To develop an instrument for measuring medical educators’ responses to learners’ lapses in professional behavior. Method. In 1999, at the Indiana University School of Medicine, a 22-item checklist of behaviors was developed to describe common responses used by educators responding to learners’ lapses in professional behavior. Four medical students were trained to portray lapses in professional behaviors. These students and seven clinical observers trained to categorize behaviors as present or absent. Interrater reliability was assessed during 18 objective structured teaching evaluations (OSTEs). Videotaped OSTEs were coded twice at a one-month interval for test–retest reliability. Items were classified as low, moderate, or high inference behaviors. Script realism and educator effectiveness were assessed. Results. Educators rated OSTE scripts as realistic. Raters observed an average of 6 ± 2 educator behaviors in reaction to learners’ lapses in professional behavior. Educators’ responses were rated as moderately effective. More experienced educators attempted more interventions and were more effective. Agreement was high among raters (86% ± 7%), while intraclass correlation coefficients decreased with increasing inference level. From videotaped OSTEs, raters scored each behavior identically 86% of the time. Conclusions. Accurate feedback on educators’ interactions in addressing learners’ professionalism is essential for faculty development. Traditionally, educators have felt that facultys responses to learners’ lapses in professional behavior were difficult to observe and categorize. These data suggest that educators’ responses to learners’ lapses in professional behavior can be defined and reliably coded. This work will help provide objective feedback to faculty when engaging learners about lapses in professional behavior.