Conflicting Curriculums: Ethics education for residents inconsistent across programs

So the program has a six-session course that aims to help cultivate the kind of leader the program’s professors hope comes out of Duke’s residency. The sessions focus on integrity, initiative, self-discipline, responsibility and accountability, and there’s an introductory session.

At Duke, producing the right kind of doctor out of residency starts with the admission process, said Liana Puscas, MD, Duke’s OHNS residency program director.

“What we’re looking for are applicants and faculty who already have these qualities, and we’re looking to develop them,” she said. “Our program is really switching over to a behavioral-based interview for our residency applicants because it’s based on the principle that the best predictor of future behavior is past behavior.”

But once in the program, residents are in a give and take with attending physicians and others about the ethical implications of situations that come up in the clinic, Dr. Lee said. Those “in the hallway” conversations are extremely important, he said.

“The resident says, ‘Why did you do this versus that, what were issues you were thinking about?’” he said. “Those kind of discussions are actually the most effective in teaching ethics.”

Missed Moments

But there is no “formal plan” for incorporating those discussions into the ethics training, they said.

One study, led by Joseph Carrese, MD, at Johns Hopkins University’s Berman Institute of Bioethics, found that opportunities for teaching “everyday ethics” were often missed. Situations included a resident performing a minor procedure without much previous experience, for example, or a patient needing to be screened for depression but not wanting to be (Med Educ. 2011;45(7):712-721).

In the study, investigators observed interactions at two clinics between residents and their preceptors, finding that ethical situations arose in 109 out of 135 cases over a two-week period. The preceptor explicitly pointed out the ethical content and taught about it in just 13 of those cases (12 percent). The investigators determined that although the content was implicitly identified in 44 cases (40 percent), the message may have been lost or misinterpreted in those cases.

“One of the best places to teach ethics is in real time with real patients as faculty preceptors and residents are standing shoulder to shoulder working with patients,” Dr. Carrese said. “There were clearly times when faculty did not explicitly identify an issue or teach about it when they were capable of doing it.” He said that in some cases the ethical issues may have been pointed out and discussed prior to the study period, but that he didn’t think that accounted for all of the missed opportunities.