Medical ethics curriculum for surgical residents: Results of a pilot project

doi:10.1016/S0039-6060(99)70125-X

Surgery

Volume 126, Issue 4, October 1999, Pages 701-707

Presented the the 56th Annual Meeting of the Central Surgical Association, St.Louis, Mo, Mar 4-6, 1999

https://doi.org/10.1016/S0039-6060(99)70125-X Get rights and content

Abstract

Introduction: This study sought to develop and evaluate a medical ethics curriculum designed specifically for surgical residents. Methods: The learning needs of surgical residents relevant to ethics were determined by using a structured literature review and synthesis strategy. We identified 5 primary areas of importance for ethics education for surgical residents: withdrawing and withholding treatment, advance directives, do-not-resuscitate orders, informed consent, and communicating bad news. Learning objectives were developed, and teaching plans were designed for four 90-minute interactive teaching episodes on the basis of adult learning principles. We surveyed residents using a published survey instrument modified for surgery to identify residents' beliefs about the usefulness of ethics training, confidence in addressing ethical issues, and factual knowledge of ethics questions. Results: Twenty surgical residents at a single institution completed the pretest and posttest close-ended surveys. Results showed that although 88% had formal ethics exposure in medical school, 93% considered ethics education at the resident level to be a “very important” or “important” topic. Residents' confidence in addressing ethical issues showed statistically significant improvement between pretest and posttest surveys for 13 of 23 items. There were no statistically significant linear relationships between postgraduate year of residency and the pretest confidence items or the number of correct responses on the pretest multiple-choice items. Conclusions: Despite the prevalence of ethics education during medical school, surgical residents welcome formal instruction on numerous ethical issues pertinent to surgical practice. A focused curriculum can be developed that has a measurable impact on residents' confidence in addressing ethical issues. (Surgery 1999;126:701-7.)

Section snippets

Methods

Twenty residents progressing through a university-based general surgery residency program participated in the study. A single group pretest and posttest research design was used to study the impact of the new ethics curriculum.

A systematic literature review was completed to determine curriculum content and identify published programs already developed and tested in undergraduate and graduate medical education. This was accomplished through MEDLINE using a search strategy on the following

Results

Twenty residents completed the pretest and posttest closed-form surveys. Seventy percent (n = 14) were men, and 30% (n = 6) were women. Respondents varied by PGY with ten PGY-1 residents, three PGY-2 residents, one PGY-3 resident, three PGY-4 residents, and three PGY-5 residents. Their average age was 28 years (SD = 2.9). Eighty-eight percent reported having had formal teaching on ethics in medical school. On a scale of 1 (poor) to 5 (very good), those residents who had ethics education rated

Discussion

These results suggest that residents perceive a need for formal ethics education within surgical residency programs. Even though 88% of surgical residents had previous exposure to formal medical ethics within medical school, 93% continue to believe that an ethics curriculum is an important part of their education during residency. Program directors should not assume that the need for a formal medical ethics curriculum has been negated by an undergraduate medical education experience in medical

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Cited by (44)

Shedding Light on the Hidden Curriculum: A Systematic Review of Ethics Education during General Surgery and Subspecialty Training
2023, Journal of Surgical Education
Ethics education in surgical residencies is often delivered in an informal and nonstructured manner as part of a “hidden curriculum”, leading to few residencies routinely including it in their core curriculum. This systematic review aimed to summarize the delivery modes, curriculum, structure, and effectiveness of ethics educational interventions for surgical trainees.
We performed a comprehensive database search including MEDLINE, Embase, Scopus and CENTRAL to search for articles describing the implementation of ethics educational interventions for general surgery or subspecialty trainees.
A total of 14 studies were included. Only 2 centers performed targeted needs assessment. Curricula covered included informed consent, the doctor-patient relationship, breaking bad news, decision-making, end-of-life care, conflicts of interest, considering patients’ personal contexts, and surgical research ethics. Modes of delivery varied across studies, including case-based learning, group discussions, didactic lectures, reading material, role-playing, simulated patients, and ethics morbidity and mortality (M&M) meetings.
Evaluations were most commonly via surveys exploring knowledge and self-reported confidence, with only 3 studies measuring actual trainee performance using objective structured clinical examinations. In general, the educational interventions increased trainees’ confidence/preparedness in handling ethical dilemmas.
We recommend comprehensive local needs assessment to guide curricular development and designing specific learning objectives and measurable milestones to ensure evaluation. Educational interventions are best delivered in a graduated manner with the complexity of the topic mirroring residents’ real-life clinical responsibilities and experiences. Teaching modalities should be tailored according to the nature of the curricular content being taught to make the learning experience more interactive and effective.
Assessing residents in surgical ethics: We do it a lot; We only know a little
2011, Journal of Surgical Research
Citation Excerpt :
Perhaps, in recognition of this situation, our residents overwhelmingly supported this initiative with over half believing it should be part of our residents’ formal curriculum. Others have investigated the perspective of surgical residents on the less traditional parts of their training and found similar interest [6, 7]. This means that residents have little undergraduate exposure to ethics, mostly gaining their understanding from medical school curriculums, which vary between institutions, that they frequently encounter these six ethical scenarios in which they have at least moderate confidence in their skills but their understanding of these topics is poor.
PGY-1 year of surgical residency brings together many persons of disparate experiences and educational backgrounds, including their exposure to ethics. We hypothesized that surgical PGY-1s would have a similar exposure to ethical scenarios but lack the confidence in practice and understanding of ethical principles compared with more senior residents.
Surgical residents were invited to resident-initiated surgical ethics workshops utilizing a standardized text. Here a survey and multiple choice tests were administered to participants. The survey determined prior exposure to ethics curricula, the frequency of exposure to various ethics topics, and their comfort with these scenarios. A multiple choice test then quantified the knowledge base of participating residents. The results were collected and compared between surgical PGY-1s and more senior residents.
Eighteen PGY-1s and 12 senior residents completed this curriculum. Resident exposure to ethical concepts was common. Resident confidence in these topics was ranked moderate or higher for both groups. Despite frequent clinical exposure and strong confidence in their skills of addressing these topics, performance on the test was poor, with an average score of 59% for PGY-1s and 47% for more senior residents (P = 0.03).
Despite clinical exposure to and confidence in their management of ethical topics, their knowledge base was poor and worse for more senior residents. Given the overall interest in a formal ethics curriculum and the knowledge deficit demonstrated, educational intervention and professional ethics support should be provided for surgical residents even with the current educational time constraints.
Ethics education in surgical residency: Past, present, and future
2010, Surgery
Citation Excerpt :
The field of surgery is demanding both technically and intellectually, and the modern patient demands both technical proficiency as well as moral awareness from his or her surgeon.23-25 Ten years ago, surgery residents worldwide viewed formal ethics training as an important yet deficient component of their professional education.17,22,26-28 Despite previous exposure to ethics education in medical school,17,26 surgery residents viewed such nontraditional aspects of their training as vital, yet under-represented, in their education.26,29
Ethics Education in Surgical Residency Programs: A Review of the Literature
2009, Journal of Surgical Education
Citation Excerpt :
The authors correctly caution that their findings provide evidence only of changes in knowledge, and that we currently do not have evidence that changes in ethical knowledge lead to changes in behavior. Angelos et al16 conducted a similar study at Northwestern University in Chicago. The researchers surveyed the literature and recognized the following 5 primary areas of importance for surgical residency ethics education: withdrawing and withholding treatment, advance directives, do-not-resuscitate orders, informed consent, and the communication of bad news.
Although ethics education in undergraduate medical school curricula has become essentially universal, and because ethics and professionalism have become integral parts of competency-based curricula for residents in nearly all specialties of medicine and surgery, it is not clear to what extent postgraduate surgical training routinely includes ethics education or skills training. Most general surgery residencies do not routinely integrate in-depth ethics skills training and assessment into their didactic curricula. In this article, we review the literature concerning ethics education in postgraduate surgical training programs. The few studies in the literature suggest that ethics education, when integrated in surgical residency curricula, can lead to measurable improvements in resident-centered outcomes, which include knowledge and confidence in handling ethical dilemmas. These curricula may lead to improvements in patient care. These findings suggest that ethics education for surgical residents is valuable but that questions regarding the optimal “dose” of ethics education and training as well as the optimal teaching methods would benefit from extended systematic evaluation and inquiry.
What surgeons tell their patients about the intraoperative role of residents: a qualitative study
2008, American Journal of Surgery
The issue of residents operating and disclosure to patients about this have not been explored from staff surgeons' perspectives.
A preliminary survey was sent to all active surgeons at the University of Toronto. A qualitative interview study followed. Thirty-nine face-to-face interviews were conducted with surgeons. Interviews were transcribed and subjected to thematic analysis by 3 reviewers.
Four encompassing themes emerged: (1) surgeons are comfortable allowing residents to operate independently with graded responsibility, (2) surgeons do not voluntarily inform patients about the involvement of residents in their operation, (3) residents are seen as important assets in a teaching hospital and are beneficial to patient care, and (4) surgeons recognize the trust their patients place in them.
Surgeons recognize their patient care and teaching responsibilities and the trust that is placed in them. Patients might benefit from a discussion with their surgeon about the role of residents in their surgery.
Bioethics principles, informed consent, and ethical care for special populations: Curricular needs expressed by men and women physicians-in-training
2005, Psychosomatics
Citation Excerpt :
The high ratings on these items indicate strong support for our hypothesis. The global impression of perceived importance of, and increased need for, ethics preparation among early career physicians replicates findings of other studies.33,41–43,59,60 Traditional topics such as respect for human dignity and compassion for suffering were seen as important, as were several topics related to expanded professional duties in society including responsibility to community, nondiscrimination, justice, truth-telling and honesty, and respecting the law.
Physicians-in-training today are learning in an ethical environment that is unprecedented in its complexity. There is a call for new approaches in preparing medical students and residents for the ethical and professional issues they will encounter. The perspectives of physicians-in-training at different levels regarding the level of curricular attention needed for emerging bioethics concepts, practical informed consent considerations, and the care of special populations are unknown.
The authors performed a hypothesis-driven, confidential survey study to assess perceived needs and preferences among medical students and residents related to medical ethics education at the University of New Mexico School of Medicine.
A total of 336 physicians-in-training volunteered (62% response rate). Overall, strong interest was expressed for increased curricular attention to the domains of bioethics principles, informed consent, and care of special populations. Women students expressed greater interest generally. For certain domains, clinical students expressed relatively less curricular need and psychiatry and primary care residents expressed relatively greater curricular need. Two of the four hypotheses were supported, a third received partial support, and a fourth was not supported by the findings.
To be valuable and effective, new ethics curricular approaches must be responsive to the current complex ethical environment and attentive to the preferences of medical students and residents of both genders, at different stages of training, with different patient care responsibilities. This hypothesis-driven study provides guidance for the inclusion of novel and important ethics domains in training curricula across medical school and diverse residency programs.

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^☆: Supported by a grant from the Central Surgical Association Foundation.

^☆☆: Reprint requests: Peter Angelos, MD, PhD, Department of Surgery, Northwestern University, 300 E. Superior Street, Tarry 11-703, Chicago, IL 60611.

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Central Surgical AssociationMedical ethics curriculum for surgical residents: Results of a pilot project☆,☆☆

Abstract

Section snippets

Methods

Results

Discussion

Clin Geriatric Med

Am J Surg

Principle of biomedical ethics

Central Surgical Association
Medical ethics curriculum for surgical residents: Results of a pilot project☆,☆☆