This study affirms the value of ethics preparation in the eyes of medical students and residents, and it documents the perceived need for greater curricular attention to practical ethics and ethically important professional development topics during medical training. As hypothesized, preclinical students compared to clinical students and residents more strongly endorse the need for substantive ethics preparation related to these topics. Similarly, women of all levels of training report greater need for additional ethics training. In comparing trainees across specialty programs, psychiatry residents express greater need for training-related ethics topics than their primary care and other specialty colleagues, and this trend tends to hold for practice-and profession-related topics as well. Further study is needed to evaluate the meaning of these patterns and to determine whether they represent generalizable phenomena that reflect consistent differences among medical specialty groups.
The most important initial observation regarding these findings is that no topic is seen to merit less curricular attention, and this is true for men and women respondents, for individuals at all levels of training, and for residents in diverse clinical disciplines. On one hand, this may signal, quite simply, inadequate ethics curricula for physicians-in-training at all phases at our survey institution; on the other hand, it appears likely that trainees continue to perceive significant ethics preparation needs as they progress through their medical education. To highlight one topic in particular, the interest from all levels of trainees in dealing with medical mistakes is heartening as medicine as a profession is attempting to move from a culture of blame to a human endeavor requiring diligence and protections to safeguard vulnerable individuals from harm.
In sum, students’ and residents’ strong endorsement of the need for more ethics instruction on almost every subject and the preference for a practical rather than theoretical approach may reflect their sense of the power and pervasiveness of the hidden curriculum and a wish to have the skills to manage the moral pressures inherent in professionalization in medicine (27
Second, as with previous studies (28
), women perceive greater curricular needs than did men respondents, and this gender difference was consistent across training-related ethics and practice- and profession-related domains, Despite this moderate size main effect of gender, the only individual item to which women and men responded significantly differently, however, was the need for additional training related to gender bias inpatient care. The reasons behind this result are unclear. Are women physicians-in-training more sensitive to gender bias in the environment? Have they personally experienced disparate care (29
)? Because women represent 48% of all medical school applicants, 44% of all graduating medical students, and as many as 74% of residents in certain specialty areas, it will be important to determine the pattern of and reasons for differential views of women and men physicians-in-training related to ethics (30
Third, as medical students and residents progress through training, they are continually confronted by a variety of ethical challenges. How one learns to identity and address these dilemmas is an important educational milestone in becoming a competent ethical physician. An educator’s ability to identify what knowledge students, in various stages of development, find valuable is a significant motivational tool for the teacher. By attempting to address the student’s educational requests, as part of a complete curriculum, the role of teacher and student may be more valuable for all involved. This survey study attempts to identify those key issues.
In this study, interesting findings related to level of training and perceived ethics curricular needs were found. As expected, preclinical medical students identified greater need for additional curricular attention to ethics topics overall or, stated more negatively, they perceived greater deficiencies in the existing curriculum. This result may represent professional anxiety as preclinical medical students begin to speculate about what ethical problems they may face in their future professional career as physicians. It may also represent the fact that they have not yet been exposed to enough teaching surrounding the topics specifically emphasized in the survey. The highly significant training group by item interaction effect we detected suggests that training groups have a complex pattern of differential needs across the specific practices and behaviors.
In any case, for residents and clinical medical students, the overall gap between what is needed and what exists is less than for the preclinical medical students. These findings may be the expression of increasing clinical exposure and responsibilities, knowledge base, and societal expectations related to their professional identities. It is interesting that our findings on level of training did not represent a simple progression. In other words, clinical medical students were not intermediate between preclinical students and residents in their responses, but rather appeared to resemble one or the other group depending on the ethics topic domain. To better understand this pattern of findings regarding level of training, it will be essential to perform other cross-sectional and longitudinal studies in other settings, ideally including both quantitative and qualitative assessments.
Fourth, residents in different fields encounter different kinds of ethical dilemmas and may experience different needs for ethics preparation (31
). In addition, differential emphasis is placed on ethics across diverse disciplines, although recent ACGME requirements have highly rated the importance of professionalism as a core competency for all physicians (32
). In this preliminary study, psychiatry residents express strong needs for enhanced preparation pertaining to training-related ethics topics. The specific topics that they were most interested in were natural extensions of psychiatrists’ everyday work—resolving interpersonal conflict, defining boundaries for scope of practice, and establishing an appropriate therapeutic-relationship framework. The different curricular needs of residents in diverse specialties continues to be an interesting area for study.
The strengths of this study are its focus on salient practical ethics and ethically important professional development issues. Its cross-sectional design permitted hypothesis-driven analyses to compare perspectives of preclinical and clinical physicians-in-training and of residents in diverse training programs. It is important to note that the perspectives of learners cannot and should not be the sole guide to curricular content; nevertheless, it is clear that for teaching to be effective, it must be meaningful—relevant, salient, useful, and connected to the ecological experience of learners. For these reasons, we suggest that the approach of this survey has value in informing curricular design.
Nevertheless, this survey study has several limitations. It relies on self-report, and it involved a sample at a single institution. The response rate of 62% was high, but does not prevent sampling bias. In addition, the number of residents in the study did not provide sufficient power to permit additional more detailed analyses. For example, it appears that psychiatry residents see the greatest need for additional ethics education in relation to several specific topics and, possibly, overall, in comparison with their colleagues in other training areas. Whether this is an index of a higher ethical sensitivity, of greater perceived ethical complexity in mental health work, of lesser prominence of psychiatric ethics in training, or other explanations is unknown but worthy of further investigation. For these reasons, we suggest that this initial project should serve as a springboard for future studies involving multiple centers and quantitative and qualitative elements with additional assessments and methodologies. Parallel work inquiring about the curricular content recommendations and about the professional development needs of academic faculty entrusted with implementing ethics and professionalism preparation would be especially worthwhile. Such efforts are essential as we seek to develop ethics preparation that is both attuned to the needs of learners and the experiences and hard-earned wisdom of their more senior faculty colleagues.