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Pediatric Bioethics

March 2019

Ethics Education During Residency

Author: Claire Seguin, MD | Resident, Children's Mercy

Column editor: John D. Lantos, MD | Director of Pediatric Bioethics | Professor of Pediatrics, UMKC School of Medicine

Ethics education for pediatric residents is essential in their development as pediatricians. Though medical school curricula have well-defined requirements for ethics education, there are only brief statements from the ACGME and ABP pertaining to the expected ethics knowledge of residency graduates. Unsurprisingly then, there is little reported in the literature about this piece of the pediatrician’s education. Many studies show the formation of physicians during residency has a lasting impact on how they practice independently. It is likely that this also pertains to their application of ethics in practice. Therefore, residency may well be the ideal time for ethics education for pediatricians, yet more explicit attention to ethics principles during residency is needed. 

While ethics education during residency has generally increased since the ABP first included it on board exams in 1987, the quality and depth of that education varies. Two studies recently found that a minority of pediatric residents did, or hypothetically would, disclose a medical mistake to families (36 and 40%).1,2 The majority of residents in these studies reported a lack of teaching about error disclosure. One study found a ≥ 20% disparity between recent grads having encountered an ethical problem and having had applicable education in 15 of the 35 proposed situations. The situations were as integral to practice as health care disparities, ethics of genetic testing, provision of care to colleagues’ families and admitting mistakes. This dearth of preparation is recognized by physicians; a surprising number of whom (64%) rated their ethics preparation as inadequate.

It is evident that ethics education for pediatric residents is important, yet lacking. No single method of teaching ethics, however, has been found to be superior. Reports from other residencies (e.g., Neurology) show that formal didactic and case-based education increases knowledge of ethics, but does not increase resident comfort in cases they are involved in.3 Surveys reveal that residents reporting the highest quality of ethics teaching received it in informal discussions with specialty fellows and attendings.4 Without comparative measures of different ethics curricula success, a surrogate such as the confidence current pediatricians have in their past training must be used. Hence, medical ethics education during residency should likely include both formal didactic teaching and informal, but explicit, discussion.

Teaching faculty should strive to integrate discussions of ethics into everyday teaching, not in general terms, but with the specific language of ethical principles, values, virtues and narrative means. One framework used by Jonsen, Siegler and Winslade in their handbook Clinical Ethics (now in its 8th edition) for faculty to consider is the Four Topics framework: given a specific case, what are the medical indications, patient preferences, quality of life and contextual features at play?5  Other frameworks may apply better to certain circumstances. As with clinical medicine where clinicians are given the conceptual framework and learn how to apply it in a few situations, with continued use they can become more adept at using these ethical precepts in other cases.   

So which topics in ethics should be taught to general pediatric residents? Clearly those such as decision-making capacity, admitting mistakes, and matters of confidentiality and privacy, which are routinely encountered, should receive significant attention. One might ask whether it is important for the community pediatrician to be able to manage ethical concerns that typically arise in tertiary care. For three reasons, tertiary care ethical issues can provide good education to all pediatric residents. First, if well-taught, the components of consideration in a tertiary care ethics case can have parallels in more common situations. The correct thought processes have translational value. Second, just as we do not omit teaching a safe knowledge of rare medical conditions to all pediatricians because first-line recognition is essential, the recognition of serious lines of ethical concern should be identifiable by all pediatricians. Finally, patients who are involved in complex ethics challenges frequently interact with the health care system at many points, and it is important for trust and cohesive care plans that the ethics behind care decisions are understood by all clinicians.  Explicit and thoughtful ethics education in pediatric residency is needed to produce pediatricians who are able to apply cohesive principles in diverse areas of practice to the benefit of families and patients.

 

References

1. Pediatricians’ Reports of Their Education in Ethics. Kesselheim J, Johnson J, Joffe S.   Arch Pediatr Adol Med. 2008; 162(4):368-373. doi:10.1001/archpedi.162.4.368  

2. Young Physicians’ Recall about Pediatric Training in Ethics and Professionalism and Its Practical Utility. Cook A, Ross L.   J Pediatrics. 2013; 163(4):1196-1201. doi:10.1016/j.jpeds.2013.04.006  

3. Education Research: A Case-Based Bioethics Curriculum for Neurology Residents. Tolchin B, Willey JZ, Prager K.  Neurology. 2015; 84(13):e91-e93. doi:10.1212/wnl.0000000000001412

4. Ethics Education for Pediatric Residents: A Review of the Literature. Deonandan R, Khan H. Can Medical Educ J. 2015; 6(1):e61-7.  

5. The “Four Quadrants” Approach to Clinical Ethics Case Analysis; An Application and Review. Sokol D.  J Med Ethics. 2008; 34(7):513-516. doi:10.1136/jme.2007.021212