what makes for effective feedback.The definition the authors givecould be used as a starting pointfor future research. In addition thedefinition may have benefit inbeing used during training of thosewho need to give feedback.

1. Sender-Liberman A, Liberman M,

Steinert Y, McLeod P, Meterissian S.

Surgery residents and attending

surgeons have different perceptions

of feedback. Med Teach

2005;27(5):470–2.

2. Wikipedia contributors, ‘‘Operational

definition.‘‘Wikipedia, The Free Ency-

clopedia, http://en.wikipedia.org/

wiki/Operational_definition

(Accessed February 8 2008)

Challenging ethical practice-the undergraduate dilemmaGillian Jackson, Fourth Year Medical Student, Newcastle University Medical School,Newcastle upon Tyne, UK

Cordingley L, Hyde C, Peters S, Vernon B,

Bundy C. Undergraduate medical

students’ exposure to clinical ethics:

a challenge to the development of

professional behaviours? Med Educ 2007;

41: 1202–1209

This study was designed toinvestigate and explore the ethi-cal experiences and challengesfacing medical students in aclinical setting. It was proposedthat, due to increasing negativemedia coverage of medico-ethicalsituations facing doctors on aregular basis, there may be anundergraduate-based flaw in theteaching of ethics and its use in awider and more true to life con-text. Although there has recentlybeen increased attention paid tothe teaching of ethics withinundergraduate medical curricula,the improvements one would ex-pect to see once students reachtheir clinical years are not appar-ent. It is unknown why thisphenomenon known as ‘morallevelling’ occurs, particularly inmedical students as this observa-tion is a stark contrast whencompared to other professionaleducation systems such as teach-ing and law. Previous research hasshown that perceptions of what ismorally or ethically acceptable is

eroded throughout the under-graduate curriculum and thatmost students and young doctorsfail to report disagreements theymay have with a senior’s views orbehaviour when faced with anethically challenging situation.

Three medical schools in theUK participated in a cross-sectional survey which consistedof web and paper style question-naires containing closed ques-tions and free discussion boxes.Researchers qualitatively assessedstudents in the clinical years oftheir training for their experiencesof ethically challenging situa-tions, their confidence inaddressing them, and their per-ceived knowledge of core ethicaland legal terms, with a 30 per centresponse rate. All experienceswere with reference to the previ-ous week of clinical exposure.

The principle findings were:

1. Students’ perceived knowledgeof key ethical and legalprinciples was good, but incontrast they rated theirconfidence and ability tochallenge these in a real lifesituation as low.

2. Students’ perceptions of whatconstitutes an ethically

challenging situation edgedtowards tolerance, the closerthey came to graduation.

3. Student’s did not make use of,and were not aware of thesupport available to them.This highlighted the need forgreater exposure for thissupport network.

The gap between students’values and what they see inpractice was described as ‘disas-trous’. For the majority of studentsbeginning their clinical years, itwas found that very little wasknown or understood about theroles and behaviours expected ofthem and of the medical staff theywere being taught by. Moststudents who reported situationsin which a senior doctor wasinvolved in the ethical challengefailed to report these behaviours.The reasons were beyond the scopeof the research, but were hypoth-esised as being due to students’perceptions that failure to act oragree with actions taken by seniorstaff may be socially or profes-sionally hazardous, a cost to themwhich was far higher than con-ducting totally ethical practice.

The early years of clinicalexposure are the foundations forbecoming well rounded and

Most studentsand young

doctors fail toreport

disagreements

70 � Blackwell Publishing Ltd 2008. THE CLINICAL TEACHER 2008; 5: 68–72

capable doctors. They shouldprovide experiences and chal-lenges that will hopefully staywith students throughout their

careers. Although some reportedchallenging situations may appearto be detrimental to student’sconcepts of an ethical practice, it

is highlighted in the study thepotential these situations havefor providing valuable learningopportunities for all those in-volved.

Some of the feedback from thefree text boxes suggested thattheoretical teaching of the ethicaland legal issues in health care waswell delivered within the curricu-lum but that practical advice andknowledge about ‘what to do if…’was rarely covered and in verylittle depth. The study suggests aneed for providing students withthe opportunity to discuss andreflect upon critical incidents, notonly alone but with experts in thefield and credible role models, toprevent perpetuation of this ‘hid-den curriculum’. For students todevelop the ability to judge eth-ical principles, which they canrely on for guidance and tonegotiate decisions where pro-fessional colleagues disagree isproblematic at best, and nearimpossible without years ofexperience and a self-taughtcollection of ‘scripts’ of ways tobest tackle such issues. Despitethis, students are still likely tobenefit from curriculum reform toincorporate the teaching andanalysis of medical practices froman ethical and professional view-point, delivered by a combinationof specialised ethicists andpractising clinicians.

Fear and Discomfort inMedical SchoolDaniel Darbyshire, Fourth Year Medical Student, Newcastle University Medical School,Newcastle upon Tyne, UK

Roberts JH, Sanders T, Wass V. Students’

perceptions of race, ethnicity and

culture at two UK medical schools:

a qualitative study. Med Educ 2008; 42:

45–52

The importance of culturallyaware doctors has been emphas-ised worldwide by organisationssuch as the General Medical

Council in UK, the USDepartment of Health, HealthCanada and the Committee ofDeans of Australian Medical

Practical adviceand knowledgeabout ’what todo if... ’ wasrarely covered.

� Blackwell Publishing Ltd 2008. THE CLINICAL TEACHER 2008; 5: 68–72 71