Medical students’ understandings of professionalism in response to ethical dilemmas

Presented at AMEE 2013

Dr Rosie Belcher, UCL Medical School

With thanks to

the students for their thoughtfulness and candour

my supervisor, Dr Catherine O’Keeffe

Background

• Medical students frequently encounter ethical dilemmas during their training1-3

• These ethical dilemmas typically involve conflicts between different elements or understandings of professionalism4

• Learning to deal with ethical dilemmas appropriately is an important part of becoming a doctor

Methods

• 14 semi structured interviews• Interpretative Phenomenological Analysis5,6

• Pierre Bourdieu7

Please tell me about any ethical

dilemmas you have

experienced at medical school

Mismatch between medical school teaching

and medical culture

Difficulties due to status as a student, and inability to undertake

certain tasks

Witnessing poor care, poor communication

or unethical behaviour by

others

Difficulties of balancing

student’s need to learn with

patient’s need for care

Please tell me about any ethical

dilemmas you have

experienced at medical school

Mismatch between medical school teaching

and medical culture

Difficulties due to status as a student, and inability to undertake

certain tasks

Witnessing poor care, poor communication

or unethical behaviour by

others

Difficulties of balancing

student’s need to learn with

patient’s need for care

I know things… aren’t in keeping with how we’re taught to do things… there’s a difference between what you’re taught and what happens in reality

Please tell me about any ethical

dilemmas you have

experienced at medical school

Mismatch between medical school teaching

and medical culture

Difficulties due to status as a student, and inability to undertake

certain tasks

Witnessing poor care, poor communication

or unethical behaviour by

others

Difficulties of balancing

student’s need to learn with

patient’s need for care

You see things that you know aren’t right by established doctors, or when you worry that their practice is perhaps not as good as it could be, and you don’t feel you’re in a position to do anything about that

Witnessing poor communication with patients, but not feeling you're in a position to say or do anything

Please tell me about any ethical

dilemmas you have

experienced at medical school

Mismatch between medical school teaching

and medical culture

Difficulties due to status as a student, and inability to undertake

certain tasks

Witnessing poor care, poor communication

or unethical behaviour by

others

Difficulties of balancing

student’s need to learn with

patient’s need for care

Your need to become competent and to perform, versus the need to be respectful to patients and also maintain their safety, I think… it’s a difficult trade off

Responses to ethical dilemmas

Immediate• Comply or do nothing• Remove themselves from

the situation• Question or confront

– Both directly and subtly

Later • Discussion with others• Reflection, application to

their future self• Take action to prevent a

similar situation for others

Just a Student

Student Professionalism

Just a Student

Student Professionalism

Students lack knowledge and experience

I do not know whether [students] would… know what is normal and abnormal

We trusted the consultant, he seemed really good. Which is the majority of the time, us trusting the consultant, trusting our seniors.

Students lack knowledge and experience

Students are disregarded and powerless

As a medical student… I’m a nobody… nobody knows who we are, we don’t have names. We are just a medical student.”

Just a Student

Student Professionalism

I feel like we are on the edge looking in, most of the time

I do know that… I’m at the bottom of the pecking order

Students lack knowledge and experience

Students are disregarded and powerless

Students should therefore be cautious about passing judgment on others

Students are powerless to act

Just a Student

Student Professionalism

Just a Student

Student Professionalism

Students are becoming part of the profession

As you go through the clinical course you realize that there isn’t going to be this point where you are no longer a medical student, you are a doctor… the change is a lot more gradual than that

Patients do see you as a member of the team, they do look up to you as sort of [a doctor]; sometimes you say, “I’m a medical student.” but they’re like, “Oh thank you doctor” at the end.

Just a Student

Student Professionalism

Students are becoming part of the profession

Students should have the same standards of behaviour as doctors

We are integrating in to that profession even though we haven’t actually qualified yet, we are doing all the same things, and we have to go by all the same ethical guidelines

Just a Student

Student Professionalism

Students are becoming part of the profession

Students should have the same standards of behaviour as doctors

Students should manage ethical dilemmas, and unethical behaviour by others in the same way as doctors

• Often in conflict:– Student Professionalism would encourage students to take action– Being Just a Student would discourage them from action– Dilemmas often involved finding a resolution between the two

Just a Studen

t

Student

Professionali

sm

Combining the dispositions

• Often in conflict:– Student Professionalism would encourage students to take action– Being Just a Student would discourage them from action– Dilemmas often involved finding a resolution between the two

• Sometimes in concert– Students perceived deference to seniors as part of Student

Professionalism

Just a Studen

t

Student

Professionali

sm

Combining the dispositions

I didn’t, and I shouldn’t have [taken a particular action]. I was right not to, because it wouldn’t have been my place to undermine any member of the clinical team

Our response

• Setting the ground rules– It’s OK to question

• Improving belonging• Challenging others and being open to challenge

I think it’s important to be able to say these things in a nice, non-criminalising way… it takes practice.

Take home message

• Ethical dilemmas for students are common• They stimulate reflection and discussion on professionalism• Students understandings of professionalism can inhibit

them from taking action• Educators can incorporate students personal ethical

dilemmas into the curriculum – to assist students in forming their own understandings of

professionalism– To assist students in responding appropriately

References

1. Christakis, D.A. & Feudtner, C., 1993, Ethics in a short white coat: the ethical dilemmas that medical students confront, Academic medicine, 68(4), pp. 249-54.

2. Feudtner, C., Christakis, D.A. & Christakis, N.A., 1994, Do clinical clerks suffer ethical erosion? Students' perceptions of their ethical environment and personal development, Academic medicine, 69(8), pp. 670-9.

3. Monrouxe, L.V. & Rees, C.E., 2012, "It's just a clash of cultures": emotional talk within medical students' narratives of professionalism dilemmas, Advances in health sciences education: theory and practice, 17, pp. 671-701.

4. Ginsburg, S et al, 2000, Context, conflict, and resolution: a new conceptual framework for evaluating professionalism, Academic medicine, 75(10 Suppl), pp. S6- S11.

5. Smith, J., 2003, Qualitative Psychology: A practical guide to research methods, Sage Publications, London.

6. Smith, J.A., 1996, Beyond the divide between cognition and discourse: using interpretative phenomenological analysis in health psychology, Psychology and Health, 11(2), pp. 261-71.

7. Bourdieu, P., 1977, Outline of a Theory of Practice, Cambridge University Press.