Accelerating Change in Medical Education

3 big ethical issues medical school doesn’t prepare you for

There is plenty of research and discussion dedicated to what medical students should be taught when it comes to being prepared to handle medical ethics issues.

Conflicts of interest, social media use, concerns about colleagues’ competence, and accepting gifts from patients are among the areas named as ethical situations that medical students need to learn how to handle. These were highlighted in “The Essential Role of Medical Ethics Education in Achieving Professionalism: The Romanell Report,” published in Academic Medicine in June 2015.

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But what about situations that arise that may not get tackled—or covered in a practical way—while earning your MD or DO? Here are three ethical situations that young doctors often don’t feel fully prepared to handle.

When to end a code

In medical school, students discuss the level of intervention a patient may want when his or her heart stops beating or if they stop breathing. End-of-life goals also are thoroughly discussed. But talking about the situation and being the one to make the call to end a code knowing the decision will end someone’s life are very different, residents say.

“There is a lot of emotional distress during a code when you are deciding when to terminate it, and I believe medical school doesn’t prepare us for that aspect of it,” said emergency medicine resident Kimberly A. Chernoby, MD, the resident/fellow member to the AMA Council on Ethical and Judicial Affairs. “The most important thing is getting medical students to think critically in real time so they can make quick decisions.”

Speaking up when something isn’t right

A student followed a supervisor’s request to obtain a blood culture from a patient and to tell anyone who asked that he was experienced and had performed many, even though it was his first time.

Another medical student witnessed an elderly surgeon with a tremor accidently nick a patient’s uterus while performing surgery and cause some bleeding, but the student did not say anything. And when confronted, the student told his resident that he didn’t know anything about the incident.

These are two ethical instances a study highlighted as examples of how students reacted in ethical situations they faced. The study—“Ethical Dilemmas in Clerkship Rotations,” published in the November 2013 Academic Medicine—looked at about 500 reports from students over a four-year period and found that the classroom and didactic teaching was not enough, and that fear of reprisal was often the reason for not speaking out. The authors called for a major culture change in medical education.

Schools in the AMA Accelerating Change in Medical Education Consortium are tackling this issue as one element of training in health systems science and patient safety. For example, faculty at Vanderbilt University School of Medicine have studied the moral distress associated with hierarchical situations in the clinical learning environment and have instituted explicit training sessions to help students address the authority gradient. And second-year Vanderbilt students rotating through clinical clerkships meet in small groups with faculty mentors to review common challenging situations and discuss language that could be used to safely speak up in the moment.

Harassment, hateful comments

More than 30 percent of medical students reported personally experiencing sexist, racist or other offensive comments, lower grades or denial of training or awards based on sex, gender identity, sexual orientation, race or ethnicity, according to the 2017 Association of American Medical Colleges graduate questionnaire. Four percent of students reported experiencing unwanted sexual advances.

“Medical schools must equip learners, faculty and staff to prevent or escape abuse, not only to protect themselves but also to intervene if they observe a colleague being targeted,” wrote Karen Antman, MD, dean of the Boston University School of Medicine, in a May 1 JAMA Viewpoint essay.

Even physicians with years of experience still struggle to handle sexual harassment, fearing retribution for reporting behavior. A 2016 research letter in JAMA  found that among clinician-researchers, 30 percent of women reported having experienced sexual harassment.

The #MeToo movement has brought sexual harassment to the forefront and discussions on how to change the culture are more frequently taking place, including a recent panel discussion in the AMA’s Accelerating Change in Medical Education Community.