Ethical and Professional Issues Encountered by Fourth-Year Medical Students during a Critical Care Clerkship before and during the COVID-19 Pandemic.

OBJECTIVES: The objective of this study was to describe ethical and professional issues encountered and the ethical and professional values cited by medical students during their critical care clerkship, with a comparison of issues encountered before and during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: In this single-center, retrospective mixed-methods study, two investigators at a midwestern US academic medical center performed qualitative content analysis on reflections written by fourth-year medical students about ethical and professional issues encountered during their critical care rotations between March 2016 and September 2021. We also analyzed the ethical/professional values mentioned in their reflections. Descriptive and inferential (χ2) statistics were performed to examine differences in issues and values cited before and during the pandemic. RESULTS: Respondents highlighted several key themes identified in prior studies, including decision making (64.1%), communication between clinicians and families (52.2%), and justice-related issues (32.1%), as well as interdisciplinary communication (25.7%) and issues related to the role of students in the intensive care unit (6.1%). Six novel subthemes were identified in this group, predominantly related to resource availability and end-of-life care. Of 343 reflections, 69% were written before the pandemic. Analysis of ethical and professional issues before and during COVID were notable for several significant differences, including increased discussion of inadequate tools/supplies/equipment (1.3% before vs 17.6% during, P = 0.005) and/or access to care (3.9% before vs 17.6% during, P = 0.03) and increased concerns about the tension between law and ethics (21.2% before vs 41.2% during, P = 0.028). Primacy of patient welfare (49.8% before vs 47.2% during, P = 0.659) and patient autonomy (51.1% before vs 38.9% during, P = 0.036) were the most commonly cited ethical principles in both time frames, often discussed concurrently and in tension. CONCLUSIONS: Although the COVID-19 pandemic was associated with increased reflection by medical students about resources in the intensive care unit, their perception of ethical issues arising in critical illness remained largely focused on enduring challenges in shared decision-making. These findings should be considered when developing ethics curricula for critical care rotations.

Epidemics and the healthcare professional's duty to care: Students' attitudes about work requirements before and during Covid-19 (2017-2021).

CONTEXT: The Covid-19 pandemic has added a new chapter to discussions about the professional duty to care. To understand how Covid-19 may have changed medical students' ethical attitudes towards this duty, we analysed policies written before and during the pandemic by first-year students completing a yearly educational exercise focused on work requirement expectations for healthcare professionals during a hypothetical epidemic. METHODS: Within a repeated cross-sectional design, consensus coding was performed on policies written over 5 years (2017-2021) using a codebook based on eight questions from the educational exercise for summative content analysis. Frequencies provided summative results and comparisons across years used Fisher's exact test. RESULTS: We analysed 142 written policies from 2017 to 2021 representing 884 first-year students working in small groups. Students' commitment to the duty to care remained stable during the Covid-19 pandemic, but during the pandemic, students were more likely to support exceptions to the duty to care (e.g. for healthcare professionals with medical conditions or concern for household members' health) and more likely to expect institutions to provide safe working conditions. Ethical values supporting students' policies were largely consistent before and during the pandemic, the most common being beneficence, justice, duty to care, non-maleficence and utility. CONCLUSIONS: Our results suggest that students' support for the duty to care remained strong during the Covid-19 pandemic. We also found that students supported exceptions to this duty to reflect the needs of healthcare professionals and their families and that they expected institutions to provide safe working conditions. These findings can help inform ethics education and future pandemic preparedness.

Practical wisdom in medicine through the eyes of medical students and physicians.

BACKGROUND: Practical wisdom is considered a multidimensional virtue of enduring relevance to medicine. Though it has received increasing attention in recent years, proposed frameworks for practical wisdom can differ, and little is known about how medical students and physicians describe its dimensions and relevance. METHODS: We used structured interviews, employing open-ended and closed-ended questions, to describe how medical students and physicians understand practical wisdom and identify the kinds of clinical situations they believe require practical wisdom. We interviewed 102 participants at two US medical schools in 2021, comprising a voluntary response sample of 40 pre-clinical medical students and 40 clinical medical students and a purposive sample of 22 nominated physicians. Interviews were conducted by videoconference using a structured interview guide. Open-ended responses were coded using qualitative content analysis (directed and conventional) and tabulated; closed-ended responses were tabulated. Quotations provided qualitative illustrations, and frequencies were used for summative results. RESULTS: Participants considered practical wisdom clinically meaningful, broadly relevant and multidimensional. Most described it as deliberative, goal-directed, context-sensitive, integrated with ethics and marked by integrity and motivation to act. Many described it as experience-based, person-centred or problem-solving. Participants also selected an average of 15.6 (SD = 4.9) additional virtues as being essential for practical wisdom in medicine and described a broad range of clinical situations that require practical wisdom in medicine. CONCLUSIONS: Participants described practical wisdom as a multidimensional capacity that entails deliberation, depends on a constellation of other virtues and is broadly applicable to medicine. Most agreed it is goal-directed and context-sensitive and involves ethics, integrity and motivation. Efforts to teach practical wisdom in medical education should clarify its dimensions and highlight its relationship to virtue ethics, professionalism, clinical judgement and the individualised care of patients as persons.

Medical Education and the Ethics of Self-Care: A Survey of Medical Students Regarding Professional Challenges and Expectations for Living Healthy Lifestyles.

OBJECTIVES: Little is known about medical students' attitudes regarding the healthy lifestyle habits they are taught to recommend to patients and whether they believe they have a professional responsibility to live a healthy lifestyle. Understanding students' attitudes and practices regarding healthy lifestyles may provide insights into the personal and professional challenges that students face as they navigate the ethical tension between obligations to care for others (altruism) and for themselves (self-care). METHODS: The authors conducted a cross-sectional, anonymous, online survey of all medical students at the University of Iowa Carver College of Medicine in fall 2019, using descriptive statistics for analysis. RESULTS: A total of 351 students participated (response rate, 52.0%). Most agreed that physicians (85.5%) and medical students (77.8%) have a responsibility to try to live a healthy lifestyle; that physicians who practice healthy behaviors are more confident in counseling patients (94.0%), more likely to counsel patients (88.3%), and more likely to have their advice followed (86.9%); that as students they are more likely to counsel patients if they practice the healthy behavior (90.0%); and that their medical school workload resulted in exercise (69.7%), sleeping (69.4%), and eating (60.2%) practices that were less healthy than they should be. CONCLUSIONS: Most medical students support the professional responsibility to live a healthy lifestyle and believe doing so increases their effectiveness in counseling patients about healthy lifestyle habits. The medical school workload may limit some students' ability to live healthy lifestyles, however. Medical students need educational opportunities in ethics and professionalism to discuss challenges and expectations for living healthy lifestyles, with an eye toward practical approaches to living the life of a medical student that are professionally responsible and personally realistic.

Discrepancies in decision making preferences between parents and surgeons in pediatric surgery.

BACKGROUND: Little data exists regarding decision-making preferences for parents and surgeons in pediatric surgery. Here we investigate whether parents and surgeons have similar decision-making preferences as well as which factors influence those preferences. Specifically, we compare parents' and surgeons' assessments of the urgency and complexity of pediatric surgical scenarios and the impact of their assessments on decision-making preferences. METHODS: A survey was emailed to parents of patients evaluated in a university-based pediatric surgery clinic and surgeons belonging to the American Pediatric Surgical Association. The survey asked respondents to rate 6 clinical vignettes for urgency, complexity, and desired level of surgeon guidance using the Controlled Preferences Scale (CPS). RESULTS: Regarding urgency, parents were more likely than surgeons to rate scenarios as emergent when cancer was involved (parents: 68.8% cancer vs. 29.5% non-cancer, p < .001; surgeons: 19.2% cancer vs. 25.4% non-cancer, p = .051). Parents and surgeons were more likely to rate a scenario as emergent when a baby was involved (parents: 45.2% baby vs. 36.2% child, p = .001; surgeons: 28.0% baby vs. 14.0% child, p < .001). Regarding decision-making preferences, parents and surgeons had similar CPS scores (2.56 vs. 2.72, respectively). Multivariable analysis showed parents preferred more surgeon guidance when scenarios involved a baby (OR 1.22; 95% CI 1.08-1.37; p < 0.01) or a cancer diagnosis (OR 1.29; 95% CI 1.11-1.49; p < 0.01), and that both parents and surgeons preferred more surgeon guidance when a scenario was considered emergent (parents: OR 1.81; 95% CI 1.37-2.38, p < 0.001; surgeons: OR 2.48 95% CI 1.76-3.49, p < 0.001). CONCLUSIONS: When a pediatric patient is a baby or has cancer, parents are more likely then surgeons to perceive the clinical situation to be emergent, and both parents and surgeons prefer more surgeon guidance in decision-making when a clinical scenario is considered emergent. More research is needed to understand how parents' decision-making preferences depend on clinical context.

Attitudes about sickness presenteeism in medical training: is there a hidden curriculum?

Background: Sickness presenteeism among healthcare professionals can compromise patient safety. To better understand what motivates this phenomenon, especially among trainees, the authors investigated attitudes of medical students, resident physicians, and faculty physicians about working when sick with what might be an infectious condition. Methods: In 2012-2013, the authors employed a mixed methods, two-stage, cross-sectional survey at the University of Iowa Hospitals and Clinics of medical students (third-year students in the first survey and fourth-year students in the second survey), resident physicians in Internal Medicine, Pediatrics, and Family Medicine (first-year residents in the first survey and second-year residents in the second survey), and faculty physicians in Internal Medicine, Pediatrics, and Family Medicine. The first survey included one open-ended question querying attitudes about sickness presenteeism, answers to which underwent content analysis that identified 17 codes used to develop 23 additional closed-ended questions for a second survey. Results: 127 participants completed the second survey (44% response rate). Sixty percent of these participants felt obligated to work when sick; and 33% felt obligated to work with influenza-like symptoms (fever, myalgias, cough), with residents and students being more likely to do so than faculty (67% vs. 35% vs. 14%, p = 0.001). Most participants (83%) were motivated to work when sick to avoid creating more work for colleagues, and residents and students were more likely than faculty physicians to want to avoid negative repercussions (84% vs 71% vs. 25%, p < 0.001) or appear lazy or weak (89% vs 75% vs. 40%, p < 0.001). Most participants also recognized the need to avoid spreading infections to patients (81%) or colleagues (75%). Conclusions: When deciding whether to work when sick, students, residents, and faculty report a mixture of motivations that focus on the interests of patients, colleagues, and themselves. Awareness of these mixed motivations, particularly among trainees, can help inform interventions aimed at limiting instances of sickness presenteeism to support a culture of patient safety and counter any tendencies toward a hidden curriculum of efficiency and achievement.

Ethical Issues Encountered During the Medical Student Surgical Clerkship.

BACKGROUND: Data regarding ethical issues encountered by medical students during the surgical clerkship are sparse. Identification of such issues facilitates development of an ethics curriculum that ensures student preparation for issues most frequently encountered on the surgical rotation. To better understand these issues, we performed content analysis of reflections written by medical students about ethical issues encountered during their surgical clerkship. MATERIALS AND METHODS: All medical students on the surgical clerkship at a university hospital from 4/2017 to 6/2018 submitted a written reflection regarding an ethical issue encountered during the clerkship. Two investigators performed content analysis of each reflection. References to ethical principles (beneficence, nonmaleficence, justice, autonomy) were tabulated. Ethical issues were classified into main categories and subcategories, based on a modified version of a previously published taxonomy. RESULTS: 134 reflections underwent content analysis. Nonmaleficence was the most frequently mentioned ethical principle. 411 specific ethical issues were identified. Ethical issues were distributed across ten main categories: decision-making (28%), communication among health care team members (14%), justice (12%), communication between providers, patients, and families (9%), issues in the operating room (9%), informed consent (9%), professionalism (5%), supervision/student-specific issues (5%), documentation (1%), and miscellaneous/other (8%). We identified two ethical issues infrequently discussed in previous reports: delivery of efficient yet high-quality care and poor communication between services/consultants. CONCLUSIONS: Students encounter diverse ethical issues during their surgical clerkships. Ethical and contextual considerations related to these issues should be incorporated into a preclinical/clinical surgical ethics curriculum to prepare students to understand and engage the challenges they face during the clerkship.

Do surgeons and patients/parents value shared decision-making in pediatric surgery? A systematic review.

BACKGROUND: Shared decision-making (SDM) is touted as the preferred approach to clinical counseling. However, few data exist regarding whether patients prefer SDM over surgeon-guided discussions for complex surgical decision-making. Even fewer data exist regarding surgeon preferences. Such issues may be especially pronounced in pediatric surgery given the complex decision-making triad between patients/parents and surgeons. The objective of this systematic review was to evaluate patient/parent and surgeon attitudes toward SDM in pediatric surgery. METHODS: A systematic review of English language articles in Medline, EMBASE, and Cochrane databases was performed. Inclusion and exclusion criteria were predefined. Text screening and data abstraction were performed by two investigators. RESULTS: Seven thousand five hundred eighty-four articles were screened. Title/abstract review excluded 7544 articles, and full-text review excluded four articles. Thirty-six articles were identified as addressing patient/parent or surgeon preferences toward SDM in pediatric surgery. Subspecialties included Otolaryngology (33%), General Surgery (30%), Plastics (14%), Cardiac (11%), Urology (8%), Neurosurgery (6%), Orthopedics (6%), and Gynecology (3%). Most studies (94%) evaluated elective/nonurgent procedures. The majority (97%) concentrated on patient/parent preferences, whereas only 22% addressed surgeon preferences. Eleven percent of studies found that surgeons favored SDM, and 73% demonstrated that patients/parents favored SDM. CONCLUSIONS: Despite recommendations that SDM is the preferred approach to clinical counseling, our systematic literature review shows that few studies evaluate patient/parent and surgeon attitudes toward SDM in pediatric surgery. Of these studies, very few focus on complex, urgent/emergent decision-making. Further research is needed to understand whether patients/parents, as well as surgeons, may prefer a more surgeon-guided approach to decision-making, especially when surgery is complex or taking place in urgent/emergent settings.

Rethinking medical oaths using the Physician Charter and ethical virtues.

OBJECTIVE: Medical oaths express ethical values that are essential to the trust within the patient-physician relationship and medicine's commitment to society. However, the contents of oaths vary between medical schools and therefore raise questions about which ethical values should be included in a medical oath. More than a decade has passed since this variability was last analysed in North America, and since that time the Physician Charter on Medical Professionalism has gained considerable attention, raising the possibility that the Charter may be influencing medical oaths and making them more consistent. METHODS: The authors conducted a content analysis of 84 oaths available in 2015 from medical schools in the USA and Canada affiliated with the Association of American Medical Colleges, organising the content into three categories: (i) ethical values, (ii) principles and commitments in the Physician Charter, and (iii) ethical virtues. RESULTS: Only five ethical values were expressed in the majority of oaths (confidentiality, obligation to the profession, beneficence, avoiding discrimination, and honour and integrity), and respect for patient autonomy was uncommon. Only three of the Physician Charter's principles and commitments (primacy of patient welfare, social justice and confidentiality) and one virtue (honour and integrity) were reflected in the majority of oaths. CONCLUSIONS: Medical oaths in North America appear to be highly variable in content. Greater attention to resources like the Physician Charter can help improve the ethical content and consistency of oaths across different institutions, and throughout their education medical students should be encouraged to discuss and reflect on the principles and virtues they will profess when they graduate.

See one, do one, teach one: hand hygiene attitudes among medical students, interns, and faculty.

An anonymous, online survey of medical students, interns, and faculty at a university hospital was conducted in 2013 to examine self-reported adherence to hand hygiene opportunities. Variation in self-reported adherence ranged from frequencies of 60%-100%. Such variation suggests the need to direct education toward hand hygiene opportunities with lower reported rates of adherence, especially toward those opportunities that are difficult to monitor.

Ethical challenges for accountable care organizations: a structured review.

BACKGROUND: Accountable care organizations (ACOs) are proliferating as a solution to the cost crisis in American health care, and already involve as many as 31 million patients. ACOs hold clinicians, group practices, and in many circumstances hospitals financially accountable for reducing expenditures and improving their patients' health outcomes. The structure of health care affects the ethical issues arising in the practice of medicine; therefore, like all health care organizational structures, ACOs will experience ethical challenges. No framework exists to assist key ACO stakeholders in identifying or managing these challenges. METHODS: We conducted a structured review of the medical ACO literature using qualitative content analysis to inform identification of ethical challenges for ACOs. RESULTS: Our analysis found infrequent discussion of ethics as an explicit concern for ACOs. Nonetheless, we identified nine critical ethical challenges, often described in other terms, for ACO stakeholders. Leaders could face challenges regarding fair resource allocation (e.g., about fairly using ACOs' shared savings), protection of professionals' ethical obligations (especially related to the design of financial incentives), and development of fair decision processes (e.g., ensuring that beneficiary representatives on the ACO board truly represent the ACO's patients). Clinicians could perceive threats to their professional autonomy (e.g., through cost control measures), a sense of dual or conflicted responsibility to their patients and the ACO, or competition with other clinicians. For patients, critical ethical challenges will include protecting their autonomy, ensuring privacy and confidentiality, and effectively engaging them with the ACO. DISCUSSION: ACOs are not inherently more or less "ethical" than other health care payment models, such as fee-for-service or pure capitation. ACOs' nascent development and flexibility in design, however, present a time-sensitive opportunity to ensure their ethical operation, promote their success, and refine their design and implementation by identifying, managing, and conducting research into the ethical issues they might face.

National survey of provider opinions on controversial characteristics of liver transplant candidates.

Candidate selection for liver transplantation presents challenging ethical issues that require balancing the principles of justice and utility. The goal of this study was to assess the opinions of U.S. transplant providers regarding the ways in which controversial medical and psychosocial characteristics influence patient eligibility for liver transplantation. An online, anonymous survey about adult patient characteristics was sent to providers (hepatologists, surgeons, psychiatrists, and social workers) at all 102 active adult liver transplant centers in the United States. A majority of the providers (251/444 or 56.5%) completed the survey. The providers were queried about 8 characteristics, and the 3 that were ranked most controversial were incarceration, marijuana use, and psychiatric diagnoses. Most providers identified a patient age ≥ 80 years (62.7%), a body mass index ≥ 45 kg/m2 (56.6%), and current incarceration with a lifetime sentence (54.7%) as absolute contraindications to liver transplantation. In a multivariate analysis, the identification of absolute contraindications varied significantly with the provider type, the center volume, and the geographical region. Less than half of the providers reported that their centers had written policies regarding most of the characteristics examined. In conclusion, providers differ significantly in their opinions on controversial patient characteristics and transplant contraindications. Along with a paucity of literature data on outcomes, these provider differences may play a role in the fact that many centers do not have formal policies for selecting patients with these characteristics. Evidence-based data on the outcomes of such patients are needed to guide the formation of written policies to better standardize eligibility criteria.

Understanding Goals of Care Statements and Preferences among Patients and Their Surrogates in the Medical ICU.

BACKGROUND: Treatment decisions should be based on patients' goals of care to provide an ethical, patient-centered framework for decision-making. OBJECTIVES: The purpose of this study is to improve our understanding about how patients' and surrogates' goals of care are communicated and interpreted in an MICU. METHODS: One hundred patients admitted to an MICU, or their surrogates, responded to an open-ended question about goals of care for their hospitalization followed by a closed-ended question regarding their most important goal of care. Investigators interpreted participants' open-ended responses and compared these interpretations with participants' closed-ended, most-important-goal selections. RESULTS: Investigators' interpretations of participants' open-ended goals of care responses matched participants' closed-ended most important goal of care in only 28 of 100 cases. However, there was good inter-rater reliability between investigators in their interpretation of participants' open-ended responses, with agreement in 78 of 100 cases. CONCLUSIONS: Clinicians should be cautious in interpreting patients' or surrogates' responses to open-ended questions about goals of care. A shared understanding of goals of care may be facilitated by alternating open-ended and closed-ended questions to clarify patients' or surrogates' responses.

Diagnostic errors in primary care: lessons learned.

BACKGROUND: Diagnostic errors occur more commonly than other kinds of errors, they are more likely to harm patients, and they are more likely to be preventable. Little is known about the presenting complaints, initial (incorrect) diagnoses, and physicians' personal lessons learned related to diagnostic errors. METHODS: In 2009 and 2010, we invited a random sample of 200 family physicians, 200 general internists, and 200 general pediatricians practicing in Iowa to describe an important diagnostic error using a 1-page, mailed questionnaire. The data were analyzed using quantitative and qualitative methods. RESULTS: The response rate was 34% (202 of 600 physicians). Common presenting complaints included abdominal pain (n = 27 of 202 patients, 13%); fever (n = 19; 9%); and fatigue (n = 15, 7%). Common initial (incorrect) diagnoses included benign viral infections (n = 35, 17%); musculoskeletal pain (n = 21, 10%); and chronic obstructive pulmonary disease/asthma (n = 13, 6%). The 202 responding physicians described 254 personal lessons learned, which we used to develop a taxonomy of 24 generic lessons. Three common lessons were: (1) consider diagnosis X in patients presenting with symptom Y (n = 37 lessons, 15%; eg, "Any discomfort above the umbilicus may be coronary artery disease."); (2) look beyond the initial, most obvious diagnosis (n = 26 lessons, 10%); and (3) be alert to atypical presentations of disease (n = 24 lessons, 9%). CONCLUSIONS: In this study, diagnostic errors often were preceded by common symptoms and common, relatively benign initial diagnoses. The lessons learned often involved various aspects of broadening the differential diagnosis.

Through students' eyes: ethical and professional issues identified by third-year medical students during clerkships.

BACKGROUND: Education in ethics and professionalism should reflect the realities medical students encounter in the hospital and clinic. METHOD: We performed content analyses on Case Observation and Assessments (COAs) written by third-year medical students about ethical and professional issues encountered during their internal medicine and paediatrics clinical clerkships. RESULTS: A cohort of 141 third-year medical students wrote 272 COAs. Content analyses identified 35 subcategories of ethical and professional issues within 7 major domains: decisions regarding treatment (31.4%), communication (21.4%), professional duties (18.4%), justice (9.8%), student-specific issues (5.4%), quality of care (3.8%), and miscellaneous (9.8%). CONCLUSIONS: Students encountered a wide variety of ethical and professional issues that can be used to guide pre-clinical and clinical education. Comparison of our findings with results from similar studies suggests that the wording of an assignment (specifying "ethical" issues, "professional" issues, or both) may influence the kinds of issues students identify in their experience-based clinical narratives.