Objective
Obstetrics and gynecology (ob/gyn) is fraught with bioethical issues, the professional significance of which may vary based on clinical experience. Our objective was to utilize our novel ethics curriculum to identify ethics and professionalism issues highlighted by ob/gyn learners and to compare responses between learner levels to further inform curricular development.
Study Design
We introduced an integrated and dynamic ob/gyn ethics and professionalism curriculum and mixed methods analysis of 181 resulting written reflections (case observation and assessments) from third-year medical students and from first- to fourth-year ob/gyn residents. Content was compared by learner level using basic thematic analysis and summary statistics.
Results
Within the 7 major ethics and professionalism domains, learners wrote most frequently about miscellaneous ob/gyn issues such as periviability and abortion (22% of students, 20% of residents) and problematic treatment decisions (20% of students, 19% of residents) rather than professional duty, communication, justice, student-/resident-specific issues, or quality of care. The most commonly discussed ob/gyn area by both learner groups was obstetrics rather than gynecology, gynecologic oncology, or reproductive endocrinology and infertility, although residents were more likely to discuss obstetrics-related concerns than students (65% vs 48%; P = .04) and students wrote about gynecologic oncology-related concerns more frequently than residents (25% vs 6%; P = .002). In their reflections, sources of ethical value (eg, the 4 classic ethics principles, professional guidelines, and consequentialism) were cited more frequently and in greater number by students than by residents (82% of students cited at least 1 source of ethical value vs 65% of residents; P = .01). Residents disagreed more frequently with the ethical propriety of clinical management than did students (67% vs 43%; P = .005).
Conclusion
Our study introduces an innovative and dynamic approach to an ob/gyn ethics and professionalism curriculum that highlights important learner-identified ethics and professionalism issues both specific to ob/gyn and common to clinical medicine. Findings will help ob/gyn educators best utilize and refine this flexible curriculum such that it is appropriately focused on topics relevant to each learner level.
Excellent medical education requires more than just training in the biomedical model of disease. Instruction in ethics and professionalism has been identified as vital to medical learners, and is required by the Liaison Committee on Medical Education (LCME), which accredits medical schools, and by the Accreditation Council for Graduate Medical Education (ACGME), which oversees resident training programs in the United States. Ethics and professionalism curricula currently in existence vary widely across institutions; however, residents, clinical medical students, and preclinical medical students express different views on the value and preferred method of ethics education and evaluation.
Medical ethics teaching is often begun in the preclinical years and typically involves group lecture and variably sized discussion sessions that provide a foundation for the understanding of ethical principles. At the University of Iowa Carver College of Medicine (UICCOM) during the time of this study, ethics education was formalized in the preclinical second-year curriculum as the health care ethics, law, and policy course. This course consisted of 16 hours of lecture on topics including clinical ethical reasoning, ethical issues in clinical education, informed consent, privacy and confidentiality, ethical issues in reproductive medicine, ethical issues in pediatrics, end-of-life decision making, conflicts of interest, the profession’s contract with society, conscientious practice, and the disclosure of medical errors. Complementing these lectures was 9 hours of small group discussions focused on real patient cases.
While such a curriculum may use practical clinical examples of ethical dilemmas, the learner cannot fully analyze the situation or apply, test, and reinforce their learning without immersion in the realities of the clinical environment. The preclinical foundation should then theoretically be augmented and integrated vertically through a continuing ethics curriculum in the clinical years of medical school and residency.
Obstetrics and gynecology (ob/gyn) is a field of medicine in which instruction in ethics and professionalism is particularly vital. Learners and practitioners in this specialty frequently face moral dilemmas such as those related to beginning of life, the maternal-fetal relationship, and a woman’s privacy, that are best identified and resolved with an understanding of clinical ethical reasoning using ethics principles (the 4 classic ethics principles of autonomy, beneficence, nonmaleficence, and justice) and other sources of ethical value (eg, professional guidelines, case-based reasoning, and consequentialism). For this reason, several institutions have specifically implemented ethics curricula into clinical clerkships in ob/gyn. One format for these curricula has been the use of learner-identified issues to serve as the catalyst for small group discussion. This format has been well received and identified as useful by students. Additionally, using this format customizes the ethics content to the learner.
The need for ethics education during the clinical years is no less important in residency than in medical school. Resident learners recognize an abundance of ethical conflicts in medical practice and acknowledge the importance of an ethics curriculum in medical training. A positive correlation has been demonstrated between the amount of time dedicated to ethical issues in residency training and the perceived influence of residency training on ethical views. Residents also express a belief that ethics training in their residency programs should be increased. A recent survey-based study of ob/gyn residency program directors demonstrated that the majority of program directors would like to not only have more ethics education (73% of respondents) but that it should also be required (85% of respondents). This suggests a need to further evaluate how an ethics curriculum can best provide for clinical practice in medical school, residency, and beyond.
The purpose of this report is to describe our novel ethics curriculum that includes a written case observation and assessment (COA) and to compare content of these COA reflections to present and refine a flexible and valuable ethics curriculum for ob/gyn learners.
Materials and Methods
Curriculum
This study took place at the UICCOM and affiliated University of Iowa Hospitals and Clinics (UIHC). These are public, secular institutions with an academic focus. UICCOM employs >1000 faculty members teaching 608 medical students and >5000 undergraduate basic science students. UICCOM faculty practice at UIHC, the state’s only comprehensive academic medical center and a regional referral hospital. UICCOM has a structured program in bioethics and humanities ( http://www.medicine.uiowa.edu/bioethics/ ) led by 3 core faculty and 12 affiliate faculty. The program achieves its mission to help health care professionals understand increasingly complex ethical questions through education, research, and service within UICCOM, UIHC, University of Iowa, and the wider Iowa community. UIHC offers ethics guidance on policy and practice through its ethics subcommittee of the hospital advisory committee and through its full-time ethics consult service ( http://www.medicine.uiowa.edu/bioethics/ecs/ ).
At UICCOM, the clerkship for third-year medical students consists of 3 weeks of clinical experience in obstetrics and 3 weeks of clinical experience in gynecology. The majority of students undertake these clerkships onsite at the UIHC; a small minority spends their time in a community hospital-based ob/gyn practice. In academic year 2010 through 2011, a mandatory ob/gyn ethics and professionalism curriculum was added to the medical student ob/gyn clerkship requirements. This curriculum had been previously developed and utilized successfully in the required inpatient internal medicine and pediatrics clerkships in an effort to extend ethics education into the clinical years and to help assess the impact of preclinical ethics education on the views of clinical students. The curriculum requires the learner to write a reflection (a COA) based on issues encountered during their clerkship, and to participate in a group discussion based on 3 or 4 students’ anonymized COA ( Figure 1 presents verbatim instructions to the students). Medical students rotating in ob/gyn are informed of this required ethics and professionalism curriculum at the start of their rotation and are reminded of the COA submission requirement in the fourth week of their 6-week rotation, shortly before the ethics and professionalism seminar takes place.
The University of Iowa ob/gyn residency is an academic training program in which the 20 residents are supervised and mentored by board-certified faculty in all available subspecialty areas. The ob/gyn residents participate in month-long rotations that switch between general and subspecialty areas of ob/gyn. Rotations vary for individual residents depending on the time of year and level of training. The ethics and professionalism curriculum described above was introduced to the ob/gyn residency program at the same time it was introduced to the ob/gyn clerkship. Ob/gyn residents are informed that there will be mandatory ethics and professionalism seminars quarterly throughout the academic year and that they are required to submit a COA electronically prior to each seminar. The dates are provided to all residents with reminder emails sent prior to the scheduled seminar date. ( Figure 1 presents directions given to the learners, with modifications made for the residents in square brackets.)
As described above and in Figure 1 , within the COA learners are asked to reflect on issues encountered during their recent clinical experiences and to personally assess the ethical propriety of the way clinical situations were handled. Ethics and professionalism seminars for medical students and residents are held separately and are facilitated by at least 1 clinical ob/gyn faculty member with formal training in bioethics. This facilitator is usually joined by a second clinical faculty member to broaden the perspective. All facilitators read the COA prior to each seminar, elicit 1-2 dominant content or value-based themes found within the submitted reflections, and base learning and discussion points on these themes. Discussions are dynamic but focused on normative ethics, and learners have the opportunity to discuss pertinent ethical and professionalism issues during the seminar as well as to pose questions and concerns about the clinical situations. Sources of ethical value, such as the 4 classic ethical principles, professional guidelines, and consequentialism, are reinforced by both learners and facilitator(s) throughout the discussion. Authors’ identities are kept anonymous (unless the authors choose to voluntarily disclose their identities), and learners are instructed that the content of the COA will remain confidential, no matter how concerning. Facilitators are instructed on formal processes and resources available to the learners in case any learners desire to pursue action related to a concerning scenario.
Content analysis
The 181 written COA from all ob/gyn learners were deidentified and qualitatively coded using directed thematic content analysis. The initial codebook was based upon 2 existing taxonomies used to represent content and ethics understanding of third-year medical students. Specifically, original taxonomy of Caldicott and Faber-Langendoen, consisting of 7 major domains of ethical issues from written medical student reflections, was modified by Kaldjian et al to preserve the 7 major themes but better represent relationships between subthemes/subcodes ( Supplementary Table ). We also maintained the 7 major domains (although changed “miscellaneous” to “miscellaneous ob/gyn”) but further modified the subcodes to exemplify our participant responses and ob/gyn-specific subthemes ( Figure 2 ). The 7 major ethics and professionalism domains consisted of: miscellaneous ob/gyn, treatment decisions, professional duty, communication, justice, student-/resident-specific issues, and quality of care.
Two investigators independently coded each COA; each coder spent an average of 10 minutes per COA. Each COA was coded for the specific ob/gyn topic, domains, subcategories within the domains, sources of ethical value, and the ethical propriety of the way the situation was handled (ie, learner agrees, disagrees, or is neutral). These investigators met regularly to discuss their findings and reach consensus. A third investigator with expertise in both clinical ob/gyn and bioethics was consulted in cases of uncertainty. Final coding was entered into NVivo 8 (QSR International, Melbourne, Australia) for data management purposes. Using NVivo 8, the frequencies of learner-identified ethical and professional issues were calculated and compared by learner level, ie, students compared to residents. Categorical frequency data were compared by learner level using the χ test without Yates correction. Fisher exact test was used instead of the χ 2 test when the expected frequency for any given cell was <5.
This study was deemed exempt from review by the institutional review board since it involved research on the effectiveness of a new educational curriculum.
Results
A total of 181 COA were collected, including 127 COA completed by 127 medical students and 54 COA completed by 18 ob/gyn residents. The mean word counts for the COA were 653 for the medical students vs 523 for the residents ( P < .0001).
COA were coded by ob/gyn topic/specialty area, including obstetrics, gynecology, oncology, and reproductive endocrinology and infertility. Ten COA (4 from medical students and 6 from residents) identified multiple cases or a case that combined several different ob/gyn topics. Figure 2 shows the frequencies for topic area by learner level. The most commonly discussed topic by both learner levels was obstetrics (48% students vs 65% residents; P = .04). The second most commonly discussed topic was gynecologic oncology for the students and gynecology for the residents. Students were significantly more likely than residents to write about issues related to gynecologic oncology (25% vs 6%; P = .002).
The relative frequencies of the 7 major ethics and professionalism domains (modified from Caldicott and Faber-Langendoen ) are compared by learner level in Figure 3 . Overall, both students and residents discussed miscellaneous ob/gyn issues (22% vs 20%; not significant) and treatment decisions (20% vs 19%; not significant) more frequently than communication, student-/resident-specific issues, justice, quality of care, and professional duty. Communication issues were identified significantly more often by students than residents (17% vs 9%; P = .04).
Within these 7 ethics and professionalism domains, content was further categorized into 42 subcategories (modified from Kaldjian et al ). More than 1 subcategory may have been identified in any given COA. Table 1 compares the 15 most common ethics and professionalism subcategories identified, organized by learner level. Overall, students and residents discussed inadequate communication (10% vs 7%; NS), extent or fulfillment of fiduciary responsibilities (9% vs 9%; NS), and responsibilities to mother vs fetus/baby (7% vs 7%; NS) most frequently. Students were significantly less likely than residents to write about willingness to ask critical questions or speak up when concerned (1% vs 5%; P = .02), uncertainties about role and scope of responsibility (1% vs 4%; P = .05), and fetal viability (1% vs 4%; P = .05).
| Issue | Medical student n (%) | Resident n (%) | P value |
|---|---|---|---|
| Inadequate communication | 34 (10) | 11 (7) | .21 |
| Extent or fulfillment of fiduciary responsibilities | 30 (9) | 15 (9) | .93 |
| Responsibilities to mother vs to fetus/baby | 22 (7) | 11 (7) | .94 |
| Wasteful/excessive level of health care | 22 (7) | 4 (3) | .06 |
| Dealing with difficult patient | 15 (5) | 9 (6) | .61 |
| Abortion/termination | 14 (4) | 8 (5) | .71 |
| Doctor wants intervention/test but patient/family does not | 14 (4) | 6 (4) | .79 |
| Consenting issues | 11 (3) | 7 (4) | .57 |
| Treatment of pain | 11 (3) | 7 (4) | .57 |
| Patient/family wants intervention/test but doctor does not | 10 (3) | 4 (3) | 1.00 |
| Health care provider treating patient disrespectfully | 10 (3) | 4 (3) | 1.00 |
| Role of religious/cultural beliefs | 10 (3) | 1 (1) | .11 |
| Willingness to ask critical questions or speak up when concerned | 4 (1) | 8 (5) | .02 |
| Uncertainties about role and scope of responsibility | 4 (1) | 7 (4) | .05 |
| Fetal viability | 4 (1) | 7 (4) | .05 |
Sources of ethical value, such as the 4 classic ethics principles, professional guidelines, and consequentialism were cited explicitly more frequently by students than by residents ( Table 2 ). When learners personally assessed the ethical propriety of the way clinical situations were handled, residents more frequently wrote about situations in which they disagreed with management compared to students (67% vs 43%; P = .005). These results are presented in Table 3 .
| Sources of ethical value | Medical student n (%) | Resident n (%) | P value |
|---|---|---|---|
| Ethical principles | 89 (43) | 18 (39) | .67 |
| Consequences | 46 (22) | 13 (28) | .36 |
| Rights | 29 (14) | 6 (13) | .88 |
| Goals | 20 (10) | 1 (2) | .14 |
| Conscientious practice | 11 (5) | 6 (13) | .06 |
| Professional guidelines | 10 (5) | 2 (4) | 1.00 |
| Comparable cases | 4 (2) | 0 (0) | — |
| Total | 209 | 46 | |
| Mentioned ≥1 source of ethical value | 104 (82) | 35 (65) | .01 ∗ |
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