Objective
The objective of the study was to assess the current status of ethics education in obstetrics-gynecology residency programs.
Study Design
A cross-sectional, web-based survey was designed in conjunction with a professional survey laboratory at the University of Chicago. The survey was piloted with a convenience sample of clinical medical ethics fellows to assess question content and clarity. The survey was deployed by e-mail to all obstetrics-gynecology residency program directors. Descriptive statistics were used to analyze participant responses. The University of Chicago’s Institutional Review Board deemed this study exempt from institutional review board formal review.
Results
Of 242 eligible obstetrics-gynecology residency program directors, 118 (49%) completed the survey. Most respondents were from university-based programs (n = 78, 66%) that were not religiously affiliated (n = 98, 83%) and trained 4-6 residents per postgraduate year (n = 64, 70%). Although 50% of program directors (n = 60) reported having ethics as part of their core curriculum, most programs teach ethics in an unstructured manner. Fifty-seven percent of respondents (n = 66) stated their program dedicated 5 or fewer hours per year to ethics. The majority of program directors (n = 80, 73%) responded they would like more to a lot more ethics education and believed that ethics education should be required (n = 93, 85%) for residents to complete their training. Respondents identified that crowding in the curriculum was a significant barrier to increased ethics training (n = 50, 45%) and two-thirds (n = 74, 67%) reported a lack of faculty expertise as a moderate barrier to providing ethics education in the residency curriculum.
Conclusion
This study found that a lack of structured curricula, inadequate faculty expertise, and limited time were important barriers for ethics education in obstetrics-gynecology programs across the nation. Despite these existing challenges, program directors have a strong interest in increasing ethics education in residency training. Therefore, additional resources are needed to assist program directors in enhancing resident ethics education.
Clinical medical ethics is an important part of any residency program, as highlighted by its inclusion as one of the Accreditation Council for Graduate Medical Education core competencies and in the Obstetrics and Gynecology Milestones. Specific milestones that assess residents’ skills in applying key ethical principles include compassion, integrity, and respect for others; respect for patient privacy, autonomy, patient-physician relationship; communication with patients and families; and informed consent and shared decision making.
The field of obstetrics-gynecology faces a unique set of ethical challenges, including situations arising from the maternal-fetal dyad and recent advancements in reproductive techniques. In light of these unique ethical challenges and the current adoption of the Obstetrics and Gynecology Milestones, educating trainees regarding key ethical principles and approaches to resolving ethical conflicts is especially relevant to obstetrics-gynecology residency training programs.
The status of ethics curricula in obstetrics-gynecology residencies was evaluated in the early 1990s by Cain et al in conjunction with the Association of Professors in Obstetrics and Gynecology and the Council on Resident Education in Obstetrics and Gynecology (APGO/CREOG). Based on their findings, the authors recommended that a uniform national curriculum be implemented. The APGO/CREOG subsequently published an educational manual on topics in obstetrics-gynecology ethics containing sample cases for discussion. However, to date, there is a paucity of literature to suggest that a formalized ethics curriculum in obstetrics-gynecology residencies is in place in the United States.
When Grossman et al performed a literature review of articles pertaining to residency ethics education in 2010, the authors found that only 4 articles had been published in the last 40 years regarding ethics education in obstetrics-gynecology residency programs compared with the 30 articles identified for both general surgery and internal medicine. Since that time, a few additional studies have been published that describe ethics education curricula, mainly in the fields of family planning and gynecologic oncology.
To help develop and effectively integrate a formalized curriculum for obstetrics-gynecology residency programs, the ethics curricula in US residency programs, including needs and barriers to teaching, must be better understood. Therefore, a survey of US obstetrics-gynecology program directors (PDs) was conducted to assess the current status of ethics curricula in obstetrics-gynecology residency programs.
Materials and Methods
Between Feb. 10, 2014, and March 20, 2014, a web-based survey was deployed via e-mail invitation to residency PDs from every APGO/CREOG–approved obstetrics-gynecology residency program. The Institutional Review Board at the University of Chicago granted this study exempt status. The introductory e-mail describing the survey explained that participation in the study was both voluntary and anonymous.
A 35 question, multiple-choice, web-based questionnaire was developed in collaboration with the University of Chicago’s Survey Research Laboratory. After obtaining permission from the authors, several question formats were adapted from a previous study by Grossman et al that surveyed general surgery residency program directors regarding ethics education in their training programs. These questions included program demographics, ethics education content and format, ethics resources, and barriers to incorporating ethics education in residency training. Obstetrics-gynecology–specific questions were developed, including questions regarding teaching resources, curricular topics relevant to the field, and the value of ethics education in obstetrics-gynecology residency training. A total of 20 survey questions were displayed across 5 pages. Before distribution, a convenience sample of clinical medical ethics fellows from the MacLean Center piloted the survey to assess question content and clarity.
An e-mail invitation was sent to the director of each of the 242 programs identified on the APGO/CREOG list of accredited obstetrics-gynecology residency training programs. The e-mail included a unique invitation-only survey link allowing for only 1 survey response per residency program. The links allowed respondents to complete the survey in multiple sessions. Respondents were allowed to review and change responses and to skip individual items. Three follow-up e-mail reminders were sent to nonresponders, and flyers were disseminated at the 2014 annual APGO/CREOG meeting that took place 2 weeks into survey deployment. As an incentive for participation, participants were invited to register in a raffle for 1 of 2 iPads upon completion of the survey.
All collected data were deidentified. Descriptive statistics were first used to describe the demographic characteristics of the respondents and their programs. Respondents were dichotomized as university based vs community based using the item, “How is the main hospital of your obstetrics-gynecology residency program best described?” Community-based hospitals were comprised of community-based, military-based, and other (eg, Kaiser, independent center, etc), whereas only those that indicated university-based hospital were included in the university-based group. χ 2 tests were used to compare groups on all categorical variables. For items in which the group response was low, a Fisher exact test was used to compare the categorical variables.
Results
A total of 119 of 242 eligible PDs opened the survey and 118 provided survey responses, for a response rate of 48.8%. The mean completion time was 8 minutes 20 seconds, with the fastest completion time taking approximately 2 minutes. Response rates varied per question; therefore, specific response rates are included for each question. Nearly two-thirds of respondents were from university programs (66.1%), and the remainder of the responders were from community-based or other programs (33.9%) ( Table 1 ).
| Demographic | Total, n, % | University, n, % | Community/other, n, % a | P value |
|---|---|---|---|---|
| Program type | 118 | 78 (66.1) | 40 (33.9) | |
| Religious affiliation (n=117) | .08 | |||
| No affiliation | 98 (83.8) | 69 (89.6) | 29 (72.5) | |
| Jewish | 4 (3.4) | 2 (2.2) | 2 (5.0) | |
| Roman Catholic | 9 (7.7) | 4 (5.2) | 5 (12.5) | |
| Christian, non-Catholic | 5 (4.3) | 1 (1.3) | 4 (10.0) | |
| Other | 1 (0.8) | 1 (1.3) | 0 | |
| Residents per class, n (n = 118) | .001 | |||
| ≤3 | 19 (16.1) | 5 (6.4) | 14 (35.0) | |
| 4-6 | 64 (70) | 45 (57.7) | 25 (62.5) | |
| ≥7 | 28 (29) | 28 (35.9) | 1 (2.5) | |
| Fellowships available at the program | ||||
| Ethics | 0 (0) | 0 (0) | 0 | .000 |
| Family planning | 18 (15.1) | 17 (21.8) | 1 (2.5) | .013 |
| Gynecology-oncology | 33 (27.7) | 30 (38.5) | 3 (7.5) | .001 |
| MFM | 48 (40.3) | 43 (55.1) | 5 (12.5) | < .001 |
| Minimally invasive surgery | 24 (20.2) | 18 (23.1) | 6 (15.0) | .429 |
| Pediatric/adolescent gynecology | 6 (4.2) | 5 (6.4) | 1 (2.5) | .249 |
| REI | 21 (17.6) | 19 (24.4) | 2 (5.0) | .019 |
| Urogynecology | 32 (26.9) | 27 (34.6) | 5 (12.5) | .019 |
| Other | 19 (16.1) | 11 (14.1) | 8 (20.0) | .575 |
| Respondent sex (n = 117) | < .001 | |||
| Male | 49 (41.9) | 23 (29.5) | 26 (66.7) | |
| Female | 68 (58.1) | 55 (70.5) | 13 (33.3) | |
| Respondents’ number of years in practice (n = 118) | .647 | |||
| 0-5 | 1 (0.8) | 1 (1.3) | 0 | |
| 6-15 | 44 (37.3) | 32 (41.0) | 12 (30.0) | |
| 16-25 | 51 (43.2) | 34 (43.6) | 17 (42.5) | |
| >25 | 22 (18.6) | 11 (14.1) | 11 (27.5) |
a Other indicators military-affiliated, Kaiser, independent academic center, or university-affiliated community program.
Whereas 58% of all respondents were female, PDs from community programs were significantly more likely to be male (66.7%) than PDs from academic programs (29.5%) ( P < .001). The majority of respondents were from non–religiously affiliated programs (83.8%). Overall, most PDs were from programs graduating 4-6 residents per year. The respondents from academic programs were more likely to have classes with 7 or more residents, and those from community programs were more likely to have classes with 3 or fewer residents ( P = .001).
In looking at ethics education in these programs, the majority of programs (57.4%) spends only 0-5 hours per year on ethics education and only half offered a formal ethics education in the form of core curriculum materials on ethics, and only 1 program had a rotation with an ethics focus ( Table 2 ). Furthermore, half of all programs do not use assigned readings for ethics education, and only 28.6% reported using the APGO/CREOG/American College of Obstetricians and Gynecologists case studies as a part of their teaching.
| Variable | Total, n (%) | Academic, n (%) | Community, n (%) | P value |
|---|---|---|---|---|
| Hours spent per year on ethics education (n = 115) | .683 | |||
| 0-5 | 66 (57.4) | 43 (55.8) | 23 (60.5) | |
| 6-10 | 37 (32.2) | 25 (32.5) | 12 (31.6) | |
| 11-15 | 7 (6.1) | 6 (7.8) | 1 (2.6) | |
| 16-20 | 5 (4.3) | 3 (3.8) | 2 (5.3) | |
| >20 | 0 | 0 | 0 | |
| Form of ethics education | ||||
| Core curriculum material on ethics | 60 (50.4) | 42 (53.8) | 18 (45.0) | .474 |
| A specific rotation with an ethics focus | 1 (0.8) | 1 (1.3) | 0 (0) | 1.00 |
| Informal discussion with faculty | 90 (75.6) | 62 (79.5) | 28 (70.0) | .359 |
| Grand rounds focused on ethics | 89 (74.8) | 57 (73.1) | 32 (80.0) | .548 |
| Supervised clinical involvement with difficult cases | 82 (68.9) | 57 (73.1) | 25 (62.5) | .332 |
| Resident conference focused on ethics | 53 (44.5) | 40 (51.3) | 13 (32.5) | .081 |
| Other | 6 (5.0) | 4 (5.1) | 2 (5.0) | 1.00 |
| Not at all | 0 (0) | 0 (0) | 0 (0) | .000 |
| Methodology of ethics education (n = 115) | .034 | |||
| Case-based learning | 52 (45.2) | 37 (48.1) | 15 (39.5) | |
| Integrated case–based and lecture | 36 (31.3) | 22 (28.6) | 14 (36.8) | |
| Lecture-based didactics | 18 (15.7) | 9 (11.7) | 9 (23.7) | |
| Other | 5 (4.3) | 5 (6.5) | 0 | |
| Standardized patients or simulation program | 4 (3.5) | 4 (5.2) | 0 | |
| Importance of teaching modality in preparing residents to deal with ethically challenging situations a | ||||
| Hands-on experience with difficult cases (n = 110) | 4.4 (SD, 0.7) | 4.5 (SD, 0.7) | 4.2 (SD, 0.9) | .032 |
| Case-based learning (n = 113) | 4.0 (SD, 0.8) | 4.0 (SD, 0.8) | 3.9 (SD, 0.9) | .617 |
| Informal discussion with faculty (n = 113) | 3.8 (SD, 0.9) | 3.9 (SD, 0.8) | 3.5 (SD, 1.0) | .037 |
| Integrated case–based and lecture (n = 112) | 3.6 (SD, 1.0) | 3.6 (SD, 1.0) | 3.6 (SD, 1.0) | .706 |
| Standardized patients or simulation program (n = 111) | 2.9 (SD, 1.0) | 2.9 (SD, 1.0) | 2.8 (SD, 1.0) | .502 |
| Lecture-based didactics (n = 110) | 2.6 (SD, 0. 8) | 2.6 (SD, 0.8) | 2.7 (SD, 0.8) | .536 |
| Reading materials used for ethics education | ||||
| No assigned readings | 59 (49.6) | 39 (50.0) | 20 (50.0) | 1.00 |
| Journal articles | 36 (30.3) | 27 (34.6) | 9 (22.5) | .254 |
| APGO/CREOG/ACOG case studies | 34 (28.6) | 20 (25.6) | 14 (35.0) | .396 |
| Other | 7 (5.9) | 5 (6.4) | 2 (5.0) | 1.00 |
| Fiction and popular books | 5 (4.2) | 4 (5.1) | 1 (2.5) | .851 |
| Newspaper articles | 4 (3.4) | 4 (5.1) | 0 | .358 |
Most ethics teaching was via informal discussions with faculty (75.6%), grand rounds on ethics topics (74.8%), and/or supervised clinical involvement with difficult cases (68.9%). The primary methodologies used in teaching ethics were either case based (45.2%) or integrated case based and lecture learning (31.3%). Compared with academic programs, community-based programs were more likely to use lecture-based didactics (23.7% vs 11.7%) and less likely to use standardized patients, simulation programs, or other teaching activities (0% vs 11.7%, P = .034). PDs believed that hands-on experience with difficult cases was the most effective and that lecture-based didactics was the least effective method of teaching residents to deal with ethically challenging situations.
When asked about resources for ethics education, PDs from academic programs were more likely than those from community programs to have a center for ethics or humanities (66.7% vs 18.9%, P < .001) and to have obstetrics-gynecology faculty with ethics education or expertise, although this finding did not reach statistical significance (52.7% vs 33.3%, P = .077) ( Table 3 ). Ethics consult services were commonly available to respondents (94.0%).
| Variable | Total, n (%) | Academic, n (%) | Community, n (%) | P value |
|---|---|---|---|---|
| Ethics resources available at your institution | ||||
| Ethics consult service (n = 116) | 109 (94.0) | 74 (97.4) | 35 (87.5) | .087 |
| Academic center for ethics/humanities (n = 112) | 57 (50.9) | 50 (66.7) | 7 (18.9) | < .001 |
| Obstetrics-gynecology faculty with ethics education/expertise (n = 113) | 52 (46.0) | 39 (52.7) | 13 (33.3) | .077 |
| Familiarity with APGO/CREOG ethics case studies (n = 117) | .647 | |||
| Never heard of them before | 10 (8.5) | 7 (9.1) | 3 (7.5) | |
| Only heard of them | 63 (53.8) | 44 (57.1) | 19 (47.5) | |
| Somewhat familiar | 20 (17.1) | 11 (14.3) | 9 (22.5) | |
| Very familiar | 24 (20.5) | 15 (19.5) | 9 (22.5) | |
| Barriers to ethics education (n = 114) a | ||||
| Curriculum crowding | 3.3 (SD, 0.8) | 3.3 (SD, 0.8) | 3.3 (SD, 0.7) | .805 |
| Limited faculty with ethics expertise | 2. 8 (SD, 0.9) | 2.7 (SD, 0.9) | 3.0 (SD, 0.9) | .047 |
| Lack of faculty interest | 2.2 (SD, 0.9) | 2.1 (SD, 0.9) | 2.3 (SD, 0.9) | .392 |
| Lack of resident interest | 2.0 (SD, 0.8) | 2.0 (SD, 0.9) | 2.0 (SD, 0.7) | .667 |
| Lack of university or departmental support | 2.0 (SD, 1.0) | 1.9 (SD, 1.0) | 2.1 (SD, 0.9) | .445 |
One ethics resource, the APGO/CREOG/American College of Obstetricians and Gynecologists ethics case studies, appears to be infrequently utilized because 8.5% of PDs had never heard of them and only 20.5% of PDs were very familiar with this tool. PDs cited curriculum crowding as the primary barrier to incorporating ethics education, followed by limited faculty expertise, lack of faculty interest, lack of resident interest, and inadequate institutional support. Respondents from community programs indicated that faculty expertise was a larger barrier compared with those from academic programs ( P = .047).
In assessing the importance of ethics education, the majority of PDs felt that ethics should be required to complete residency (84.1%) ( Table 4 ). However, PDs reported that only 35.2% of their residents were very well prepared to deal with ethically challenging situations, with the majority (64%) unprepared or only somewhat prepared. PDs from academic programs responded that a significantly higher percentage of their residents were very well prepared compared with PDs from community programs (41.5% vs 22.7%, P = .003). When asked about the quantity of ethics education, using a scale of 1 as wanting a lot more to 5 as wanting a lot less, PDs leaned slightly toward wanting more ethics education (2.2, SD, 0.6) and believed that residents and faculty generally would want less ethics education (3.5, SD, 0.8 and 3.3, SD, 0.6, respectively).
