- Email: [email protected]
Analysis of clinical bioethics teaching in pediatric surgery residency
Analysis of Clinical Bioethics Teaching in Pediatric Surgery Residency By Michael
Be&ground/Purpose: Although clinical (CBT) is not a required component of the for pediatric surgery residency, ethical accompany surgical decision making for This study was designed to quantitate surgery residency (PSR) and to determine formal bioethics instruction.
L. Robin and Donna Cofumbus, Ohio
bioethics teaching essential curriculum considerations often infants and children. CBT during pediatric preferences about
Methods:An so-item questionnaire was mailed to 140 graduates of accredited PSR in the United States and Canada. Questions included demographic data, experience in CBT during and after PSR, preferred topics and teaching methods, and self-assessed and objective competency in bioethics.
A. Caniano
important CBT topics, while euthanasia, clinical research trials, and cultural diversity were given low priority. The preferred teaching methods were case-based discussions and consultation with an ethicist. Although 97% favored additional CBT in all postgraduate training, respondents who completed advanced study in medical ethics (P< .05), were women (P< .05), or were members of a hospital ethics committee (P < .05) were more likely to advocate a standardized bioethics curriculum during PSR. A majority (86%) expressed competency in handling ethical problems in clinical practice, however, 47% gave incorrect responses or were unsure about routine bioethics questions.
Results: The response rate was 78% (n = 109); 72% completed PSR between 1990 and 1995 (mean, 1991). Formal CBT within the curriculum of PSR was reported by 9% of respondents; lecture and consultation with an ethicist were the most frequent teaching methods. Informal CBT was noted by 88% of pediatric surgeons; observation of patient cases with ethical dilemmas was the primary mode of instruction. Quality of life, withholding/withdrawal of care, informed consent, child abuse, and economics ranked highest for most
Conc/usions: Formal instruction in clinical bioethics is not included in the curriculum of most residencies in pediatric surgery. Recent graduates of PSR favor case-based and practice-oriented teaching in clinical bioethics. J Pediatr Surg 33:373-377. Copyright o 1998 by W.B. Saunders Company.
D
handling individual patient scenarios.6x7Caniano et al* have shown that pediatric surgeons in the United States are reluctant to withdraw life support from neonates after implementation of a do-not-resuscitate status, a situation that may be explained, in part, by confusion about the ethical distinction between withholding and withdrawal of medical therapy. Although residents in pediatric surgery participate in the care of patients with diverse clinical and ethical challenges, the formal teaching of bioethics is not listed in the Pediatric Surgery Curriculum Guidelines, a document that outlines in detail the recommended educational content for accredited programs.9 We undertook the present study to determine how residents in pediatric surgery acquire knowledge in
URING THE PAST two decades, undergraduate and graduate medical educators have recognized the significance of bioethics in the contemporary practice of medicine and have responded by incorporating relevant educational programs into their respective curricula. 1 Currently, all allopathic medical schools in the United States and Canada provide courses in the basic principles of bioethics and the skills of moral reasoning.2 Several residencies, notably internal medicine, obstetrics and gynecology, and pediatrics, have included medical ethics as an essential curricular component with emphasis on the practical application to clinical decision making, resource allocation, and the recognition and resolution of moral conflicL3 Although bioethics teaching is not required during general surgery residency, recent studies have demonstrated that some programs offer education in the form of grand rounds or seminars on ethics-related topics4 and focused interventions, such as end-of-life decision analysis during critical care rotations.5 Pediatric surgeons from the United States and Canada have indicated by their responses to previous surveys that complex ethical dilemmas arise in the case of infants and children, and that they find it difficult to balance ethical guidelines, legal concerns, and personal moral beliefs in Journal
ofpediatric
Surgery,Vol33,
No 2 (February),
1998: pp 373-377
INDEX surgery
WORDS: residency.
Bioethics,
residents,
education,
pediatric
From the Division of Pediatric Surgery Department of Surgery, The Ohio State Universify College of Medicine, and Children’s Hospital, Columbus, OH. Preserzted at the 28th Annual Meeting of the American Pediatric Surgical Association, Naples, Florida, May 18-21, 1997. Address reprint requests to Donna A. Caniano, MD, Department of Pediatric Surgery, ED 335, Children S Hospital, 700 Children k DI; Columbus, OH 43205. Copyright o 1998 by WB. Saunders Company 0022-3468/98/3302-0044$03.00/O 373
374
ROBIN
bioethics and the skills for resolving ethical dilemmas that are often used in clinical practice. A cohort of pediatric surgeons from the United States and Canada were requested to (1) share their educational experiences in medical ethics during pediatric surgery residency (2) identify preferred topics in clinical bioethics with relevance to actual practice, and (3) respond to questions that tested awareness of and reasoning skills in pediatric ethical issues. MATERIALS
AND METHODS
The directors of all accredited programs for pediatric surgery residency (PSR) in the United States and Canada were asked to forward a mailing list of graduates between 1980 and 1995. Complete information was received for 140 pediatric surgeons who formed the study population.
The Survey An SO-item questionnaire was designed to elicit objective data about the respondent’s personal demographics (age, gender, religious ahiliation, type of practice); expertise in bioethics (coursework during undergraduate and postgraduate education, advanced study, member of hospital ethics committee); profile of educational experiences in bioethics during pediatric surgery residency (actual and preferred topics and teaching methods); knowledge of advanced directives for children and adults in state of residence; and skill in addressing simulated patient cases. Clinical bioethics was considered to be part of the formal curriculum of either general surgery or pediatric surgery residency if there were scheduled lectures or grand rounds, consultation with an ethicist, ethics rounds, or a journal club. The teaching of clinical bioethics was considered to be part of the informal curriculum of either general surgery or pediatric surgery residency if there was management of individual patient ethical dilemmas in which the resident observed and participated in decision making. Subjective information was collected by asking for a self-assessment of competency in dealing with ethical conflicts in current practice and in providing comments about the design of a teaching program in bioethics for PSR. A pilot study of five sample surgeons was used to measure survey relevancy and instruction clarity. Minor revisions were made based on their suggestions and an average time to complete the survey of 12 minutes was reported by the pilot assessment. A preceded confidential questionnaire was mailed to all participants in May 1996 with an introductory letter explaining the purpose of the study. Four weeks later, an additional questionnaire and follow-up letter were sent to all nonrespondents. Confidentiality was ensured by coding of the questionnaire and anonymous entry of responses into a computerized database by one of the authors (MLR). The study was closed in July 1996. Data were analyzed by the SPSSPC + Version 2.0 for DOS-based computers. Statistical evaluation was performed by the Student’s r test or x2 analysis. Significance was assigned to P value of less than .05.
RESULTS
Completed surveys were returned by 109 pediatric surgeons, a response rate of 78%. The mean age of the group was 39 years (range, 34 to 51) and 18% were women. The majority (72%) completed PSR between 1990 and 1995 (mean, 1991). Religious affiliation included 42% Protestant, 23% Roman Catholic, 17% Jewish, and 18% undeclared. Type of clinical practice
AND
CANIANO
was characterized as academic, full-time university (66%), private (25%), military (3%), and undeclared (6%). Details of the group’s educational experiences in clinical bioethics are shown in Table 1. Completion of a course in bioethics during medical school was noted by 48% of respondents. Pediatric surgeons who graduated from medical school after 1980 were significantly more likely to have studied bioethics during their undergraduate medical education as compared with graduates between 1972 and 1979 (64% v 6%, P < .05). The teaching of clinical bioethics during PSR was classified as formal if scheduled educational events were included in the curriculum, and as informal if no specific education was planned in the curriculum. Ten of the 109 pediatric surgeons (9%) reported that clinical bioethics was included in the formal curriculum of their PSR; all completed training between 1992 and 1995. Grand rounds or lectures on topics in bioethics and consultations with an ethicist were the most frequent teaching methods. Informal bioethics instruction, as noted by 88% of respondents, was characterized as participation in the management of patient ethical dilemmas and observation of faculty surgeons. Thirty-one surgeons (28%) had additional expertise in bioethics, either as members of a hospital ethics committee or by advanced study in bioethics. The majority of these surgeons wrote extensive comments about the importance of bioethics instruction during PSR and in continuing medical education after residency. The surgeons ranked a series of topics in bioethics according to whether they were taught on a formal or informal basis during PSR (Table 2). They were also requested to evaluate the relevance of these topics to their current clinical practice. As depicted in Table 2, several of the ethical issues surrounding healthcare economics, innovative and experimental surgery, confidentiality, and care of adolescents were taught to less than half of the surgeons during PSR. Significant differences emerged in Table
1. Educational
and Practical
of Pediatric
Experience
Surgeons
in Clinical
Yes, ” 1%) Medical School Course in bioethics Graduated in 1972-1979
52 (48) (n = 31)
2 (6) 50 (64)
Graduated in 1980-1987 (n = 78)” General Surgery Residency Clinical bioethics in curriculum Pediatric Surgery Residency Clinical bioethics in curriculum Informal instruction Postresidency Member, hospital ethics Advanced study (course, *Significant difference, tlncludes two surgeons
57 (52) 29 (94) 28 (36) 100 (92)
IO (9)
99 (91) 13 (12)
26 (24)t IO (9)
study
No, n (%)
9 (8)
96 (88)
committee seminars)
P < .05. with advanced
Bioethics
(n = 109)
in bioethics.
83 (76) 99 (91)
CLINICAL
BIOETHICS
375
TEACHING
Table 2. Bioethics
Topics
Taught
by Relevance
During
to Clinical
PSR and Ranking
Practice Taught in
Ranking by k?kwancet
PSR (%)*
Topic
Child abuse
75
4.64
2 0.25
Quality of life “benefits/risks of treatment Withholding and withdrawal of treatment Infants and children with major develop-
75
4.48
r+_0.31
75
4.50
+ 0.11
mental anomalies Resolution of conflict
63
4.62
? 0.21 i. 0.34
between
patient,
family, and doctor Do-not-resuscitate status Informedconsent
Economic
influences
sions Using an ethics Innovative,
on healthcare
consultant
experimental
Rights and privacy Confidentiality
surgery
issues
4.31
4.50 z 0.18
55
4.62
k 0.38
49
4.02
i
45
3.99 2 1.10
44
3.89 k 1.11
deci-
or committee
Role of culture, patient values, Clinical trials and research
61 60
religion
for adolescents
Peer review Euthanasia and ohvsician-assisted
0.81
42
3.88 t
37
3.67 + 1.81
33
4.07 k 0.34
30
3.91 2 0.96
23
3.95 + 0.85
13
2.82 i
suicide
1.20
1.65
*Percentage of pediatric surgeons in which the topic was taught during residency. tRanking ranges from 1, low relevance to 5, high relevance. Data expressed
mean
t standard
deviation.
the ranking of topics by relevance to clinical practice between surgeons who served on an ethics committee versus the remainder of the group. Ethics committee members were more likely to give higher ranking to ethical issues surrounding culture, patient values, and religion; ethical issues in clinical research; peer review; and euthanasia. Several respondents commented that most of the topics outlined in Table 2 should be taught during PSR because they often surface in the care of pediatric surgical patients. The preferences of the pediatric surgeons for the methods of teaching clinical bioethics during PSR are listed in Table 3. All respondents favored case discussions led by a knowledgeable individual and supervised sessions dealing with real patient dilemmas as the two Table 3. Preferred During
Methods Pediatric
of Teaching Clinical Surgery Residency
Rankingt
Method
Case discussions leader Supervised Observation
with
knowledgeable 2.6 t
experience of surgical
with real patients faculty
Ethics consultant* Journal club* Grand Ethics
Bioethics
rounds, rounds
lecture
1.65
2.8 -c 0.45 3.0 + 1.53 3.8 i
1.69
4.7 t
1.42
5.0 2 1.22 6.1 2 0.53
NOTE. Data expressed as mean t standard deviation. *Significant differences in ranking between surgeons with advanced study in bioethics or membership on hospital ethics committee and remainder tRanking ranges
of cohort, P < .05. from 1, best method
to 5, worst
method.
best teaching modalities. Pediatric surgeons with advanced study in bioethics or membership on a hospital ethics committee ranked teaching by an ethics consultant and journal club as significantly better teaching methods (P < .05) in comparison with observation of the surgical faculty, which was preferred by the remainder of the group. Passive learning experiences, including grand rounds or lecture and ethics rounds, received the lowest ratings from all respondents. The pediatric surgeons were asked to comment on a series of factual questions and case scenarios in clinical bioethics. Although 95% of surgeons gave correct responses to queries about advance directives and living wills for adults, 47% were either incorrect or uncertain about the status of these end-of-life issues for children. All respondents agreed that they would provide lifesaving blood transfusions to a 3-year-old child with massive hemorrhage over the religious objection of Jehovah Witness parents. However, one quarter of surgeons expressed uncertainty about their role in securing a court order for permission to transfuse or what information should be communicated to the parents. In response to the question, “Do you feel competent to handle ethical conflicts in your clinical practice,” 86% answered affirmatively. Ninety-seven percent of surgeons agreed that clinical bioethics should be within the curriculum during PSR, whereas 52% favored a uniform standardized curriculum that would be available to all programs. Respondents who had completed advanced study in bioethics, were women, or served on a hospital ethics committee were significantly more likely (P < .05) to advocate a standardized bioethics curriculum. DISCUSSION
This study represents the first comprehensive effort to characterize the scope of clinical bioethics education during the training of pediatric surgeons. The large sample size of 109 pediatric surgeons, as well as the fact that the majority completed residency between 1990 and 1995, permits the evaluation of several questions. Question 1: “Is clinical bioethics taught during pediatric surgery residency, and if so, how?” Formal instruction in clinical bioethics occurs in a minority of pediatric surgery residencies, whereas topics in bioethics are seldom included in the traditional educational mechanisms of grand rounds and lectures. In some training programs an ethicist participates in resident education by providing consultation for specific patient dilemmas. The majority of programs provide informal teaching by having residents involved in the direct care of patients whose situations present ethical quandry, along with an opportunity to observe faculty surgeons resolve these cases.
376
Question 2: “What is the justification for adding clinical bioethics education to pediatric surgical residency?” As noted by Mark Siegler, MD, in a recent article in the Bulletin of the American College of Surgeons, “patients and society expect physicians to demonstrate not only technical proficiency but also the practical ability to identify and respond to ethical issues.” lo Dr. Siegler, a physician and director of the MacLean Center for Clinical Medical Ethics at the University of Chicago, goes on to list several reasons why clinical bioethics expertise is particularly essential for contemporary surgeons: the rapid growth in scientific knowledge, expansion in the availability and efficacy of medical technologies, a more equal relationship between patients (and their advocates) and physicians, new organizational relationships in healthcare delivery, and pressures to contain cost. Although most residents entering training in pediatric surgery will have completed coursework in bioethics during medical school, most will have a limited or uneven exposure to clinical bioethics problem solving during general surgery residency. Furthermore, it is unlikely that the bioethics issues unique and specific to pediatrics will have been addressed during general surgery training. Over half of the participants in our survey commented that their surgical practice included frequent ethical dilemmas and that more instruction in bioethics would have been beneficial during training. These sentiments were echoed strongly by the pediatric surgeons who served on a hospital ethics committee, where cases of ethical dispute between parents and physicians are often brought for resolution. Some respondents observed that it is easier to provide the technical expertise of surgery than participating in the tough management decisions that surround critically ill infants and children, abrogating this aspect of care to neonatologists, intensivists, and other colleagues. Question 3: “What topics in bioethics should be included in the education of pediatric surgeons?” Medical educators and physician ethicists agree that the content of a teaching program in bioethics should reflect the kinds of clinical patient situations that the residents are likely to encounter in actual practice.11J2 The topics listed in Table 2 cover a broad range of bioethical issues, some such as child abuse, withholding and withdrawal of treatment, and quality of life, which our survey respondents and the literature acknowledge as fundamental areas in pediatrics and pediatric surgery.13J4Experience of the pediatric surgeons influenced how certain topics were ranked. For example, members of a hospital ethics committee were more likely to give higher ratings to issues about culture, patient values and religion, clinical
ROBIN
AND
CANIANO
research, peer review, and euthanasia, presumably because it is useful for them to have understanding and knowledge in these areas that may result in ethical conflict and come to the attention of an ethics committee. Question 4: “How should bioethics be taught during pediatric surgery residency?” The results of our survey agree with those of other reports in support of case-based bioethics instruction.15-18 A key element in case discussions includes patient scenarios that are drawn from actual practice or carefully simulated to mirror realistic situations. Also, the leader of case-based discussions must be knowledgable about the bioethics relevant to the cases and be skilled at coordinating educational sessions that balance knowledge acquisition, resident participation, and focused decision making. Respondents rated supervised experience with real patients as a highly preferred teaching method. This type of instruction would probably be most amenable to the faculty in pediatric surgery because it is similar to the mentored experiences that occur in the operating room and clinics. However, an essential component of resident interaction with actual patient ethical dilemmas is discussion with faculty before and after the experience to review and critique performance. As noted in Table 3, surgeons with advanced study or service on an ethics committee were more likely to rate teaching by an ethics consultant and journal club on bioethics issues as efficacious teaching methods compared with the remainder of survey respondents. These preferences may reflect a greater familiarity with the process of seeking ethics consultation, as well as additional expertise in the bioethics literature. Question 5: “Should pediatric surgery residencies use a standardized curriculum in bioethics?” Although 97% of pediatric surgeons supported formal instruction in bioethics during training, only 52% were in favor of a standardized curriculum. Negative comments about a standardized curriculum centered on loss of control over topics and teaching methods, difficulty enforcing quality, concern about the unique differences among training programs, and the varied resources for bioethics expertise among institutions. Members of a hospital ethics committee, surgeons with advanced study in bioethics, and a majority of the female respondents advocated a standardized curriculum for reasons that included uniformity of experience among residents and presumed agreement that the topics selected would reflect consensus among pediatric surgical educators and ethicists. A major limitation of this study was our inability to survey all graduates of pediatric surgery residencies. Two programs did not furnish a list of their residents, whereas others supplied insufficient or outdated information for
CLINICAL
BIOETHICS
TEACHING
377
mailing purposes. Use of survey methodology to collect objective information about teaching during pediatric surgery residency raises concern about the accuracy of retrospective recall. However, because 72% of respondents were recent graduates, their judgement about bioethics instruction should be reliable. The subjective aspects of the questionnaire did not depend on valid recall, but queried the relationship to current clinical practice. A majority of respondents wrote unsolicited comments about the necessity of formal bioethics teaching and made suggestions about educational methods,
curricular design, and the kinds of patient dilemmas that cause them concern. Incorporation of bioethics teaching into the formal curriculum of pediatric surgery residency is supported by the majority of surgeons who participated in our study. They favor bioethics topics that are relevant to clinical practice and advocate an educational methodology that is case-based and experiential. The leadership in pediatric surgery should consider these recommendations as they review and modify curricular goals and objectives for residency training.
REFERENCES 1. Ledbetter EO: Ethics education in medicine. Advances in Pediatr 38:365-387, 1991 2. Pellegrino ED: Teaching medical ethics: Some persistent questions and some responses. Acad Med 64:701-703, 1989 3. American Medical Association: Graduate Medical Education Directory: Essentials of Accredited Residencies. Chicago, American Medical Association, 1994 4. Downing MT, Way DP, Caniano DA: Results of a national survey on ethics education in general surgery residency programs. Am J Surg 174:364-368. 1997 5. Holloran SD, Starkey GW, Burke PA, et al: An educational intervention in the surgical intensive care unit to improve ethical decisions. Surgery 118:294-299, 1995 6. Shaw A. Randolph JG, Manard B: Ethical issues in pediatric surgery: A national survey of pediatricians and pediatric surgeons. Pediatrics 60:588-599, 1977 7. Bagwell CE, Goodwin SR: Spinning the wheels: A CAPS survey of ethical issues in pediatric surgery. J Pediatr Surg 27:1385-1390, 1992 8. Caniano DA, Hazebroek FWJ, DenBesten KE, et al: End-of-life decisions for surgical neonates: Experience in The Netherlands and United States. .I Pediatr Surg 30:1420-1424, 1995 9. Association of Pediatric Surgery Training Program Directors: Curriculum for Post Graduate Training in Pediatric Sugery. Association of Pediatric Surgery Training Program Directors, Inc, January, 1991
10. Siegler M: Identifying the ethical aspects of clinical practice. Bull Amer Co11 Surg 81:23-25, 1996 11. Pellegrino ED, Siegler M, Singer PA: Teaching clinical ethics. J Clin Ethics 1:175-180, 1990 12. Miles SH, Lane LW, Bickel J, et al: Medical ethics education: Coming of age. Acad Med 64:705-714, 1989 13. Committee on Bioethics of the American Academy of Pediatrics: Guidelines on forgoing life-sustaining medical treatment. Pediatrics 93532-536, 1994 14. Nelson LJ, Rushton CH, Cranford RE, et al: Forgoing medically provided nutrition and hydration in pediatric patients. J Law Med Ethics 23133-46, 1995 15. Jacobson JA, Tolle SW, Stocking C, et al: Internal medicine residents’ preferences regarding medical ethics education. Acad Med 64:760-764, 1989 16. White BD, Zaner RM: Clinical ethics training for staff physicians: designing and evaluating a model program. J Clin Ethics 4:229-234. 1993 17. Levitt C, Freedman B, Kaczovowski J, et al: Developing an ethics curriculum for a family practice residency. Acad Med 69:907914,1994 18. Cain JM, Elkins T, Bernard PF: The status of ethics education in obstetrics and gynecology. Obstet Gyncol83:315-320, 1994
Be&ground/Purpose: Although clinical (CBT) is not a required component of the for pediatric surgery residency, ethical accompany surgical decision making for This study was designed to quantitate surgery residency (PSR) and to determine formal bioethics instruction.
L. Robin and Donna Cofumbus, Ohio
bioethics teaching essential curriculum considerations often infants and children. CBT during pediatric preferences about
Methods:An so-item questionnaire was mailed to 140 graduates of accredited PSR in the United States and Canada. Questions included demographic data, experience in CBT during and after PSR, preferred topics and teaching methods, and self-assessed and objective competency in bioethics.
A. Caniano
important CBT topics, while euthanasia, clinical research trials, and cultural diversity were given low priority. The preferred teaching methods were case-based discussions and consultation with an ethicist. Although 97% favored additional CBT in all postgraduate training, respondents who completed advanced study in medical ethics (P< .05), were women (P< .05), or were members of a hospital ethics committee (P < .05) were more likely to advocate a standardized bioethics curriculum during PSR. A majority (86%) expressed competency in handling ethical problems in clinical practice, however, 47% gave incorrect responses or were unsure about routine bioethics questions.
Results: The response rate was 78% (n = 109); 72% completed PSR between 1990 and 1995 (mean, 1991). Formal CBT within the curriculum of PSR was reported by 9% of respondents; lecture and consultation with an ethicist were the most frequent teaching methods. Informal CBT was noted by 88% of pediatric surgeons; observation of patient cases with ethical dilemmas was the primary mode of instruction. Quality of life, withholding/withdrawal of care, informed consent, child abuse, and economics ranked highest for most
Conc/usions: Formal instruction in clinical bioethics is not included in the curriculum of most residencies in pediatric surgery. Recent graduates of PSR favor case-based and practice-oriented teaching in clinical bioethics. J Pediatr Surg 33:373-377. Copyright o 1998 by W.B. Saunders Company.
D
handling individual patient scenarios.6x7Caniano et al* have shown that pediatric surgeons in the United States are reluctant to withdraw life support from neonates after implementation of a do-not-resuscitate status, a situation that may be explained, in part, by confusion about the ethical distinction between withholding and withdrawal of medical therapy. Although residents in pediatric surgery participate in the care of patients with diverse clinical and ethical challenges, the formal teaching of bioethics is not listed in the Pediatric Surgery Curriculum Guidelines, a document that outlines in detail the recommended educational content for accredited programs.9 We undertook the present study to determine how residents in pediatric surgery acquire knowledge in
URING THE PAST two decades, undergraduate and graduate medical educators have recognized the significance of bioethics in the contemporary practice of medicine and have responded by incorporating relevant educational programs into their respective curricula. 1 Currently, all allopathic medical schools in the United States and Canada provide courses in the basic principles of bioethics and the skills of moral reasoning.2 Several residencies, notably internal medicine, obstetrics and gynecology, and pediatrics, have included medical ethics as an essential curricular component with emphasis on the practical application to clinical decision making, resource allocation, and the recognition and resolution of moral conflicL3 Although bioethics teaching is not required during general surgery residency, recent studies have demonstrated that some programs offer education in the form of grand rounds or seminars on ethics-related topics4 and focused interventions, such as end-of-life decision analysis during critical care rotations.5 Pediatric surgeons from the United States and Canada have indicated by their responses to previous surveys that complex ethical dilemmas arise in the case of infants and children, and that they find it difficult to balance ethical guidelines, legal concerns, and personal moral beliefs in Journal
ofpediatric
Surgery,Vol33,
No 2 (February),
1998: pp 373-377
INDEX surgery
WORDS: residency.
Bioethics,
residents,
education,
pediatric
From the Division of Pediatric Surgery Department of Surgery, The Ohio State Universify College of Medicine, and Children’s Hospital, Columbus, OH. Preserzted at the 28th Annual Meeting of the American Pediatric Surgical Association, Naples, Florida, May 18-21, 1997. Address reprint requests to Donna A. Caniano, MD, Department of Pediatric Surgery, ED 335, Children S Hospital, 700 Children k DI; Columbus, OH 43205. Copyright o 1998 by WB. Saunders Company 0022-3468/98/3302-0044$03.00/O 373
374
ROBIN
bioethics and the skills for resolving ethical dilemmas that are often used in clinical practice. A cohort of pediatric surgeons from the United States and Canada were requested to (1) share their educational experiences in medical ethics during pediatric surgery residency (2) identify preferred topics in clinical bioethics with relevance to actual practice, and (3) respond to questions that tested awareness of and reasoning skills in pediatric ethical issues. MATERIALS
AND METHODS
The directors of all accredited programs for pediatric surgery residency (PSR) in the United States and Canada were asked to forward a mailing list of graduates between 1980 and 1995. Complete information was received for 140 pediatric surgeons who formed the study population.
The Survey An SO-item questionnaire was designed to elicit objective data about the respondent’s personal demographics (age, gender, religious ahiliation, type of practice); expertise in bioethics (coursework during undergraduate and postgraduate education, advanced study, member of hospital ethics committee); profile of educational experiences in bioethics during pediatric surgery residency (actual and preferred topics and teaching methods); knowledge of advanced directives for children and adults in state of residence; and skill in addressing simulated patient cases. Clinical bioethics was considered to be part of the formal curriculum of either general surgery or pediatric surgery residency if there were scheduled lectures or grand rounds, consultation with an ethicist, ethics rounds, or a journal club. The teaching of clinical bioethics was considered to be part of the informal curriculum of either general surgery or pediatric surgery residency if there was management of individual patient ethical dilemmas in which the resident observed and participated in decision making. Subjective information was collected by asking for a self-assessment of competency in dealing with ethical conflicts in current practice and in providing comments about the design of a teaching program in bioethics for PSR. A pilot study of five sample surgeons was used to measure survey relevancy and instruction clarity. Minor revisions were made based on their suggestions and an average time to complete the survey of 12 minutes was reported by the pilot assessment. A preceded confidential questionnaire was mailed to all participants in May 1996 with an introductory letter explaining the purpose of the study. Four weeks later, an additional questionnaire and follow-up letter were sent to all nonrespondents. Confidentiality was ensured by coding of the questionnaire and anonymous entry of responses into a computerized database by one of the authors (MLR). The study was closed in July 1996. Data were analyzed by the SPSSPC + Version 2.0 for DOS-based computers. Statistical evaluation was performed by the Student’s r test or x2 analysis. Significance was assigned to P value of less than .05.
RESULTS
Completed surveys were returned by 109 pediatric surgeons, a response rate of 78%. The mean age of the group was 39 years (range, 34 to 51) and 18% were women. The majority (72%) completed PSR between 1990 and 1995 (mean, 1991). Religious affiliation included 42% Protestant, 23% Roman Catholic, 17% Jewish, and 18% undeclared. Type of clinical practice
AND
CANIANO
was characterized as academic, full-time university (66%), private (25%), military (3%), and undeclared (6%). Details of the group’s educational experiences in clinical bioethics are shown in Table 1. Completion of a course in bioethics during medical school was noted by 48% of respondents. Pediatric surgeons who graduated from medical school after 1980 were significantly more likely to have studied bioethics during their undergraduate medical education as compared with graduates between 1972 and 1979 (64% v 6%, P < .05). The teaching of clinical bioethics during PSR was classified as formal if scheduled educational events were included in the curriculum, and as informal if no specific education was planned in the curriculum. Ten of the 109 pediatric surgeons (9%) reported that clinical bioethics was included in the formal curriculum of their PSR; all completed training between 1992 and 1995. Grand rounds or lectures on topics in bioethics and consultations with an ethicist were the most frequent teaching methods. Informal bioethics instruction, as noted by 88% of respondents, was characterized as participation in the management of patient ethical dilemmas and observation of faculty surgeons. Thirty-one surgeons (28%) had additional expertise in bioethics, either as members of a hospital ethics committee or by advanced study in bioethics. The majority of these surgeons wrote extensive comments about the importance of bioethics instruction during PSR and in continuing medical education after residency. The surgeons ranked a series of topics in bioethics according to whether they were taught on a formal or informal basis during PSR (Table 2). They were also requested to evaluate the relevance of these topics to their current clinical practice. As depicted in Table 2, several of the ethical issues surrounding healthcare economics, innovative and experimental surgery, confidentiality, and care of adolescents were taught to less than half of the surgeons during PSR. Significant differences emerged in Table
1. Educational
and Practical
of Pediatric
Experience
Surgeons
in Clinical
Yes, ” 1%) Medical School Course in bioethics Graduated in 1972-1979
52 (48) (n = 31)
2 (6) 50 (64)
Graduated in 1980-1987 (n = 78)” General Surgery Residency Clinical bioethics in curriculum Pediatric Surgery Residency Clinical bioethics in curriculum Informal instruction Postresidency Member, hospital ethics Advanced study (course, *Significant difference, tlncludes two surgeons
57 (52) 29 (94) 28 (36) 100 (92)
IO (9)
99 (91) 13 (12)
26 (24)t IO (9)
study
No, n (%)
9 (8)
96 (88)
committee seminars)
P < .05. with advanced
Bioethics
(n = 109)
in bioethics.
83 (76) 99 (91)
CLINICAL
BIOETHICS
375
TEACHING
Table 2. Bioethics
Topics
Taught
by Relevance
During
to Clinical
PSR and Ranking
Practice Taught in
Ranking by k?kwancet
PSR (%)*
Topic
Child abuse
75
4.64
2 0.25
Quality of life “benefits/risks of treatment Withholding and withdrawal of treatment Infants and children with major develop-
75
4.48
r+_0.31
75
4.50
+ 0.11
mental anomalies Resolution of conflict
63
4.62
? 0.21 i. 0.34
between
patient,
family, and doctor Do-not-resuscitate status Informedconsent
Economic
influences
sions Using an ethics Innovative,
on healthcare
consultant
experimental
Rights and privacy Confidentiality
surgery
issues
4.31
4.50 z 0.18
55
4.62
k 0.38
49
4.02
i
45
3.99 2 1.10
44
3.89 k 1.11
deci-
or committee
Role of culture, patient values, Clinical trials and research
61 60
religion
for adolescents
Peer review Euthanasia and ohvsician-assisted
0.81
42
3.88 t
37
3.67 + 1.81
33
4.07 k 0.34
30
3.91 2 0.96
23
3.95 + 0.85
13
2.82 i
suicide
1.20
1.65
*Percentage of pediatric surgeons in which the topic was taught during residency. tRanking ranges from 1, low relevance to 5, high relevance. Data expressed
mean
t standard
deviation.
the ranking of topics by relevance to clinical practice between surgeons who served on an ethics committee versus the remainder of the group. Ethics committee members were more likely to give higher ranking to ethical issues surrounding culture, patient values, and religion; ethical issues in clinical research; peer review; and euthanasia. Several respondents commented that most of the topics outlined in Table 2 should be taught during PSR because they often surface in the care of pediatric surgical patients. The preferences of the pediatric surgeons for the methods of teaching clinical bioethics during PSR are listed in Table 3. All respondents favored case discussions led by a knowledgeable individual and supervised sessions dealing with real patient dilemmas as the two Table 3. Preferred During
Methods Pediatric
of Teaching Clinical Surgery Residency
Rankingt
Method
Case discussions leader Supervised Observation
with
knowledgeable 2.6 t
experience of surgical
with real patients faculty
Ethics consultant* Journal club* Grand Ethics
Bioethics
rounds, rounds
lecture
1.65
2.8 -c 0.45 3.0 + 1.53 3.8 i
1.69
4.7 t
1.42
5.0 2 1.22 6.1 2 0.53
NOTE. Data expressed as mean t standard deviation. *Significant differences in ranking between surgeons with advanced study in bioethics or membership on hospital ethics committee and remainder tRanking ranges
of cohort, P < .05. from 1, best method
to 5, worst
method.
best teaching modalities. Pediatric surgeons with advanced study in bioethics or membership on a hospital ethics committee ranked teaching by an ethics consultant and journal club as significantly better teaching methods (P < .05) in comparison with observation of the surgical faculty, which was preferred by the remainder of the group. Passive learning experiences, including grand rounds or lecture and ethics rounds, received the lowest ratings from all respondents. The pediatric surgeons were asked to comment on a series of factual questions and case scenarios in clinical bioethics. Although 95% of surgeons gave correct responses to queries about advance directives and living wills for adults, 47% were either incorrect or uncertain about the status of these end-of-life issues for children. All respondents agreed that they would provide lifesaving blood transfusions to a 3-year-old child with massive hemorrhage over the religious objection of Jehovah Witness parents. However, one quarter of surgeons expressed uncertainty about their role in securing a court order for permission to transfuse or what information should be communicated to the parents. In response to the question, “Do you feel competent to handle ethical conflicts in your clinical practice,” 86% answered affirmatively. Ninety-seven percent of surgeons agreed that clinical bioethics should be within the curriculum during PSR, whereas 52% favored a uniform standardized curriculum that would be available to all programs. Respondents who had completed advanced study in bioethics, were women, or served on a hospital ethics committee were significantly more likely (P < .05) to advocate a standardized bioethics curriculum. DISCUSSION
This study represents the first comprehensive effort to characterize the scope of clinical bioethics education during the training of pediatric surgeons. The large sample size of 109 pediatric surgeons, as well as the fact that the majority completed residency between 1990 and 1995, permits the evaluation of several questions. Question 1: “Is clinical bioethics taught during pediatric surgery residency, and if so, how?” Formal instruction in clinical bioethics occurs in a minority of pediatric surgery residencies, whereas topics in bioethics are seldom included in the traditional educational mechanisms of grand rounds and lectures. In some training programs an ethicist participates in resident education by providing consultation for specific patient dilemmas. The majority of programs provide informal teaching by having residents involved in the direct care of patients whose situations present ethical quandry, along with an opportunity to observe faculty surgeons resolve these cases.
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Question 2: “What is the justification for adding clinical bioethics education to pediatric surgical residency?” As noted by Mark Siegler, MD, in a recent article in the Bulletin of the American College of Surgeons, “patients and society expect physicians to demonstrate not only technical proficiency but also the practical ability to identify and respond to ethical issues.” lo Dr. Siegler, a physician and director of the MacLean Center for Clinical Medical Ethics at the University of Chicago, goes on to list several reasons why clinical bioethics expertise is particularly essential for contemporary surgeons: the rapid growth in scientific knowledge, expansion in the availability and efficacy of medical technologies, a more equal relationship between patients (and their advocates) and physicians, new organizational relationships in healthcare delivery, and pressures to contain cost. Although most residents entering training in pediatric surgery will have completed coursework in bioethics during medical school, most will have a limited or uneven exposure to clinical bioethics problem solving during general surgery residency. Furthermore, it is unlikely that the bioethics issues unique and specific to pediatrics will have been addressed during general surgery training. Over half of the participants in our survey commented that their surgical practice included frequent ethical dilemmas and that more instruction in bioethics would have been beneficial during training. These sentiments were echoed strongly by the pediatric surgeons who served on a hospital ethics committee, where cases of ethical dispute between parents and physicians are often brought for resolution. Some respondents observed that it is easier to provide the technical expertise of surgery than participating in the tough management decisions that surround critically ill infants and children, abrogating this aspect of care to neonatologists, intensivists, and other colleagues. Question 3: “What topics in bioethics should be included in the education of pediatric surgeons?” Medical educators and physician ethicists agree that the content of a teaching program in bioethics should reflect the kinds of clinical patient situations that the residents are likely to encounter in actual practice.11J2 The topics listed in Table 2 cover a broad range of bioethical issues, some such as child abuse, withholding and withdrawal of treatment, and quality of life, which our survey respondents and the literature acknowledge as fundamental areas in pediatrics and pediatric surgery.13J4Experience of the pediatric surgeons influenced how certain topics were ranked. For example, members of a hospital ethics committee were more likely to give higher ratings to issues about culture, patient values and religion, clinical
ROBIN
AND
CANIANO
research, peer review, and euthanasia, presumably because it is useful for them to have understanding and knowledge in these areas that may result in ethical conflict and come to the attention of an ethics committee. Question 4: “How should bioethics be taught during pediatric surgery residency?” The results of our survey agree with those of other reports in support of case-based bioethics instruction.15-18 A key element in case discussions includes patient scenarios that are drawn from actual practice or carefully simulated to mirror realistic situations. Also, the leader of case-based discussions must be knowledgable about the bioethics relevant to the cases and be skilled at coordinating educational sessions that balance knowledge acquisition, resident participation, and focused decision making. Respondents rated supervised experience with real patients as a highly preferred teaching method. This type of instruction would probably be most amenable to the faculty in pediatric surgery because it is similar to the mentored experiences that occur in the operating room and clinics. However, an essential component of resident interaction with actual patient ethical dilemmas is discussion with faculty before and after the experience to review and critique performance. As noted in Table 3, surgeons with advanced study or service on an ethics committee were more likely to rate teaching by an ethics consultant and journal club on bioethics issues as efficacious teaching methods compared with the remainder of survey respondents. These preferences may reflect a greater familiarity with the process of seeking ethics consultation, as well as additional expertise in the bioethics literature. Question 5: “Should pediatric surgery residencies use a standardized curriculum in bioethics?” Although 97% of pediatric surgeons supported formal instruction in bioethics during training, only 52% were in favor of a standardized curriculum. Negative comments about a standardized curriculum centered on loss of control over topics and teaching methods, difficulty enforcing quality, concern about the unique differences among training programs, and the varied resources for bioethics expertise among institutions. Members of a hospital ethics committee, surgeons with advanced study in bioethics, and a majority of the female respondents advocated a standardized curriculum for reasons that included uniformity of experience among residents and presumed agreement that the topics selected would reflect consensus among pediatric surgical educators and ethicists. A major limitation of this study was our inability to survey all graduates of pediatric surgery residencies. Two programs did not furnish a list of their residents, whereas others supplied insufficient or outdated information for
CLINICAL
BIOETHICS
TEACHING
377
mailing purposes. Use of survey methodology to collect objective information about teaching during pediatric surgery residency raises concern about the accuracy of retrospective recall. However, because 72% of respondents were recent graduates, their judgement about bioethics instruction should be reliable. The subjective aspects of the questionnaire did not depend on valid recall, but queried the relationship to current clinical practice. A majority of respondents wrote unsolicited comments about the necessity of formal bioethics teaching and made suggestions about educational methods,
curricular design, and the kinds of patient dilemmas that cause them concern. Incorporation of bioethics teaching into the formal curriculum of pediatric surgery residency is supported by the majority of surgeons who participated in our study. They favor bioethics topics that are relevant to clinical practice and advocate an educational methodology that is case-based and experiential. The leadership in pediatric surgery should consider these recommendations as they review and modify curricular goals and objectives for residency training.
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10. Siegler M: Identifying the ethical aspects of clinical practice. Bull Amer Co11 Surg 81:23-25, 1996 11. Pellegrino ED, Siegler M, Singer PA: Teaching clinical ethics. J Clin Ethics 1:175-180, 1990 12. Miles SH, Lane LW, Bickel J, et al: Medical ethics education: Coming of age. Acad Med 64:705-714, 1989 13. Committee on Bioethics of the American Academy of Pediatrics: Guidelines on forgoing life-sustaining medical treatment. Pediatrics 93532-536, 1994 14. Nelson LJ, Rushton CH, Cranford RE, et al: Forgoing medically provided nutrition and hydration in pediatric patients. J Law Med Ethics 23133-46, 1995 15. Jacobson JA, Tolle SW, Stocking C, et al: Internal medicine residents’ preferences regarding medical ethics education. Acad Med 64:760-764, 1989 16. White BD, Zaner RM: Clinical ethics training for staff physicians: designing and evaluating a model program. J Clin Ethics 4:229-234. 1993 17. Levitt C, Freedman B, Kaczovowski J, et al: Developing an ethics curriculum for a family practice residency. Acad Med 69:907914,1994 18. Cain JM, Elkins T, Bernard PF: The status of ethics education in obstetrics and gynecology. Obstet Gyncol83:315-320, 1994