Results of a national survey on ethics education in general surgery residency programs

Results of a National Survey on Ethics Education in General Surgery Residency Programs Marc T. Downing,

MD, Dave P. Way, MEd, Donna A. Caniano,

BACKGROUND: Medical ethics is a required part of the curriculum in all medical schools in the United States, and an essential component of the educational guidelines for most postgraduate residency programs. Currently, general surgery does not specify ethics education in its essential curriculum for surgical training. This study was designed to determine the existing educational activities in ethics for residents in general surgery, as well as to characterize the attitudes of surgical educators about the role of ethics teaching in residency training. METHODS: An 80-item questionnaire was mailed to the program directors of all accredited general surgery residencies in the United States. They were requested to provide information about their teaching activities in ethics, their resources for ethics instruction, and their attitudes about the importance of education in clinical ethics for surgical residents. RESULTS: The survey had a 71% response rate with a representative distribution of programs based on size, geographic location, and community versus university affiliation. Fifty-six programs (28%) offered no formal ethics education, 94 (48%) held one teaching event in ethics, and 48 (24%) conducted two or more activities. The format for instruction in ethics included grand rounds (50%), resident conferences (41 Oh), and ethics rounds (9%). Residencies with a faculty surgeon having expertise or special interest in ethics had a greater number of ethics teaching activities (P <0.05), whereas programs with a hospital ethicist were more likely to provide ethics rounds (P ~0.01). A standardized curriculum in ethics was favored by 85% of respondents with critical content in end-of-life decisions, managing ethical conflict, and informed consent. The majority of program directors were opposed to (50%) or undecided (20%) about inclusion of

From the Division of Pediatric Surgery (MTD, DAC), Department of Surgery, and the Office of Academic Services for Medical Education (DPW), Ohio State University College of Medicine and Children’s Hospital, Columbus, Ohio. Requests for reprints should be addressed to Donna A. Caniano, MD, Associate Professor of Surgery, Ohio State University College of Medicine, Department of Pediatric Surgery-ED335, Children’s Hospital, 700 Children’s Drive, Columbus, Ohio 43205. Manuscript submitted January 14,1997 and accepted in revised form April 29, 1997.

364

0 1997 by Excerpta All rights reserved.

Medica,

Inc.

MD, Coh~mbus, Ohio

ethics questions on the American Board of Surgery Inservice Training Examination CABSITE) and Qualifying Examination in General Surgery. CONCLUSIONS: The majority of program directors of general surgery residencies support the teaching of clinical ethics and favor a standardized curriculum. However, most residencies in general surgery do not include ethics instruction as part of their on-going, regular educational schedule. Am J Surg. 1997;174:364-368. @31997 by Excerpta Medica, Inc.

D

uring the past 3 decades, ethics has assumed an increasing role in all aspects of contemporary medicine, both at the public policy level and wil:hin the context of the patient-physician relationship. Medical educators have responded by developing curricula in ethics with an emphasis on enhancing the student’s moral reasoning skills and on promoting the ethical dimensions of professionalism.’ By 1994, every medical school in the United States included ethics education in its formal curriculum.2 It was not until recently that most postgraduate residency programs incorporated the teaching of ethics into their curricula,3 despite numerous reports that residents and practicing physicians desired instruction in dealing with ethical issues.4-7 Although all programs approved by the Accreditation Council for Graduate Medical Education must provide residents “an opportunity to develop an understanding of ethical, socioeconomic, and medical/legal issues that affect graduate medical education and of how to apply cost containment measures in the provision of patient care,“’ general surgery remains one of the few postgraduate disciplines that does not specify ethics education among its esential components for residency training. We designed the present study to evaluate the current status of ethics teaching in general surgery residencies in the United States, and to determine how well positioned the residency programs would be to provide formal instruction in ethics if such a curriculum became a required component. Three interrelated aspects of ethics education were evaluated in general surgery residencies: (1) the resources available in residency programs to support ethics teaching; (2) the type and frequency of educational activities in ethics currently in place; and (3) the attitudes of the directors of general surgery residencies about the relevance and necessity of ethics instruction for surgeons-in-training.

MATERIALS AND METHODS Study Population The study group comprised all 278 accredited residency programs in general surgery, as recognized by the American 0002-961 O/97/$1 7.00 PII SOOsO2-961 0(97)00112-E

ETHICS

EDUCATION

Council for Graduate Medical Education in the United States in 1994. The director of the residency program and/ or the chairperson of the department of surgery was the primary respondent to the survey questionnaire. The Survey An SO-item questionnaire was designed to elicit objective data about the program’s demographics, availability of ethicists and others with expertise in ethics, established hospital programs in ethics, and curricular activities in ethics for residents, such as lectures, grand rounds, and clinical rounds. The respondents were asked to share subjective information about their attitudes toward the importance of ethics instruction for surgical residents, topics that should be taught if ethics were part of the curriculum, and whether ethics should be included in standardized surgical examinations. A preceded, confidential questionnaire was mailed to all programs with an introductory letter to the residency director explaining the purpose of the survey. At two subsequent time points all nonrespondents were sent additional questionnaires, followed by a reminder card. Confidentiality was protected by coding of the questionnaire and anonymous entry into a computerized database by a single author (MTD). Study Analysis The survey questions were arranged into related sets; respondents with a negative response to the first question in a set were instructed to proceed to the next set of queries. If a respondent inappropriately answered a related set of questions with an initial negative response, the subsequent responses within the set were deleted and treated as missing data. Response rates to each question varied because some surveys were returned with partially completed entries. Data analysis procedures included checks for data entry errors and invalid survey responses, descriptive statistical analyses, and simple tests of proportion. All analyses were conducted using SPSSPC + Version 2.0 for DOS-based computers. Chi-square tests of proportions were used to test for differences between respondents and nonrespondents on key variables, as well as to assess differences among subgroups of respondents. One set of survey items was treated as a series of binomial trials and analyzed with a binomial test of proportions. Questions that required a Likert-type scale response were assessed for frequency, and data were collapsed into three categories for analysis: strongly disagree or disagree, neutral, and agree or strongly agree. RESULTS Surveys were returned by 198 residency program directors, for a response rate of 71%. No systematic or statistical differences were observed between respondents and nonrespondents in terms of regional representation, institutional size, or university affiliation. Programs were designated as university-affiliated in 102 residencies (51.5%) and community-based in 96 (48.5%). In addition to the primary teaching site at the university or community hospital, the residencies included at least one rotation at a children’s hospital (41.3%), Veterans Administration hospital (34.2%), cancer hospital (10.7%), and public hospital (10.7%). THE AMERICAN

IN GENERAL

SURGERY

RESIDENCIES/DOWNING

ET AL 1

Resources for Ethics Education More than half of the responding community-based and university-affiliated residencies have one or more educational resources for providing ethics instruction. In 75% of the university-affiliated surgical residencies, there is a university department or medical college program in medical ethics whose mission includes education for undergraduate as well as postgraduate physicians. In 56% of the surgical programs, one or more medical ethicists are employed by the primary teaching hospital, with no statistical difference between community-based and university-affiliated residencies. In addition to providing support for the hospital’s ethics committee and directing a clinical ethics consultative service, the medical ethicist was noted to have a teaching role for physicians in all but one residency. The medical ethicist was reported to have a background 1.n medicine (46%), philosophy (24%), theology (14%), social sciences (lo%), or law (6%). Thirty-five percent of the respondents indicated that a member of the surgical faculty had either a special interest in ethics or had additional training in ethics. In 116 residencies, a surgeon was a member of the ethics committee and in 10% of cases was the chairperson of the ethics committee. There was no statistical difference between community-based and university-affiliated programs for surgical faculty participation on ethics committees. Educational Programs in Ethics No residency indicated that it had a regularly established curriculum in ethics as part of the general educational schedule for surgical housestaff. Respondents were asked to identify all ethics-related activities that were sponsored during the previous academic year. Of 198 residencies, 94 (48%) sponsored at least one teaching event in ethics, 48 (24%) conducted more than one activity, and 56 (28%) had no scheduled opportunities. The two most frequent activities were surgical grand rounds on an ethics topic (7 1 residencies) and a formal lecture or teaching conference in ethics (58 programs). Examples of ethics topics included organ transplantation, withdrawal of life support, and surgical care for geriatric patients. Residencies with a faculty surgeon having expertise or special interest in ethics sponsored a greater number of ethics teaching activities (P <0.05). Eighteen of the 110 programs ( 17%) with a medical ethicist on staff of the primary teaching hospital scheduled clinical rounds conducted by the ethicist with the surgical residents. There was no statistical difference between community-based and university-affiliated residencies for this educational modality. Programs with a hospital ethicist were more likely (P
OF

SURGERY@

VOLUME

174

SEPTEMBER

1997

365

ETHICS TABLE

EDUCATION I Sources

from

IN GENERAL

SURGERY

Which Surgeons Should Education in Ethics*

RESIDENCIES/DOWNING

Derive

Program Who

Directors Agree

Number Religious values Family values Personal life experiences+ Medical school Education in residency+ Experience in residency+ Experience after residency

41 43 76 41 74 79 47 87 respondents

ranked

set of propoti~ons.

according to a 5point Likert-type scale (Table II). Among the topics that included general areas of clinical ethics, only physician-assisted suicide and resource allocation failed to have overwhelming support. The respondents were asked a series of questions about the role of teaching and testing ethics during graduate and postgraduate medical education (Table III). Fifty percent of program directors did not favor including ethics on either the American Board of Surgery In-Service Training Examination (ABSITE) or the Qualifying Examination in General Surgery, while 30% were in agreement with testing and 20% were undecided. The majority of program directors indicated that responsibility for teaching ethics should be within the surgical faculty, with 54% favoring surgeons with formal training in ethics as the primary educator and 30% rating a practicing surgeon with an interest in ethics. A minority of respondents, 16%, preferred a nonphysician, philosopher-ethicist as the primary educator. Sixteen questionnaires contained a notation that a combination of a surgeon and a philosopher-ethicist would be the best teaching arrangement.

COMMENTS The strength of this study rests with its ability to accurately reflect the current status of ethics education in nearly three quarters of accredited general surgery residency programs in the United States. To the authors’ knowledge, it is the only report that comprehensively evaluates ethicsrelated teaching activities as well as the attitudes of residency directors about the importance of including ethics in the surgical curriculum. As such, its findings provide an objective basis for surgical educators to consider whether ethics should be an essential curricular requirement, whether most residencies have appropriate resources to formally teach ethics, and which topics in ethics are appropriate for the surgeon-in-training. ‘When queried about how a surgeon should acquire knowledge in ethics, education during residency (82%) and experience during residency (88%)) in addition to personal life experience (84%), were the major determinants of the program directors. That 85% of the respondents in this study favored a standardized curriculum in ethics is in agreement with the leadership of other postgraduate residencies, 366

THE

AMERICAN

JOURNAL

OF

SURGERY8

VOLUME

of Topics

in Ethics According Surgical Curriculum*

Topic %

45 48 84 46 82 88 52

* Based on 7 7 7 respondents who ranked the cho!ces; all seven choices equally * Statistically significant ranking based on the binomial

TABLE II Ranking

Their

174

Withholding, withdrawing treatment Recognizing ethical conflicts Informed consent Patient self-determination Brain death Confidentiality The incompetent patient Methods to resolve ethical conflict Care of terminally ill patient Living wills Resource allocation Physician-assisted suicide * Based

on percentage

to lrnpottance

in

Agree %

Neutral %

Disagree %

97.4

2.1

0.5

94.3 94.3 94.2 92.2 90.7 89.6

5.2 4.6 5.1 4.2 7.7 6.7

0.5 1.1 0.7 3.6 1.6 3.7

88.2

9.8

2.0

87.1 85.9 74.0

10.3 13.0 19.3

2.6 1.1 6.7

38.9

25.5

35.6

of respondents.

including obstetrics and gynecology, pediatrics, and internal medicine. As noted in a recent survey of ethics teaching for residents in obstetrics and gynecology, “the reinvestment in ethics education is a response to the recognition that technological expertise alone does not constitute an effective physician.’ Distinguished physician-ethicists have argued that teaching clinical ethics improves the quality of patient care, by acknowledging that a serious medical decision involves two essential.and necessary components: a technical decision that requires application of basic scientific and clinical knowledge and a moral decision that takes into account what ought to be done for an individual patient.‘” A majority of surgery residencies in this survey sponsored one or more ethics-related educational activities during the previous academic year. Three quarters of these programs had either a grand rounds or formal lecture on a topic in ethics, whereas 17% of residencies had regularly scheduled clinical rounds led by a medical ethicist bith the surgical housestaff. Much discussion has centered around the most appropriate modes of teaching ethics to postgraduate physicians. Physician-ethicist educators generally agree that case-based methods that promote active adult learning, rather than topic-oriented theoretical lectures that use passive learning styles, offer several advantages for resident teaching: The use of real-life cases stimulate interest and target relevancy, cases assist the residents in identifying specific ethical principles and dilemmas, and cases encourage ethical problem-solving to be in concert with the technical ‘lo’ Focused clinical ethics teachsurgical problem-solving. ing for surgical residents may result in mea:,urable improvements in patient care and outcomes. Halloran et all3 used a series of case-based sessions dealing with end-of-life issues for surgical residents rotating through a tertiary surgical intensive care unit and noted that, along with increased physician knowledge and confidence in caring for terminally ill SEPTEMBER

1997

1 ETHICS TABLE

EDUCATION

IN GENERAL

SURGERY

RESIDENCIES/DOWNING

Graduate

and Postgraduate

Education*

ET A

Ill Issues

About

the Teaching

Teaching and testing of ethics should Teaching and testing of ethics should The ABSlTE+ should contain questions The Qualifying Examination in General * Based on percentage of respondents. + Amencan Board of Surgery Inservice

Training

and Testing

occur in medical occur in surgical on ethics Surgery should

of Ethics

During

school residency contain

questions

on ethics

Agree %

Neutral %

Disagree %

81.1 85.3 27.2 29.8

11.4 10.3 22.6 20.0

7.5 4.4 50.2 50.2

Examination.

patients, objective aspects of care such as length of stay and cost were also positively affected. Lack of faculty expertise in clinical ethics is frequently cited as the major reason for its lack of inclusion in postgraduate education. I4 One third of the program directors in our study noted that at least one member of their surgical faculty had either training or special interest in ethics, and that these surgeons typically served on or were the chairperson of their hospital’s ethics committee. Furthermore, well over half of the residencies included a medical ethicist on staff at their hospital, a position often occupied by a physician and with responsibility for education. In our study, those residencies with surgical faculty having expertise in ethics or a hospital ethicist were more likely to sponsor ethics instructional activities. Additional barriers to teaching ethics in residency programs involve several issues, including a preoccupation with the scientific and technical aspects of medicine, time constraints of the residents’ busy schedules, lack of support by faculty for planning ethics sessions, and a tendency of residents to view ethics as peripheral to their learning agenda.15 Educators have stressed that, to be effective, a curriculum in ethics for postgraduate physicians must have goal-driven objectives that are agreed upon by the faculty and residentsI Such a curriculum would include, but not necessarily be limited to, a set of topics or key issues incorporated into a case-based methodology. As illustrated in Table II, the program directors rated several areas as important for teaching, notably issues surrounding the withholding or withdrawal of treatment, recognition of ethical conflict, and informed consent. An area of disagreement among the program directors concerned the inclusion of ethics on standardized surgical examinations, such as ABSITE and the Qualifying Examination in General Surgery. Questions on ethical issues are present in all phases of the United States Medical Licensing Examination Steps 1-3, assessing knowledge and decisionmaking skills. ‘r Although a minority of program directors supported the addition of ethics questions to the written, multiple-choice style standardized surgical examinations, our survey did not query their reasons and opinions. The American Board of Surgery Certifying Examination, an oral examination that involves a series of patient scenarios, allows the examiners discretion to include questions on cost containment and ethics. Respondents may have assumed that oral style examinations provide a more suitable context for evaluating the candidate’s reasoning skills in ethics. There is a general consensus among educators that clinical THE

AMERICAN

ethics should be evaluated in both its cognitive aspects and its applied behavioral skills.‘* Innovative techniques that could be utilized to assess a resident’s overall ability in clinical ethics include the objective structured clinical examination,” as well as videotaping with simulated patients and direct observation. The main limitation of this study is the lack of information about ethics teaching in the 80 nonresponding programs. Although the high response rate of 71% and the representative distribution in terms of size, geographic location, and community-based versus university-affiliated residencies lends credibility to our findings, we do not know if the 29% of surgical residencies whose program directors did not respond to our survey offer teaching in ethics or support such an effort. Furthermore, we relied on the respondents to provide data about past educational activities and did not require documentation of the actual event, such as copies of program schedules or grand rounds announcements. Thus, we may have overestimated or underestimated the true extent of ethics-related teaching conferences. Our study focused on the formal components of ethics education, such as structured seminars, rounds, and so forth, and did not evaluate what educators term the hidden or informal aspects of residency training.*’ These would include the critical determinants of establishing a surgical identity, which places high values on dedication, honesty, thoroughness, and trustworthiness. In the landmark sociologic study of surgical residency, Forgive ad Remember, C. L. Bask” observed that the ethical training of surgical housestaff, while not strong in terms of conferences and seminars, was replete with normative standards of appropriate behavior, skills, and moral codes. He also noted that faculty supervisors routinely stressed these attributes within everyday clinical affairs, with particular emphasis on the morbidity and mortality conference and daily rounds as mechanisms to reinforce these standards. The findings of our study raise several questions about the future of ethics education for surgical residency. These include whether there should be a national standardized curriculum in ethics for all surgical programs, and if so, what it should aim to accomplish. If ethics teaching were to be a mandatory requirement, surgical educators would have to resolve the issue of evaluating competence. Finally, since the majority of our survey’s respondents believe that clinical ethics should be taught by surgeons, most residencies would need to promote faculty development and education in ethics, with particular regard for goal-directed and casebased instruction. JOURNAL

OF SURGERY8

VOLUME

174

SEPTEMBER

1997

367

ETHICS

EDUCATION

IN GENERAL

SURGERY

RESii%ii%iii

REFERENCES 1. Bickel 1. Promoting Medical Student’s Ethical Deueiopmenc: A Resource Guide. Wash&ton, DC: Association of Ame&an Medical Colleges; 1993. 2. Fox E, Arnold RM, Brady B. Medical ethics education: past, present, and future. Acud Med. 1995;70:761-769. 3. lserson KV, Stocking C. Requirements for ethics, socioeconomic, and legal education in postgraduate medical programs. J Clin Ethics. 1993;4:225-229. 4. Pellegrino ED, J-lart RJ, Henderson SR, et al. Relevance and utility of courses in medical ethics. JAMA. 1985;253:49-53. 5. Sulmasy DP, Geller G, Levin DM, et al. Medical house officers’ knowledge, attitudes, and confidence regarding medical ethics. Arch Intern Med. 1990;150:2509-2513. 6. Barnard D. Residency ethics teaching: a critique of current trends, Arch Jntem 1Med. 1988;148:1836-~838. 7. Jacobson JA, Tolle SW, Stocking C, et al. Internal medicine residents’ preferences regarding medical ethics education. Acad Med. 1989;64:760-764. 8. Graduate Medicul Education Directory: Essentinls of Accredited Residencies. Chicago: American Medical Association; 1996:27, 286290. 9. Cain JM, Elkins T, Bernard PF. The status of ethics education in obstetrics and gynecology. Obstet Gynecol. 1994;83:3 15-320. 10. Pellegrino ED, Siegler M, Singer PA. Teaching clinical ethics. J Clin Ethics. 1990;1:175-180. 11. Jonsen A. Medical ethics teaching programs at the University of California, San Francisca and the University of Washington. Acad Med. 1989;64:718-722.

EDITORIAL

COMMENT

When is medical care considered futile? How should living wills be followed when family members disagree and the patient is unable to respond? Who decides what is appronriate care when financial resources are limited? The first two questions are ones that have faced all physicians for decades. The latter question, unfortunately, 1s becoming a L

.--

more common and sureeons

dilemma for many doctors. Most physicians would hoDe that they are not asked to make

patient care decisions based on financial situations, but this is becoming the reality for many. As noted in this article. all medical schools have implemented courses in medical ethics within the last few years. Many residency programs have also added ethics to their curricula. Most surgery programs have not followed suit, perhaps because as with many things in surgery, we still embrace the “see one, do one, teach one” philosophy. Although this phil-

368

THE

12. Walker R, Lane L, Siegler M. Development of a teaching program in clinical medical ethics at the University of Chicago. Acad Med. 1989;64:723-729. 13. Halloran SD, Starkey GW, Burke PA, et at. An educational intervention in the surgical intensive care unit to improve ethical decisions. Surgery. 1995;118:294-299. 14. Ledbette;Eb. Ethics education in medicine. Adcanc Pediaa. 1991:38:365-387. 15. Strong C, Connelly JE. Forrow L. Teachers’ perceptions of difficulties in teaching ethics in residencies. .4cud Med. 1992;67:398402. 16. Miles SH, Lane LW, Bickel J, et al. Medical ethics education: coming of age. Acad Med. 1989;64:705-714. 17. Federation of State Medical Boards of the U.S., Inc., and the Nationat Board of Medical Examiners. United States Medical Licensing Exum~n~tion- i 997~Steps 1, 2,3, General J~t~~ctio~s, Content Description, and Sample Items. P~ladelphia: Federation of State Medical Boards of the U.S.; 1996. 18. Singer P, Cohen R, Robb A, et al. The ethics objective structured clinical examination. J Gen Intern Med. 1993;8:23-28. 19. Sloan DA, Donnelly MB, Schwartz RW, et al. The objective structured clinical examination-the new gold standard for evaluating postgraduate clinicai performance. Ann Surg. 1995;222:735742. 20. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69:861871. 21. Bosk CL. Forgi~ and Remember. Chicago: University of Chicago Press; 1979.

AMERICAN

JOURNAL

OF SURGERY@

VOLUME

174

osophical underpinning has worked well for decades in the training of surgeons, the recent economic-based shift in care from the inpatient to the outpatient setting has made many of our traditional teaching opportunities obsolete. Program directors rated experience in residency and life as sources for this type of education; since some of this (especially the clinical decisions that have some economic impact) is often decided outside the resident’s normal educational environment, a more formal educational experience is probably needed, The next step in developing such a course would be a needs assessment of newly practicing surgeons to identify areas they have experienced in their practice that should have been covered in such a curriculum. Leigh Netmayer, MD VA Medical Center Salt Lzke C@, UtatZ

SEPTEMBER

1997