Module for Interns in Medical Ethics: A Developmental Diegesis.

BACKGROUND: Media report is rife with incidences of doctor-patients' conflict, and this partly is due to communication gap and unethical practices being adopted by the doctors. Our regular curriculum fails to impart any training in ethical issues in patient care. Imparting training to students in these soft-skills is the need of the hour. AIM AND
OBJECTIVES: To develop a module for interns in medical ethics (MIME) in patient care, validate it and pilot run the module for standardization.
METHODOLOGY: After conducting faculty development workshop in curriculum designing and three rounds of Delphi with alumni, a module in medical ethics was developed and peer validated. The questionnaire for pilot run, questionnaire for future use of module delivery and pre- and post-test were also peer validated. The module was delivered to 17 interns as pilot run in the form of 4 days' workshop. After pilot run, the module was standardized to 10 broad topics and 3 days' workshop. The questionnaire for future delivery of module in regular routine was also validated during pilot run.
RESULTS: Twenty-five faculty members participated in 1 day faculty development workshop and 59 alumni completed three rounds of Delphi. After peer review by five experts, a module of 11 broad areas was developed and was pilot run on 17 interns. Based on the feedback from pilot run, a standardized, validated 18 h teaching MIME in patient care was developed.
CONCLUSION: Pilot study proves that curriculum innovation in the form of medical ethics training to interns; when as undergraduate students, they actively participate in patient care under supervision will go a long way in inculcating soft skills like ethics, compassion and communication in them.

Introduction

Medical ethics is a system of moral principles that apply values and judgments to the practice of medicine. A number of characteristics are associated with medical ethics such as autonomy, nonmaleficence, confidentiality, dignity, honesty, justice, and beneficence.[1] Medical ethics has developed over centuries, commencing from the time of Hippocrates and over time several codes have been developed.[2]

Health-care decisions are based not only on clinical and technical grounds but also on ethical grounds.[2] It is expected that doctors are professionally sound with all required competencies. It is also expected that while they are practicing medicines and are dealing with patients, attendants, relatives of patients; they practice ethical behavior with relevant competencies.[3] With the changes in complexities in medical practice, the doctors are now encountering an increased number of litigations against them most of which are related to ethical issues.

Recently, media was rife with many reports of unethical practices by Indian physicians. It was said that some doctors in lieu of commission refer patients to specific hospitals and diagnostic labs for various tests. It was also reported that doctors sometimes prescribe unnecessary tests to the patients.[4567] There is sufficient evidence of lack of ethical practices on the part of physicians, and lack of formal training in medical ethics during medical teaching can be one of the reasons for the same.

Although Medical Council of India (MCI) introduced Code of Ethics Regulations in 2002, the same has not been made the part of the undergraduate training in India.[8] Training module of Medical Ethics has earlier been introduced at undergraduate level in various countries; which either run as a capsule-course for 1–2-week duration or is the part of regular undergraduate training and is conducted for the entire duration of undergraduate course.[910] In 1999, the World Medical Association “strongly recommended” to medical schools that the teaching of ethics and human rights should be made compulsory in their curricula.[11]

It is generally believed that soft-skills such as professionalism, ethics, and communication are caught, and not taught, and there is no need to have a structured curriculum for learning these soft-skills. Such soft-skills were previously diffused passively to the students through “the hidden curriculum.” In hidden curriculum, students learn by watching their teachers, but it leaves a lot to chance,[12] so in this fast-paced world, where passive virtues get unrevealed or unnoticed, active teaching of principles of professionalism and ethics are the need of the hour.[13] This is not to reduce the value of the hidden curriculum but to empower it.[14]

After having established the need of having a structured curriculum and training in medical ethics, the question cropped - when such training should be imparted? In a case–control study, Papadakis et al. concluded that problematic behavior in medical school is associated with a subsequent disciplinary action by a state medical board.[15] In another retrospective cohort study, Papadakis et al. concluded that poor performance on behavioral and cognitive measures during residency is associated with greater risk for state licensing board actions against practicing physicians.[16] As medical students in India come directly in contact with patient-care under supervision, during internship, it was considered the right time to impart training in medical ethics.

Considering these points, it was concluded that a training module of Medical Ethics for Interns is the need of the hour. Thus, in this curriculum innovation research project, a module for interns in medical ethics (MIME) in patients’ care was designed, validated, and standardized through pilot run.

Methodology

The project was carried out at a Medical College with attached tertiary care hospital in North India, having annual intake of 150 undergraduate students. After permission of the University Ethics Committee, a core committee consisting of six faculty members from different departments was formed. A workshop on curriculum designing was conducted in the Institute, for the training of the core committee and other faculty members. E-mail addresses of college alumni were collected. Need assessment of topics was ascertained by conducting three rounds of Delphi on college alumni, who were already working as Senior Residents, Postgraduate students, Medical Officers, and General Duty Medical Officers in Armed Forces.

MIME was prepared through intensive core committee meetings as well as online discussion on Google group, based on – (a) Need assessment on topics through alumni feedback through Delphi, (b) Local conditions and feedback by core committee members, and (c) MCI 2002 code of Medical Ethics. The prepared module was peer validated by five experts for content. A multiple choice questions and short answer questions based test was framed and peer validated. Feedback questionnaire for evaluation for students for pilot run and module delivery were prepared and peer validated for content and face validity.

As a pilot run, the module was delivered to 17 interns of the college in the form of 4 days’ workshop, after taking oral consent. Feedback questionnaire for module delivery was also pilot run. After feedback, the necessary changes in the module and feedback questionnaire for module delivery were carried out and a structured and standardized module of 18 h was developed. A flow chart of methodology is detailed in Figure 1.

Figure 1

Flow chart of methodology

Results

A total of 25 faculty members, including six core committee members participated in 1 day workshop on curriculum development. After the workshop, 25 topics for module were shortlisted. These topics were: Medical oaths and their relevance, MCI regulations, Ethical principles in patient care, duties and rights of doctors and patients, legal and ethical issues in organ donation, legal and ethical issues in abortion, medical termination of pregnancy (MTP), respect for a cadaver, time management, stress management, reflective writing, informed consent, patients’ confidentiality, medical negligence, consumer protection act (CPA), ethical principles in clinical research, leadership, euthanasia, conflict of interest, ethical dilemmas and resolving them, conscientious objection, drug and cosmetic acts, communication skills, professionalism, and self-directed learning.

For the first round of Delphi, these topics were sent to alumni with two instructions – based on your field experience suggest five topics which you think must be part of module; and if you want that any other topic (besides 25 already suggested) merits to be included in the module. After three rounds of Delphi completed by 59 alumni, the five topics on which consensus was built were: Ethical principles in patient care, duties and rights of doctors and patients, legal and ethical issues in abortion, medical oaths and their relevance, and legal and ethical issues in organ and body donation, in the same order of preference. Surprisingly, topic of “legal and ethical issues in body donation” was the one suggested by the alumni itself.

After core faculty members meetings, considering MCI code of medical ethics 2002, 11 topics for 4 days’ workshop were finalized as: group dynamics; medical oaths and their relevance; MCI and other regulations; principles of ethics, rights and duties of patients and doctor; legal and ethical issues in body and organ donation, abortion, MTP, etc. Informed consent; Patient's confidentiality, and medical negligence, CPA; Euthanasia; Conflict of interest, Ethical dilemmas and their resolution; Communication skills; and self-directed learning.

Based on these finalized topics, a module along with hand-outs was developed and peer validated. Case scenario and role plays were finalized and faculty guide for every session was prepared. After pilot run, based on feedback of interns, topic of self-directed learning was removed from the module and other changes in the teaching-learning methodology and case scenarios were made and a standardized validated 18 h teaching MIME in patient care was developed [Table 1]. A flowchart depicting the whole sequence is shown in Figure 2.

Table 1

Brief description of 18 h structured and standardized module for interns in medical ethics

Figure 2

Flowchart of standardization and validation of module

Cronbach's alpha value for feedback questionnaire for delivering module was 0.7835 with a mean of 71. High level of Cronbach's alpha value for overall questionnaire indicates internal consistency. Furthermore, the value never changed much on deleting any question, thus not mandating deletion of any question due to issues of internal consistency.

Discussion

Modules for ethical training has been developed and implemented in some institutes already, based on institutional needs, but most of these curricula address the residency programs;[1718] although efforts have been made to include the same at the undergraduate level,[192021] and now most medical schools in the USA and UK have ethical curricula as integral part of undergraduate training.[2122]

In India, St. John's Medical College, Bengaluru is running a longitudinal program in medical ethics since 1988, and the same has been adopted by its affiliating university-Rajiv Gandhi University of Health Sciences in the form of 40 h program throughout MBBS training.[23] In other institutes, sporadic efforts have been made to develop and implement ethical teaching on experimental basis, but reports of including it as a part of curricula are lacking.

In a similar sounding project, 2-day workshop on teaching effective communication skills and principles of medical ethics conducted at Foundation University Medical College, Pakistan, where 102 last year medical students participated. Teaching strategies included interactive discussions on basic principles of doctor–patient relationship, PowerPoint presentations, day-to-day case scenarios, video clips, and role plays.[24] Our project is a 3 days module incorporating interactive lectures, flipped-classroom, cinemeducation, case-based learning, and role plays as teaching-learning strategies. The module has been developed after need-assessment through Delphi.

Other such studies have largely tried to assess the knowledge, attitudes, and practices of doctors and students in medical ethics and communication,[2526] without imparting any training or developing any structured module. The current study is also limited in the sense that it is a pilot run. Further refinement will happen in the module, with use and experience.

Conclusion

Curriculum innovation in the form of medical ethics training to interns; when as undergraduate students, they actively participate in patient care under supervision will go a long way in inculcating soft skills in them and are need of the hour. Further efforts should be made to impart training to interns through this module and record their perceptions and improvement in learning and skills.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.