Antecedents and Consequences of Medical Students’ Moral Decision Making during Professionalism Dilemmas

Lynn Monrouxe, Malissa Shaw, and Charlotte Rees
AMA Journal of Ethics. June 2017, Volume 19, Number 6: 568-577.

Abstract

Medical students often experience professionalism dilemmas (which differ from ethical dilemmas) wherein students sometimes witness and/or participate in patient safety, dignity, and consent lapses. When faced with such dilemmas, students make moral decisions. If students’ action (or inaction) runs counter to their perceived moral values—often due to organizational constraints or power hierarchies—they can suffer moral distress, burnout, or a desire to leave the profession. If moral transgressions are rationalized as being for the greater good, moral distress can decrease as dilemmas are experienced more frequently (habituation); if no learner benefit is seen, distress can increase with greater exposure to dilemmas (disturbance). We suggest how medical educators can support students’ understandings of ethical dilemmas and facilitate their habits of enacting professionalism: by modeling appropriate resistance behaviors.

Here is an excerpt:

Rather than being a straightforward matter of doing the right thing, medical students’ understandings of morally correct behavior differ from one individual to another. This is partly because moral judgments frequently concern decisions about behaviors that might entail some form of harm to another, and different individuals hold different perspectives about moral trade-offs (i.e., how to decide between two courses of action when the consequences of both have morally undesirable effects). It is partly because the majority of human behavior arises within a person-situation interaction. Indeed, moral “flexibility” suggests that though we are motivated to do the right thing, any moral principle can bring forth a variety of context-dependent moral judgments and decisions. Moral rules and principles are abstract ideas—rather than facts—and these ideas need to be operationalized and applied to specific situations. Each situation will have different affordances highlighting one facet or another of any given moral value. Thus, when faced with morally dubious situations—such as being asked to participate in lapses of patient consent by senior clinicians during workplace learning events—medical students’ subsequent actions (compliance or resistance) differ.

The article is here.

Medical students track former patients' electronic health records

By Stephen Feller
United Press International
Originally published July 26, 2016

Although it is suspected to be largely for educational purposes, researchers in a recent study say the following of patient electronic health records as part of training poses ethical questions for the handling of those records.

A majority of medical students reported they find it beneficial to follow patient medical histories by accessing electronic health records, but some are checking cases they are not involved with out of curiosity -- which may not pose an actual problem, but poses an ethical one, say researchers at Northwestern University.

Some doctors have complained that electronic records, considered essential for better coordination of patient care and improvement of precision medicine, is too significant a burden on their time.

At the same time, most hospitals and doctors have invested heavily in moving to electronic records, with some groups of medical professionals saying the shift from paper to digital has made their jobs easier.

The article is here.

Moral luck, agent regret and the doctor as drug

By Jonathon Tomlinson
BMJ Blogs
Originally posted April 3, 2014

Here is an excerpt:

Professional identity is particularly strong in doctors and medical students, and perhaps more than our non-medical peers we assimilate this into our personal identity. With this, comes an enhanced sense of moral responsibility; we cannot avoid thinking that we are morally responsible for what happens to our patients.

This spectrum of moral responsibility is intrinsic to our underlying constitution and moral predispositions. The efforts of lawyers, ethicists and moral philosphers to impose definitions seem far removed from experiences like those described above and our self-imposed moral standards. It is not only our attachment to our professional identity, but the nature of our work that makes us vulnerable to moral luck and agent regret. 

 The entire article is here.

Are medical students ethically illiterate?

By Xavier Symons
BioEdge
Originally published June 1, 2013

Here is an excerpt:

Many experts believe that there needs to be more ethical education at a practical clinical level if students are to retain the information. “I would really encourage [faculties] to think about how to integrate ethical education also into the clinical realm,” said Dr Lauris Kaldjian, principal author and director of bioethics and humanities at the University of Iowa Carver College of Medicine.

The entire article is here.

Here is a link to the original study.

Loyola Bioethics Study: Med Students Reflections on Caring for Dying Patients

Loyola Bioethics Online
Originally posted January 14, 2014

The imminent death of a patient is riddled with emotions for a patient and family as well as the medical team. A study based on the reflections of third-year Loyola University Chicago Stritch School of Medicine students is shedding light on the struggle physicians in training often face when trying to control their own emotions while not becoming desensitized to the needs of the dying patient and his or her family.

“Medical students are very aware they are undergoing a socialization process by which they become desensitized to the difficult things they see every day in the hospital. They realize this is necessary to control their emotions and focus on caring for the patients. On the other hand, they are very concerned about becoming insensitive to the spiritual, emotional and personal needs of the patient,” said Mark Kuczewski, PhD, leader author and director of the Loyola University Chicago Stritch School of Medicine Neiswanger Institute for Bioethics.

The entire article is here.

An interview with Mark Kuczewski, PhD by Randi Belisomo

Burnout, Dissatisfaction Seem Rampant Among Medical Residents

By Kathleen Doheny

HealthDay Reporter

Latest Mental Health News

MedicineNet.com

TUESDAY, Sept. 6 (HealthDay News) -- The medical resident of today -- possibly your doctor in the future -- is exhausted, emotionally spent and likely stressed out about debt, a new study indicates.

"About 50% of our trainees are burned out," said study leader Dr. Colin P. West, an associate professor of medicine and biostatistics at the Mayo Clinic in Rochester, Minn.

Higher levels of stress translated into lower scores on tests that gauge medical knowledge and more emotional detachment, among other fallout.

The study is published in the Sept. 7 issue of the Journal of the American Medical Association, a themed issue devoted to doctors' training.

West and his team evaluated results of surveys and exams given to nearly 17,000 internal medicine residents, who were said to represent about 75% of all U.S. internal medicine residents in the 2008-9 academic year. The participants included 7,743 graduates of U.S. medical schools. They were asked about quality of life, work-life balance, burnout and their educational debt.

Among the findings:

• Nearly 15% said their overall quality of life was "somewhat bad" or "as bad as it can be."
• One-third said they were somewhat or very dissatisfied with work-life balance.
• Forty-six percent said they were feeling emotionally exhausted at least once a week.
• Nearly 29% said they felt detached or unable to feel emotion at least once a week.
• More than half said they had at least one symptom of burnout.

 The more educational debt the residents had incurred, the greater their emotional distress, the researchers found. Those with more than $200,000 of debt had a 59% higher chance of reporting emotional exhaustion, 72% greater likelihood of suffering burnout, and an 80% higher chance of feeling depersonalization.

Perhaps more alarming is the finding that greater stress was associated with lower test scores, and those students who were academically hurt by stress never caught up with their peers.

West said he can't explain why those more laden with debt are more stressed out. One possibility is that they may be more prone to stress to begin with.

Medical residents' stress has made news for years, and efforts are under way to improve their working conditions. However, West said, "to our knowledge, this is the first national study of residents' distress issues. And it's also the first national study to connect those issues to other important outcomes like medical knowledge."

As for solutions, he said "we have not yet identified the best ways to reduce burnout and promote well-being for residents, or for physicians in general."

He hopes that this new data, now gathered nationally, will help lead to solutions.

The findings come as no surprise to Dr. Peter Cronholm, an assistant professor of family medicine and community health and also a senior fellow at the Center for Public Health Initiatives of the University of Pennsylvania.

Cronholm, who published a study on resident burnout in 2008, said the residents of today may put more emphasis on work-life balance than previous generations.

One disturbing finding, he said, is that a stressed-out resident has less empathy over time. Already, close to one-third said they felt detached emotionally at least weekly.

However, he said, it's difficult to balance obligations to patients and get sufficient sleep and personal time. "Those two things sort of continue to compete with each other," he said.

Solutions aren't available yet, as "the problem is not yet totally understood. This is part of the conversation about health care reform," he said.

Drug Marketing Often Targets Med Students: Analysis

Robert Preidt
Medicine.net

Drug company marketing to those attending medical school is common and can cloud students' ethical judgment, researchers warn.

A team led by Kirsten Austad and Aaron S. Kesselheim at Harvard Medical School in Boston analyzed published studies that included a total of 9,850 students at 76 medical schools in the United States. The investigators found that most of the students had some type of interaction with drug companies and that this contact increased during the clinical years, with up to 90% of clinical students receiving some form of marketing materials from drug makers.

Among the students queried, most believed there was no ethical problem in accepting gifts from drug companies. Their justifications included financial hardship or pointing out that most other medical students accepted such gifts.

Nearly two-thirds of the medical students claimed that drug company promotions, gifts or interactions with sales representatives did not affect their impartiality regarding drug makers and their products.

The study authors said their findings suggest that strategies to educate medical students about interactions with drug makers should directly address widely held misconceptions about the effects of marketing.

In addition, medical schools need to introduce reforms, such as rules limiting contact between students and drug company representatives.

"These changes can help move medical education a step closer to two important goals: the cultivation of strong professional values, as well as the promotion of a respect for scientific principles and critical review of evidence that will later inform clinical decision-making and prescribing practices," the researchers concluded.

The study is published in the May 24 online edition of the journal PLoS Medicine.