|ORIGINAL RESEARCH PAPER
|Year : 2010 | Volume
| Issue : 3 | Page : 330
Interns' Perceptions on Medical Ethics Education and Ethical Issues at the Dokuz Eylul University School of Medicine in Turkey
S Ozan, S Timbil, S Semin, B Musal
Dokuz Eylul University School of Medicine, Medical Education Department, Inciralti, Izmir, Turkey
|Date of Submission||26-Mar-2009|
|Date of Acceptance||08-Oct-2010|
|Date of Web Publication||30-Nov-2010|
Dokuz Eylul University School of Medicine, Medical Education Department, Inciralti, 35340 Izmir
Source of Support: None, Conflict of Interest: None
Aim: In Turkey and its neighboring countries, few studies have investigated medical students' reactions to ethics education and ethical issues they encounter. The aim of this study was to investigate interns' perceptions of medical ethics education and ethical issues.
Background: In students' first three years at the Dokuz Eylul University School of Medicine, various teaching methods are used in ethics education, including problem-based learning, interactive lectures and movies. During the clinical years, the curriculum helps students consider the ethical dimension of their clinical work, and during the internship period a discussion on ethical issues is held.
Material and methods: Data were collected through a questionnaire distributed to interns in the 2005-2006 academic year. Its questions asked about interns' perceived adequacy of their ethics education, any interpersonal ethical problems they had witnessed, their approaches to ethical problems, obstacles they believe prevented them from resolving ethical problems and whether they felt themselves ready to deal with ethical problems. 67.2 % of interns were reached and all of them responded.
Results: In the assessment of the adequacy of ethics education, the most favorable score was given to educators. Students' most often mentioned ethical problems encountered were between physicians and students and between physicians and patients. Interns believed that difficult personalities on the team and team hierarchy were important obstacles to resolving ethical problems. There were significant differences between the approaches students currently used in dealing with ethical problems and how they anticipated they would approach these problems in their future professional lives.
Conclusion: We obtained information about students' perceptions about ethics education and ethical problems which helped us to plan other educational activities. This study may assist other medical schools in preparing an ethics curriculum or help evaluate an existing curriculum.
Keywords: Medical ethics education, ethical problems, interns′ perceptions, medical students
|How to cite this article:|
Ozan S, Timbil S, Semin S, Musal B. Interns' Perceptions on Medical Ethics Education and Ethical Issues at the Dokuz Eylul University School of Medicine in Turkey. Educ Health 2010;23:330
|How to cite this URL:|
Ozan S, Timbil S, Semin S, Musal B. Interns' Perceptions on Medical Ethics Education and Ethical Issues at the Dokuz Eylul University School of Medicine in Turkey. Educ Health [serial online] 2010 [cited 2020 Nov 28];23:330. Available from: https://www.educationforhealth.net/text.asp?2010/23/3/330/101480
The World Medical Association (WMA) declared in 1999 that the topics of medical ethics and human rights should be included in the curriculum of medical schools worldwide1. The WMA states that the goal of ethics education is to enable students to identify difficult situations and deal with them in a rational and principled manner2. Ethics education aims to help medical students understand moral principles and analyze and define their own values3.
Interns witness and become involved in ethical situations starting from their first year of training4, including ethical situations arising from interactions among persons in the educational and healthcare teams2,5. Therefore, ethics education should be part of training from the start of the first year. Moreover, while undergraduate medical education is the best time to introduce medical ethics, the most efficient learning takes place when students encounter ethical problems and face real-life ethical issues, which is during their later, clinical years6,7. Evidence finds that students act more ethically in the beginning of their medical education, and during their education they tend to demonstrate regression in their ethical skills8.
Medical schools have been advised to develop their ethics program according to local needs and criteria9, while it has also been emphasized that all students should learn essentially the same core ethical principles10. Although there is not a single “best” teaching method, methods such as visual aides, small group studies, role play and integration within problem-based learning (PBL) scenarios are recommended. Various assessment methods are suggested, including faculty observation of students and the use of portfolios, peer and self-assessments, Objective Structured Clinical Examinations (OSCE), written examinations, and standardized patients11-14.
At the Dokuz Eylul University School of Medicine (DEUSM) in Turkey, students’ reactions are continuously and systematically solicited within the context of program evaluation studies. These reactions take place in the first level of Kirkpatrick’s program evaluation model15. Due to the importance of students’ opinions and experiences and the fact that in Turkey and neighboring countries studies that investigate interns’ reactions to ethics education and ethical issues are limited, the aim of the study was to investigate interns’ perceptions of the medical ethics program at DEUSM. The general research questions were to investigate interns’ perceptions of their medical ethics education and the ethical issues they encounter and their perceived readiness to deal with ethical problems and their approaches to these issues.
Since the establishment of a modern medical school in Turkey, lectures regarding medical ethics were given by various faculties in different classes, but over time greater focused importance was given to ethics education. The first medical history and deontology department was established in 193316. Nowadays, 32 of 50 medical schools have medical ethics/deontology departments. In schools where these departments do not exist, ethics is taught by faculty members from public health, forensic medicine and clinical departments17.
At the Dokuz Eylul University School of Medicine, medical ethics education has been part of the curriculum since the 1980’s. Starting with the 1997-1998 academic year, DEUSM has used problem-based learning (PBL) methods in its first three years of the curriculum18. In the 2000-2001 academic year, task-based learning was incorporated into the students’ clinical training of their fourth and fifth years19. The sixth year of medical school, which is the last year of the standard Turkish medical school curriculum, consists of an internship.
Medical ethics education was reviewed and adapted when the DEUSM changed over to the PBL system. The curriculum is given principally in the first three years under the supervision of the Medical Ethics Department, and is taught by various departments.
Interactive lectures, case studies and PBL, discussions of current media news, and movies are the ethics teaching methods in the first three years. In the third year, mini-scenarios are also used in small group studies where ethical problems are identified and discussed. In the clinical years, the aim is to enable students to consider the ethical dimension while performing their clinical tasks. During the internship period, a two-hour discussion session is held. Details of topics and teaching methods of DEUSM medical ethics program are given in Table 1.
Table 1: The topics and teaching methods of the DEUSM medical ethics program
Material and methods
In this cross-sectional study, during the 2005-2006 academic year a questionnaire was administered to students two months before graduation. The questionnaire was prepared by the authors and through literature review. All necessary approvals were obtained from DEUSM Dean’s Office: no additional review or approval is required at the school. Since interns practice in several different clinics, we gathered students together at their respective clinics for a presentation on the study. Students were informed of the survey’s aim, told that it was voluntary and anonymous, and reassured that there would be no consequences for non-participation. We reached 80 of the 119 interns at the clinics (67.2%) and all agreed and completed the questionnaire. The questionnaire queried students’ age and gender. Students were asked about the perceived adequacy of their ethics education, how they were assessed in ethics, how often they witnessed interpersonal ethical problems during their clinical rotations, how they approached ethical problems and how they anticipated they would deal with ethical issues in their future professional lives. Students were also asked about the obstacles they believed prevented them from solving ethical problems they faced at school, their opinions on the existence of ethical problems related to healthcare issues and the need for education and also whether they felt themselves ready to deal with ethical problems in their future professional lives. The questionnaire was piloted with ten fifth-year students.
A five-point scale was used for responses regarding the adequacy of medical ethics education, with higher scores indicating better adequacy (1=not at all adequate, 3=somewhat adequate, 5=very adequate). As for the assessment between adequacy and readiness, the total score of items related with the adequacy of medical ethics education were calculated. Median value of the total score of adequacy was considered as a cut-off point for comparison. The data were analyzed using SPSS 11.0 descriptive analysis, chi-square test, McNemar tests and Spearman correlations. A p<0.05 level was considered statistically significant.
Interns’ average age was 24.4±1.0, 56.3 % (n=45) were male and 43.8 % (n=35) female. On average, the interns’ ratings were above the median value of “3” for all items assessing the adequacy of their medical ethics education in its various aspects (Table 2). In addition, 55% of respondents indicated that assessment in ethics was not necessary, 5% said that they were uncertain whether assessment was useful and 40% indicated that assessment was necessary. Students preferred essay questions (42%) for being assessed in ethics, multiple choice questions (MCQ) (36%), projects or papers (31%), OSCE (25%) and standardized patient interviews (22%).
Table 2: Interns’ (n=80) opinions of the adequacy of medical ethics education at DEUSM
Interns’ observations regarding the frequency of interpersonal ethical problems they encountered in their clinical work are presented in table 3. Interns reported that they faced ethical problems most frequently between physicians-students, physicians-patients, physicians-nurses.
Table 3: The frequency of ethical problems between persons observed by interns (n=80) during their clinical training
Table 4 includes data on how the interns approached ethical problems as students and how they anticipate they will approach these problems during their professional lives. Most interns preferred talking to a reliable friend and keeping their opinions and feelings to themselves when they faced an ethical problem. On the other hand, they felt that they would directly talk to individual(s) involved in the issue and discuss the issue with the team in their future professional lives. A significant difference was found between their perceptions for the time of their education and their perceptions for the time in their future professional lives. Male and female interns’ differed in their approaches only in talking to a reliable friend(s) (χ2 =4.879, p= 0.027; respectively 48.9%, 73.5%) and keeping my feelings and opinions to myself (χ2 = 5.756, p=0.016; respectively 46.7%, 20.6%).
Table 4: How interns (n=80) approach ethical problems and how they anticipate they would approach ethical issues in their future professional livesa
Table 5 presents interns’ opinions on obstacles they believe prevent resolving ethical problems based on their observations at school. Difficult team members and team hierarchy were the obstacles most often seen as “very important”. While nothing would change even if I tried was the most often chosen item as being “not important” (18%), 26% of students also stated this was a “very important” reason.
Table 5: Interns’ (n=80) opinions on the perceived importance of various obstacles in preventing them from resolving ethical problems
Based on their observations, interns were asked about the ethical problems they believed existed in Turkey and whether students should be educated in these areas (Table 6). The most often stated ethical problems within Turkey were the organization of healthcare service, healthcare news covered by the media, knowledge on basic medical ethics principles/rules, and monetary relations between physicians and patients. The organization of healthcare services in Turkey, genetic applications, malpractice and monetary relations between physicians and patients were the most frequently selected issues for which ethics education was needed. Differences between male and female interns in their evaluation of the ethics topics for which education is needed were found only for physicians’ responsibilities towards the patients and the community (χ2=5.222, p= 0.022); 94.1% of male interns stated that there is a need for education on this topic whereas for females this was 73.3%. When asked if they felt themselves ready to deal with ethical problems in their future professional lives, 13.9% of the interns said that they felt “ready”, 74.7% felt “partially ready”, while 11.4% felt “not ready”.
Table 6: Percentage of interns (n=80) who perceived various ethical topics to be issues/problems within Turkey and the percentages who perceived a need for students to be educated in these areas
The correlation coefficient between the adequacy of medical ethics training score and the perceived readiness to deal with ethical problems in future professional life point was 0.396. Adequacy of medical ethics training was found significantly associated with the readiness to deal with ethical problems in the future (χ2=5.767, p= 0.016). Of the interns who stated their medical ethics training was not sufficient, 76.5% felt ready/partially ready to deal with an ethical problem in their future professional life; of interns who stated that medical ethics training was sufficient, 97.5% felt ready/partially ready.
This study provided data on interns’ opinions of their medical ethics education at DEUSM. Educators were given the highest adequacy score among components of their ethics curriculum. This was similar with the finding in a previous study in our school, which investigated interns’ opinions on the efficacy of the education in school20.
The lowest adequacy rating in students’ ethics education was given to the acquisition of skills to solve ethical problems. Another relevant finding was that most interns felt themselves to be “partially ready” to deal with ethical problems in their future professional lives. Perhaps students are ready, but they may be naive about what it will take to respond to ethic issues. This may be due to their lack of experience in real world clinical practice. Due to the social nature of ethical problems, a variety of factors play a role in their resolution. Resolution is less dependent on the knowledge and skills of individuals and more dependent on an appropriate social environment and team approach. The need for continued and reinforced education in ethics after graduation has been emphasized6,10.
More than half of our students felt that assessment of their ethics skills was “not necessary”. Since students tend to pay more attention to curriculum if they are tested on it6,21,22, medical ethics should be subject to assessment just like other core curriculum items23. Among interns who felt assessment was necessary, the most often preferred assessment approach was through essay questions, an approach that enables students to discuss their opinions, solutions and recommendations for specific ethical issues. This method is also recommended in the literature11. However, at DEUSM, the most commonly used assessment method has been the multiple choice questionnaire, which was the second method preferred by the interns. In another study, students considered that multiple choice questions, best matching answers and single best answers were inappropriate for ethics evaluation. They preferred case studies with short written answers24.
The most often perceived ethical problems in students’ clinical experiences were between physicians and students. This finding reveals how important it is to review this issue from the students’ perspective. In fact, teachers must be aware of the impact of their attitudes and behaviors on the development and professional socialization of their students. They must realize that they are expected to interact with students respectfully and serve as role models in the ethical provision of services2,25.
The data on how our interns approach ethical problems and how they anticipate they will approach ethical problems in their future, professional lives suggest that interns anticipate they will adopt more effective approaches and take more initiative when they enter their professional careers. When students encounter ethical problems, experience has shown us that students tend to act to succeed or simply survive in their roles, even when they think their actions are unethical: they often feel they don’t have adequate knowledge about these situations and recognize their inexperience and that they are the lowest ranking member of the medical team. Nevertheless, they also believe that in the future they will follow sound ethical codes in their professional lives, when they have greater knowledge and power26.
During their time as learners, most interns’ first choice for addressing ethical problems was talking to a reliable friend. Although this seems to be positive in terms of expressing and sharing a problem, use of this method exclusively is generally not effective in resolving problems. Students’ second most often preferred approach was keeping their feelings and opinions to themselves, indicating that they have not yet adopted adequate and effective approaches to resolving ethical problems. Huijer et al. report that interns hesitate to talk or ask critical questions when they don’t agree with the values and behaviors of their supervisors3.
For their future work as fully trained physicians, students most often indicated that they would talk to the individuals involved in ethical problems they encountered and discuss the issue with the healthcare team. This suggests that they are aware of their responsibilities and believe that in the future they will be more proactive in addressing ethical issues.
Having difficult team members and the team hierarchy were most often stated as most important obstacles preventing the resolution of ethical problems. This reveals how important the educational milieu is to ethical issues. Students spend long hours with clinical lecturers and learn how they should approach patients by observing their lecturers27. Teachers, acting as role models, play a crucial role in shaping the behaviors and attitudes of tomorrow’s physicians6.
A lack of suitable environment in which to discuss ethical issues was also rated as very important/important by most interns, confirming similar findings by Satterwhite et al.26. Hicks et al. reported that clinical students rarely discussed and resolved ethical problems with clinical lecturers5.
Another obstacle, perceived by over half of students, to preventing resolution of ethical problems was a belief that nothing would change even if tried. This feeling of hopelessness and pessimism is unfortunate and should not be reinforced.
The most often perceived ethical problem in Turkey was the organization of healthcare services, and interns perceived highest need for education in this area. In recent years, substantial changes have taken place in Turkey’s organization of healthcare services. These changes may be the reason why this was the most identified area of ethical concern. The least chosen identified area of ethical concern within Turkey was the provision of emergency health service, which was also the least chosen item for educational need. This may be because the number of physicians specializing in emergency medicine has steadily increased in Turkey, the emergency ambulance services network has become more effective and public awareness has increased through training.
Most interns responded that they felt themselves “partially ready” to deal with ethical problems after graduation. While solutions to specific ethical problems are defined clearly and appropriate conduct is described, this is not possible for some more complex ethical problems2. Even practicing physicians tend to avoid conflict when faced with an ethical problem and ask for support in making decisions28. Despite a number of challenges preventing resolution of ethical problems, the finding that most of DEUSM’s interns felt themselves at least partially ready to address ethical problems we consider to be positive news, even if students’ perceptions are not fully accurate, as the study’s aim was to investigate the interns’ perceptions. Although the correlation between the perceived adequacy of ethics education and the interns’ perceived readiness to deal with ethical problems is not particularly high, they are nevertheless correlated.
One of the study’s limitations was that we could not reach the entire target population due to the interns’ rotation to different clinics. A further limitation was that the questions about the approaches interns do and will take towards ethical problems rely on self-reports and how interns anticipate the future, which may not reflect their actual current or future behavior. It would be valuable to know what their actual approach in their future professional practice will be.
In this study we obtained information about DEUSM intern’s perceptions about their ethics education and the ethical problems they encounter. While applying interns’ evaluation of their ethical educational needs, in the coming years we plan to have students write reports or papers on books, movies and specific ethical issues, emphasize the critical ethical principles when they carry out clinical tasks as learners, and structure various activities using standardized patient interviews. It is our goal to develop and sustain new applications to be implemented in the medical ethics education at DEUSM. In the field of medical ethics where clinicians face many problems, the findings and related discussions of this study may highlight issues and point to solutions for other medical schools as they create their ethics curriculum and evaluate their existing curriculum.
1. Peeling RW, Saxena A. Books & Electronic Media. Medical Ethics Manual. Bulletin of the World Health Organization. 2006; 84(2):159-160, Available from http://www.who.int/bulletin/volumes/84/2/159.pdf
2. Williams JR. World Medical Association Medical Ethics Manual. The Ethics Unit of the World Medical Association. WMA: Ferney-Voltaire, France; 2005.
3. Huijer M, Van Leeuwen E, Boenink A, Kimsma G. Medical Students’ cases as an empirical basis for teaching clinical ethics. Academic Medicine. 2000; 75:834-839.
4. Satterwhite WM, Satterwhite RC, Enarson CE. “Doing what I know is wrong” – a survey on unethical conduct at one medical school. Academic Medicine. 1998; 73:529-531.
5. Hicks LK, Lin Y, Robertson DW, Robinson DL, Woodrow SI. Understanding the clinical dilemmas that shape medical students’ ethical development: questionnaire survey and focus group study. British Medical Journal. 2001; 322:709-710.
6. Braunack-Mayer AJ, Gillam LH, Vance EF, Gillett GR, Kerridge IH, McPhee J, Saul P, Smith DE, Wellsmore HM, Koczwara B, Rogers WA, McNeill PM, Newell CJ, Parker MH, Walton M, Whitehall JS. An ethics core curriculum for Australasian medical schools. Medical Journal of Australia. 2001; 175:205-201.
7. Singer PA. Strengthening the role of ethics in medical education. Canadian Medical Association Journal. 2003; 168:854-855.
8. Patenaude J, Niyonsenga T, Fafard D. Changes in students’ moral development during medical school: a cohort study. Canadian Medical Association Journal. 2003; 168:840-844.
9. Musick DW. Teaching medical ethics: A review of the literature from North American medical schools with emphasis on education. Medicine, Health Care and Philosophy. 1999; 2(3):239-254.
10. Martinez SA. Currents in contemporary ethics. The Journal of Law, Medicine & Ethics. 2002; 30:452-454.
11. Shumway JM, Harden RM. AMEE Guide No 25: The assessment of learning outcomes for the competent and reflective physician. Medical Teacher. 2003; 25:569-584.
12. Miles SH, Bannick-Mohrland S, Lurie N. “Advance-treatment planning discussions with nursing home residents: pilot experience with simulated interviews.” Journal of Clinical Ethics. 1990; 2:108-112.
13. Singer PA, Robb AK. The Ethics OSCE: Standardized patient scenarios for teaching and evaluating bioethics. University of Toronto: EFPO; 1994. Available from http://wings.buffalo.edu/faculty/research/bioethics/osce.html
14. Smith SR, Balint JA, Krause KC, Moore-West M, Viles PH. Performance-based assessment of moral reasoning and ethical judgment among medical students. Academic Medicine. 1994; 69:381-386.
15. Nickols F. Evaluating training: There is no “cookbook” approach. 2003. Available from http://www.nickols.us/evaluating_training.pdf
16. Demirhan Erdemir A. Türkiye’deki tip etigi calismalarinin dünya kültürlerine etkisi üzerine görüsler (Opinions on the impact of medical ethics studies’ in Turkey on world cultures). 2006. Available from http://www.medimagazin.com.tr/mm-turkiyedeki-tip-etigi-calismalarinin-dunya-kulturlerine-etkisi-uzerine-gorusler-ky-50784.html
17. Sayek I, Kiper N, Odabasi O. Turk Tabipleri Birligi Mezuniyet Oncesi Tip Egitimi Raporu (Undergraduate Medical Education Report), Turk Tabipleri Birligi Yayinlari, Ankara. 2006. Available at: http://www.ttb.org.tr/kutuphane/mote_2006.pdf
18. Musal B, Taskiran C, Kelson A. Opinions of Tutors and Students about Effectiveness of PBL in Dokuz Eylul University School of Medicine. Medical Education Onlineserial online. 2003; 8:16. Available from http://med-ed-online.net/index.php/meo/article/view/4345/4527
19. Ozkan H, Degirmenci B, Musal B, Itil O, Akalin E, Kilinc O et al. Task-Based Learning programme for clinical years of medical education. Education for Health. 2006; 19: 32-42.
20. Ozan S, Karademir S, Gursel Y, Taskiran HC, Musal B. First graduates’ perceptions on Problem-Based and Task-Based Learning Curriculum. Education for Health. 2005; 18:256-271.
21. Boon K, Turner J. Ethical and Professional conduct of medical students: Review of current assessment measures and controversies. Journal of Medical Ethics. 2004; 30:221-226.
22. Savelescu J, Crisp R, Fulford KWM, Hope T. Evaluating ethics competence in medical education. Journal of Medical Ethics. 1999; 25:367-374.
23. Goldie J, Schwartz L, McConnachie A, Morrison J. The impact of three years’ ethics teaching, in an integrated medical curriculum, on students’ proposed behavior on meeting ethical dilemmas. Medical Education. 2002; 36:489-497.
24. Johnston C, Haughton P. Medical students’ perceptions of their ethics teaching. Journal of Medical Ethics. 2007; 33:418–422.
25. Neitzke G, Fehr F. Teachers’ responsibility: a Socratic dialogue about teaching medical ethics. Medical Teacher. 2003; 25:92-93.
26. Satterwhite RC, Satterwhite III WM, Enarson C. An ethical paradox: the effect of unethical conduct on medical students’ values. Journal of Medical Ethics. 2000; 26:462-465.
27. Haghdoost AA, Shakibi MR. Medical student and academic staff perceptions of role models: an analytical cross-sectional study. BMC Medical Education. 2006; 6:9. Available from http://www.biomedcentral.com/1472-6920/6/9
28. Hurst SA, Hull SC, Duval G, Danis M. How physicians face ethical difficulties: A qualitative analysis. Journal of Medical Ethics. 2005; 31:7-14.