Guest Post: Dr Selena Knight and Dr Wing May Kong

Paper: Bridging the education-action gap – a near-peer case-based undergraduate ethics teaching programme

Medical ethics and law is a compulsory part of the UK undergraduate medical school curriculum. By the time they qualify, new junior doctors will have been exposed to ethics teaching in lectures and seminars, through assessments, and during clinical placements. However, does this really prepare them for the ethical minefield they will encounter as doctors?

Following my own graduation from medical school I started as a foundation year doctor in a busy London teaching hospital. Despite having had more exposure to ethics and law teaching than most by having completed an intercalated BSc in the subject, I found as a new doctor that I was often encountering ethical dilemmas on the wards but felt surprisingly ill-equipped to deal with them. I was generally able to identify that I was facing an ethical dilemma, but frequently found myself stuck when coming up with a practical solution.

If I felt like this having had an additional year of studying ethics and law, how on earth were other new doctors coping? In fact, when questioning my peers about their experiences they described that they also encountered dilemmas, but either didn’t specifically identify them as ethical in nature (e.g. they described feeling uncomfortable or uneasy with a decision made or a particular situation but couldn’t pinpoint why) and frequently described being unable to do anything to improve the situation either because they didn’t know what to do or they didn’t feel confident to speak up/rock the boat e.g. if they experienced a consultant acting unprofessionally

It became clear that even if ethics teaching at medical school was providing sufficient knowledge to enable junior doctors to identify ethical dilemmas, it was failing to prepare them to actually deal with such issues in practice. My own experiences, together with those I heard from my peers, formed the inspiration for the teaching programme that was subsequently designed.

The aim of the teaching programme was to create an informal space where medical students could bring ethically challenging cases they had encountered on their placements to small groups for discussion. Such groups would be facilitated by foundation doctors, who crucially had recently been students themselves, so may be more likely to be able to relate to the students’ experiences. Discussions would give students the opportunity to think through the dilemmas out loud, identify and analyse the ethical issues and tease out what the real barriers to ethical practice were. Importantly, the second part of the discussion was for students to work together to come up with practical courses of action that they would feel able to follow if they were in a similar situation in the future.

Feedback from students and foundation doctors was extremely positive, with students valuing the opportunity to discuss cases in this format, and foundation doctors enjoying offering a different type of teaching. Just having the opportunity to discuss their dilemmas was welcomed by many students giving them confidence to trust their moral instincts.

One of the most interesting findings on reviewing the themes and feedback emerging from sessions was that students were frequently able to identify the “ethically correct” course of action but felt unable to follow it. This was due to a number of barriers, such as hierarchal barriers, lack of confidence, or a perceived lack of experience. However, a lack of, or incorrect, knowledge of ethics and law was rarely the reason for their “unethical” choice of course of action.

This resonated with my own experiences, highlighting the fact that simply having knowledge of ethics and law is not sufficient in enabling students and junior doctors to practice ethically. The challenge facing medical educators is how to adequately prepare medical students for ethics in practice in an increasingly constrained curriculum. A programme such as this provides students with the opportunity to practice applying their knowledge of ethics and law to real cases, and develop their ethical reasoning skills. It also helps them develop their ethical sensitivity, as they identify the dilemmas themselves. It is hoped that this might better prepare them for life as junior doctors where they will continue to face ethical dilemmas and will need to be resourceful in how they work through such issues.