Issues that students rate as important but in which their confidence is low are likely to be important learning goals for students. GP teachers will be less likely to facilitate student learning if they fail to identify learning opportunities when they arise, underestimate their importance to students or overestimate student confidence in these issues. This study was aimed at identifying the most important ethical issues from the viewpoint of students and teachers, to assist both parties in meeting students’ learning goals.
Methods
Two cohorts of Brisbane-based, University of Queensland students who had completed their general practice placements in November 2011 and March 2012 were invited to complete a paper-based survey. A GP teacher survey was mailed to each practice at which a Brisbane-based student had been accepted for placement in November 2011. All surveys were anonymous and no follow-up of non-returned surveys was undertaken.
A new survey was developed for this study as no previous relevant survey could be identified. Thirty-two common and/or important ethical issues were included and participants were asked to rate the importance of students learning about each issue.
The initial selection of issues was based on international literature about student self-reported experiences of ethical issues on clinical placements.4–8 A number of issues were excluded because they arose predominantly in the context of hospital practice (including futile treatments and ethics in research). This preliminary list was then compared with a descriptive content analysis of interview transcripts from a 2010 study in which 13 Australian urban GP teachers from diverse general practices described ethical issues that arose in their general practices.3 Most of the initially selected issues were also identified by the Australian GP teachers. Three issues from the international literature were included in the final survey, despite not being reported in the Australian study: ethics in medical education;7–11 ethical lapses in colleagues;8,9,11 and discriminatory treatment of patients.8–10 The Jameton determinants of moral action, as described by Kelly and Nisker,8 were also included; these are moral sensitivity, moral judgement, moral motivation and moral courage. Ginsburg’s phrase ‘altruism without self-neglect’ was added to clarify moral motivation, and ‘speaking up’ was added to clarify moral courage for participants who might be unfamiliar with these determinants. Two issues present only in the Australian GP teacher data were included in the final survey (practice business management and doctor health and life balance) because they were identified as common and/or important by the GP participants. Finally, the Royal Australian College of General Practitioners resource for doctors, Face-to-face: challenging cases in medical practice12 (which included some of ‘the most common, professionally challenging situations doctors face in medical practice’), was reviewed to ensure there were no omissions of importance to Australian general practice. The full list of issues is shown in Table 1.
Table 1. Ethical issues included in final participant surveys
| Allocation of healthcare resources, including GP gatekeeper role |
Knowing your limits |
| Bending rules |
Medical advice to family and friends |
| Bioethics dilemmas, including euthanasia and pregnancy termination |
Medical mistakes |
| Blurring boundaries, including sexually |
Medicolegal issues, including ‘defensive’ medicine |
| Career and training decisions |
Moral courage, including speaking up |
| Certification |
Moral judgement, including ethical analysis |
| Consent dilemmas |
Moral motivation, including altruism without self-neglect |
| Cross-cultural issues |
Moral sensitivity |
| Discrimination against patients |
Patient confidentiality |
| Doctor health and life balance |
Patient substance dependence and drug-seeking |
| Doctor social and political responsibilities |
Practice business management, including income and fees |
| Ethical lapses in colleagues |
Relationship with pharmaceutical companies |
| Ethics in the teaching and learning environment |
Systems for ensuring safe clinical practice |
| Gifts from patients |
Terminating the doctor–patient relationship |
| Impaired colleagues |
Truth telling in medical care, including requests to falsify clinical information |
| Keeping up to date |
Working with medical and inter-professional colleagues |
The survey was piloted in 2011 with 13 GP teachers and three students, and several topics were reworded for greater clarity following feedback. For each issue, participants were asked to rate on a 5-point scale the extent to which they agreed or disagreed with the statement ‘Medical students should learn about’ each issue. Students were also asked to rate their ‘confidence in this area’ for each issue on a 5-point scale (very low scored –2 to very high scored +2).
An average score for importance was calculated for each issue (for student and teacher respondents). These scores were then ranked with the highest ranking given to the highest average score. Ranked scores were sorted into quartiles and teacher and student rankings were compared. An average score for student confidence was also calculated for each issue. The issue ‘Practice business management, including income and fees’ was included only in the 2012 student survey and the GP teacher survey. The student ranking on this issue is therefore based only on the 2012 student survey.
Ethics approval was obtained from the University of Queensland Human Research Ethics Committee for the study (Reference number 2011000488).
Results
The medical student survey had a response rate of 91.7 % (121 out of 132 surveys returned). The GP teacher survey had a response rate of 56.9% (37 of 65 surveys returned). Participant rankings are compared in Tables 2 and 3. Commonalities between GP teacher and student rankings (those ethical issues ranked in the highest or lowest quartile by both groups of participants) are shown in Table 2. Differences between GP teacher and student rankings (those issues ranked in the highest or lowest quartile by only one of the two groups) are shown in Table 3.
Table 2. Participant ratings of the importance of students learning about ethical issues: commonalities between GPs and students
| Ethical issues |
|---|
| Rated by BOTH GPs and students in the HIGHEST quartile of importance |
Medical mistakes |
| Patient confidentiality |
| Patient substance dependence and drug-seeking |
| Working with medical and inter-professional colleagues |
| Rated by BOTH GPs and students in the LOWEST quartile of importance |
Bending rules |
| Doctor social and political responsibilities |
| Gifts from patients |
| Moral judgment |
| Moral motivation |
| Moral sensitivity |
Table 3. Participant ratings of the importance of students learning about ethical issues: differences between GPs and students
| Ethical issues |
|---|
| Rated by ONLY STUDENTS in the HIGHEST quartile of importance |
Bioethics dilemmas |
| Career and training decisions |
| Consent dilemmas |
| Cross-cultural issues |
| Rated by ONLY STUDENTS in the LOWEST quartile of importance |
Ethics in the teaching and learning environment |
| Moral courage, including speaking up |
| Rated by ONLY GPs in the HIGHEST quartile of importance |
Doctor health and life balance |
| Keeping up to date |
| Knowing your limits |
| Medicolegal issues |
| Rated by ONLY GPs in the LOWEST quartile of importance |
Ethical lapses in colleagues |
| Relationship with pharmaceutical companies |
Minimum, maximum and mean scores for each ethical issue are presented in Table 4.
Table 4. Minimum, maximum and mean scores for each ethical issue
| GPs (importance) | Students (importance) | Students (confidence) |
|---|
| Min | Max | Mean | Min | Max | Mean | Min | Max | Mean |
|---|
| Allocation of healthcare resources, including GP gatekeeper role |
0 |
3 |
1.95 |
0 |
3 |
1.68 |
–2 |
2 |
0.160 |
| Bending rules |
–1 |
3 |
1.18 |
–1 |
3 |
1.42 |
–2 |
2 |
–0.06 |
| Bioethics dilemmas, including euthanasia and pregnancy termination |
–1 |
3 |
1.59 |
0 |
3 |
1.93 |
–1 |
2 |
0.30 |
| Blurring boundaries, including sexually |
1 |
3 |
1.97 |
–1 |
3 |
1.72 |
–1 |
2 |
0.38 |
| Career and training decisions |
0 |
3 |
1.76 |
0 |
3 |
1.93 |
–2 |
2 |
0.03 |
| Certification |
0 |
3 |
1.60 |
0 |
3 |
1.67 |
–2 |
2 |
0.13 |
| Consent dilemmas |
0 |
3 |
1.77 |
0 |
3 |
1.90 |
–2 |
2 |
0.27 |
| Cross-cultural issues |
0 |
3 |
1.56 |
0 |
3 |
1.84 |
–1 |
2 |
0.29 |
| Discrimination against patients |
0 |
3 |
1.84 |
–1 |
3 |
1.74 |
–2 |
2 |
0.40 |
| Doctor health and life balance |
0 |
3 |
2.22 |
–1 |
3 |
1.68 |
–1 |
2 |
0.38 |
| Doctor social and political responsibilities |
–1 |
3 |
1.49 |
–1 |
3 |
1.59 |
–2 |
2 |
0.13 |
| Ethical lapses in colleagues |
0 |
3 |
1.35 |
0 |
3 |
1.63 |
–1 |
2 |
0.24 |
| Ethics in the teaching and learning environment |
0 |
3 |
1.76 |
–1 |
3 |
1.61 |
–2 |
2 |
0.28 |
| Gifts from patients |
0 |
3 |
1.09 |
0 |
3 |
1.47 |
–1 |
2 |
0.21 |
| Impaired colleagues |
0 |
3 |
1.81 |
0 |
3 |
1.73 |
–2 |
2 |
0.28 |
| Keeping up to date |
0 |
3 |
2.05 |
0 |
3 |
1.84 |
–1 |
2 |
0.34 |
| Knowing your limits |
1 |
3 |
2.22 |
0 |
3 |
1.75 |
–1 |
2 |
0.36 |
| Medical advice to family and friends |
0 |
3 |
1.84 |
0 |
3 |
1.68 |
–2 |
2 |
0.20 |
| Medical mistakes |
1 |
3 |
2.27 |
0 |
3 |
1.86 |
–2 |
2 |
0.12 |
| Medicolegal issues, including ‘defensive’ medicine |
0 |
3 |
2.08 |
–1 |
3 |
1.76 |
–2 |
2 |
0.24 |
| Moral courage, including speaking up |
0 |
3 |
1.71 |
–1 |
3 |
1.60 |
–2 |
2 |
0.18 |
| Moral judgment, including ethical analysis |
–1 |
3 |
1.47 |
–1 |
3 |
1.61 |
–1 |
2 |
0.31 |
| Moral motivation, including altruism without self-neglect |
–1 |
3 |
1.44 |
–1 |
3 |
1.54 |
–2 |
2 |
0.24 |
| Moral sensitivity |
–1 |
3 |
1.37 |
0 |
3 |
1.59 |
–1 |
2 |
0.39 |
| Patient confidentiality |
1 |
3 |
2.51 |
–1 |
3 |
1.98 |
–1 |
2 |
0.67 |
| Patient substance dependence and drug-seeking |
1 |
3 |
2.09 |
0 |
3 |
1.84 |
–2 |
2 |
0.28 |
| Practice business management, including income and fees |
–1 |
3 |
1.60 |
–1 |
3 |
1.63 |
–2 |
2 |
-0.13 |
| Relationship with pharmaceutical companies |
0 |
3 |
1.49 |
–1 |
3 |
1.66 |
–2 |
2 |
0.27 |
| Systems for ensuring safe clinical practice |
0 |
3 |
1.87 |
0 |
3 |
1.79 |
–1 |
2 |
0.23 |
| Terminating the doctor–patient relationship |
0 |
3 |
1.59 |
–1 |
3 |
1.63 |
–2 |
2 |
-0.02 |
| Truth telling in medical care, including requests to falsify clinical information |
0 |
3 |
2.03 |
0 |
3 |
1.76 |
–2 |
2 |
0.25 |
| Working with medical and inter-professional colleagues |
1 |
3 |
2.16 |
–1 |
3 |
1.87 |
–2 |
2 |
0.36 |
The results for student self-rated confidence in managing all issues are summarised in Table 5.
Three GP teacher participants added comments in a free text section, including a statement about the importance of sexual morality and prejudice.
Table 5. Student self-rated confidence in ethical areas
| Ethical issues |
|---|
| Self-rated student confidence in the HIGHEST quartile |
Blurring boundaries, including sexually |
| Discrimination against patients |
| Doctor health and life balance |
| Keeping up to date |
| Knowing your limits |
| Moral sensitivity |
| Patient confidentiality |
| Working with medical and inter-professional colleagues |
| Self-rated student confidence in the LOWEST quartile |
Allocation of healthcare resources |
| Bending rules |
| Career and training decisions |
| Certification |
| Doctor social and political responsibilities |
| Medical mistakes |
| Practice business management, including income and fees |
| Terminating the doctor–patient relationship |
Discussion
This study found that there is considerable agreement between GP teachers and students with respect to the ethical issues rated the most important for student learning. Of these issues, student confidence was lowest in medical mistakes, which therefore seems to be a key learning goal for students. A study by Martinez and Lo13 concluded that medical educators should increase student exposure to exemplary responses to medical error, and that there are many missed opportunities to teach students how to respond to and learn from errors. Students who witnessed senior doctors taking responsibility for errors in this study described these as powerful and aspirational experiences. Others who witnessed non-disclosure described considerable moral distress.
High student confidence in the area of confidentiality suggests that students consider this issue relatively unproblematic. GPs, by contrast, report a range of confidentiality dilemmas, including treating practice staff, mandatory notification and various requests for release of medical records.3 Indeed, it has been argued that ‘to pretend that we are confidential is currently misleading’ given the increased sharing of originally confidential information among other parties.14 Context is important in teaching professionalism15 and student exposure to confidentiality issues in more problematic contexts is likely to be beneficial.
Student self-reported confidence was high in several other areas that were rated particularly important by GP teachers, including doctor health and life balance, keeping up to date, knowing your limits, and working with medical and inter-professional colleagues. Relationships with senior doctors and new multi-professional teams are, however, reported to be a significant source of stress in the transition from medical student to junior doctor.16
Of the ethical issues included in the highest quartile of importance only by students, career and training decisions was notable for being ranked in the lowest quartile of importance by GP teachers. Students also rated their confidence in this area in the lowest quartile. This is an important finding for GP teachers, many of whom are interested in showcasing general practice as a career;17 they should not hesitate to discuss general practice (and other specialty) career and training decisions explicitly with students.
There was considerable agreement between students and GP teachers with respect to the ethical issues ranked the least important for student learning. Both included moral sensitivity, motivation and judgement in the lowest quartile. Students also included moral courage in their lowest quartile. This may be related to unfamiliarity with this terminology, or participants may be uncomfortable conceptualising professionalism as an ‘ethos grounding an approach to medical practice’18 rather than a set of attributes or behaviours. However, it can be argued that virtues such as moral courage, particularly the courage to ‘speak up’ about, and ‘say no’ to, unethical practices even at some personal risk (including the risk of lower grades), are part of the social contract between members of the medical profession and society.19 Discussion about when and how to do this may be invaluable for students and reduce the risk of moral distress20 or increasing moral cynicism.
It is also noteworthy that GPs teachers and students rated gifts from patients as either the least or the second least important issue for students to learn about, perhaps reflecting an acceptance of this relatively common phenomenon. GP teachers also rated relationships with pharmaceutical companies in their lowest quartile of importance, perhaps reflecting a view that this was an issue of limited current relevance to medical students.
This survey study has a number of limitations. The list of ethical issues is not definitive and a case could be made for (and against) the inclusion of various other topics. Explanatory footnotes would have reduced the risk of misinterpretation of the terminology used. No comment can be made about possible differences between responder and non-responder GP teachers. Further research using other qualitative methodologies, including observations of actual consultations, are indicated to explore the complexity of student learning and GP teaching, in this interesting and challenging domain.
Medical student responses to the survey instrument will, however, assist GPs to identify opportunities for teaching about ethical issues, and help students to meet their learning goals.
Key points
- Learning how to respond to medical error is a key learning goal for students, and opportunities to observe a doctor disclosing a medical error are highly valued.
- Students and GP teachers may underestimate the importance of learning and teaching about moral sensitivity, moral reasoning, moral motivation and moral courage.
- GP teachers should not hesitate to discuss general practice (and other specialty) career and training decisions explicitly with students
- Students are likely to benefit from discussion about the more problematic contexts in which confidentiality, and working with colleagues, arise in general practice.
Competing interest: None.
Provenance and peer review: Not commissioned; externally peer reviewed.