Patients and technology

December 2014

Research

How confident are general practitioners in teaching medical students about ethical issues on general practice placements?

Volume 43, No.12, December 2014 Pages 880-883

Nancy J Sturman

Nargess Saiepour

Background

Despite a paucity of evidence to guide teaching about medical professionalism and ethical issues, there is a widespread consensus that medical students should learn about these issues on clinical placements. Exploring the confidence of general practitioners (GPs) in teaching various topics will identify areas for further discussion, support and/or training.

Methods

A survey was developed and distributed to 65 teaching practices. Thirty-seven GPs responded by rating their confidence in teaching about 32 different ethical issues.

Results

Overall, GPs were confident in teaching about these issues. Confidence was lowest for doctors’ social and political responsibilities; ethical lapses in colleagues; impairment in colleagues; cross-cultural issues; and moral motivation, judgement, courage and sensitivity.

Discussion

Further training for GP teachers may be particularly useful in the important areas of impairment and lapses in colleagues, and cross-cultural issues. Uncertainty about the scope of doctors’ social and political responsibilities may limit GP confidence in teaching in these areas.

In addition to improving their clinical knowledge and skills, medical students learn about medical ethics and professionalism in general practice during clinical placements with general practitioner (GP) teachers. A recently published Australian study reported that GP teachers readily identify a diverse range of common and important ethical issues in urban general practice,1 but there are no published studies of Australian GP teachers’ confidence in teaching medical students about particular ethical issues during their general practice placements.

The aim of this study was to identify common and important ethical issues that GP teachers are less confident in teaching, to encourage further discussion and to inform the provision of appropriate training and support in these areas.

Methods

A survey consisting of 32 common and/or important ethical issues that arise in general practice was mailed to every general practice in Brisbane that placed a University of Queensland third-year medical student in the final 8-week clinical placement block in 2011. Selection of issues was based on international literature about medical students’ experiences of ethics and professionalism while on clinical placements2–5 and on interview transcripts from a study in which 13 Australian urban GP teachers from diverse general practices described ethical issues that arose in their clinical work.1 The Jameton determinants of moral action, as described by Kelly and Nisker,5 were also included as issues for consideration; these issues are moral sensitivity, moral judgement, moral motivation and moral courage. Further information about the construction of the survey is available in a previous article.6 For each issue, participants were asked to rate their ‘confidence in teaching this area’ on a 5-point scale ranging from very low to very high.

A pilot survey of 13 GP teachers was conducted in 2010 and, following feedback, several topics were reworded or further explained for greater clarity. For example ‘including altruism without self-neglect’ was added to clarify ‘moral motivation’, ‘including ethical analysis’ was added to clarify ‘moral judgement’, and ‘including speaking up’ was added to clarify ‘moral courage’. The full list of issues included in the final GP teacher survey is shown in Table 1.

All surveys were anonymous. No participant demographic data were collected and no follow-up of non-returned surveys was undertaken. Survey responses were sorted into frequency tables showing the number of responses in each category for each ethical issue. Scores were assigned to the confidence ratings as follows: 1 (very low), 2 (low), 3 (adequate), 4 (high), 5 (very high). An average score for confidence was calculated for each issue.7 These scores were then ranked and the highest ranking was given to the highest average score. Ranked average scores were sorted into quartiles. The Wilcoxon signed-rank test was also used to compare ratings of ethical issues in the lowest quartile of average confidence with those in the highest quartile.8

Ethics approval was obtained from the University of Queensland Behavioural and Social Science Ethical Research Committee (2011000488) for the study.

Table 1. Ethical Issues included in the GP teacher survey of confidence in teaching

Allocation of healthcare resources, including GP gatekeeper role

Bending rules

Bioethics dilemmas, including euthanasia and pregnancy termination

Blurring boundaries, including sexually

Career and training decisions

Certification

Consent dilemmas

Cross-cultural issues

Discrimination against patients

Doctor health and life balance

Doctor social and political responsibilities

Ethical lapses in colleagues

Ethics in the teaching and learning environment

Gifts from patients

Impaired colleagues

Keeping up-to-date

Knowing your limits

Medical advice to family and friends

Medical mistakes

Medico-legal issues, including ‘defensive’ medicine

Moral courage, including speaking up

Moral judgement, including ethical analysis

Moral motivation, including altruism without self-neglect

Moral sensitivity

Patient confidentiality

Patient substance-dependence and drug-seeking

Practice business management, including income and fees

Relationship with pharmaceutical companies

Systems for ensuring safe clinical practice

Terminating the doctor–patient relationship

Truth telling in medical care, including requests to falsify clinical information

Working with medical and inter-professional colleagues

Results

The GP teacher survey had a response rate of 56.9% (37 of 65 surveys returned). Overall, participants reported being confident teaching about most ethical issues. Average confidence levels for all ethical issues were in the adequate-to-high range, except for one issue (patient confidentiality) in which average confidence was in the high-to-very high range. There were only six issues (doctor social and political responsibilities, moral motivation, moral courage, bending rules, ethical lapses in colleagues, and certification) in which more than 10% of participants rated their confidence in the low-to-very low range.

Those issues ranked in the highest and lowest quartiles of average self-rated teaching confidence are shown in Table 2. Minimum, maximum and mean scores for teaching confidence in each ethical issue are presented in Appendix 1 (available online only).

The Wilcoxon signed-rank test was used to compare ratings of ethical issues in the lowest quartile of average confidence with those in the highest quartile.8 Ratings for all issues in the lowest quartile were found to be significantly lower (P <0.05) than the ratings for those in the highest quartile. Appendix 2 (available online only) shows the z-scores and significance levels (values).

Table 2. GP teacher ratings of their confidence in teaching about ethical issues

 

Ethical issues

Rated in the HIGHEST quartile of average confidence
(in descending order of confidence)

Patient confidentiality

Working with medical and inter-professional colleagues

Keeping up-to-date

Medical mistakes

Systems for ensuring safe clinical practice

Practice business management, including income and fees

Truth telling in medical care, including requests to falsify clinical information

Relationship with pharmaceutical companies

Rated in the LOWEST quartile of average confidence
(in descending order of confidence)

Gifts from patients

Bending rules

Moral judgement, including ethical analysis

Impaired colleague

Moral motivation, including altruism without self-neglect

Cross-cultural issues

Ethical lapses in colleagues

Doctor social and political responsibilities

Discussion

Although GP teachers seem overall to be confident teaching about ethical issues, they are more confident teaching in some common and important ethical areas than others. Participant confidence was lowest in teaching about the issue of doctors’ social and political responsibilities. There is some evidence that medical students and GP teachers consider this to be a less important area for students to learn about.6 Sylvia and Richard Cruess,9 however, argue that medical professionalism should be understood as a social contract between members of the profession and society.

Despite acknowledging that medicine's influence on public policy declined in the 1960s and 1970s, along with challenges to many forms of authority, they claim that society continues to expect the medical profession to promote the public good, by concerning itself ‘with issues of importance to society’, as well as addressing ‘the problems faced by individual patients’.

The concept of ‘health advocacy’ encompasses a doctor’s responsibility to identify, and respond to, the social determinants of health, healthcare disparities and the needs of vulnerable or marginalised populations, in addition to ‘going in to bat for’ individual patients.10 The solutions to these issues may of course be controversial and contested, and it would seem appropriate to avoid indoctrinating students with personal opinion or party political views. Some doctors might argue that these discussions would be inappropriate and intrusive in clinical placements. Many would also deny that doctors have a specially privileged voice on social and political issues, merely by being medical practitioners. However, if the concept of health advocacy is accepted, it can be argued that clinical teachers should support medical student engagement with important social and political issues as new members of the medical profession, because doctors have a particular duty or responsibility to promote the public good in this way. Given a low confidence in the area on the part of GP teachers and students,6 the scope of these social and political responsibilities may merit further discussion within the profession.

Cross-cultural issues is another area in which GP teacher confidence is low and there is evidence that students rate this issue as being of high importance for students to learn about.6 Culturally competent health professionals will be essential for delivering effective, safe, patient-centred healthcare to the increasingly diverse Australian population11 and to close the gaps in health outcomes and access to healthcare for Aboriginal and Torres Strait Islander patients, migrant groups and other cultural minorities.12 Doctors will also increasingly be working in cross-cultural inter-professional teams and teaching culturally diverse students. Further support and training would therefore seem indicated to improve the confidence and competence in cross-cultural issues of both GP teachers and students.

GP teacher confidence is also relatively low in teaching about ‘impaired colleagues’ and ‘ethical lapses in colleagues’. The issues are difficult. In a 2010 North American study, only 69% of physicians from a range of specialities reported being somewhat or very prepared to deal with a colleague who practised medicine while they were impaired.13 There is also evidence that some GP teachers consider that the concept of ethical lapses in clinical practice is, on occasion, slippery: although some lapses are obvious and repugnant, other areas of professional difference are more nuanced and ‘grey’.14 Given the gravity of these issues, further discussion about how to recognise, manage and teach about impaired and/or transgressing colleagues is warranted.

Overall, participants rated their teaching confidence highly and there may have been a reluctance to admit to lower levels of confidence, even anonymously, in the context of a survey affiliated with the local discipline of general practice. High self-ratings of confidence are not, of course, direct evidence of high-quality teaching, and no inference can be made from these data about the quality of teaching or learning on GP placements. Unfortunately, this latter area is a difficult one to explore. There is little evidence in the literature to guide the evaluation of teaching, or the assessment of student learning, in the ethical and professional domain.15 Our findings also do not distinguish between a relative lack of GP confidence in dealing with the ethical issues and a lack of confidence specifically in teaching these issues in general practice. Teachers may, for example, consider that busy general practice consultations do not afford the time or opportunity to discuss some complex issues, or that it may be more appropriate to teach these issues in other contexts or at a more advanced stage of junior doctor training. Further research using other qualitative methodologies, including direct observation of practice-based teaching, is warranted to explore the complexity of student learning and GP teaching in this interesting and challenging domain.

The study has a number of limitations. The list of ethical issues in the survey is not definitive, and a case could be made for the inclusion of various other topics (although this would have had the disadvantage of further lengthening the survey). Explanatory footnotes may 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.

We have, however, identified a number of important ethical and professional issues which GP teachers are less confident teaching and in which they may welcome further discussion, training and support.

Implications for general practice

  • Although GPs’ confidence in teaching ethical issues was high overall, it was low in the difficult areas of ethical lapses in colleagues and impairment in colleagues, suggesting that further discussion and support may be useful.
  • More training is warranted to increase GP teacher confidence in teaching about cross-cultural issues.
  • Consideration should be given to encouraging further discussion among the profession about doctor social and political responsibilities.

Competing interests: None.
Provenance and peer review: Not commissioned, externally peer reviewed.

References

  1. Sturman NJ, Parker M, van Driel ML. The informal curriculum – general practitioner perceptions of ethics in clinical practice. Aust Fam Physician 2012;41:981–84.
  2. Caldicott CV, Faber-Langendoen K. Deception, discrimination, and fear of reprisal: lessons in ethics from third-year medical students. Acad Med 2005;80:866–73.
  3. Fard NN, Asghari F, Mirzazadeh A. Ethical issues confronted by medical students during clinical rotations. Med Educ 2010;44:723–30.
  4. Karnieli-Miller O, Vu TR, Holtman MC, Clyman SG, Inui TS. Medical students' professionalism narratives: a window on the informal and hidden curriculum. Acad Med 2010;85:124–33.
  5. Kelly E, Nisker J. Increasing bioethics education in preclinical medical curricula: what ethical dilemmas do clinical clerks experience? Acad Med 2009;84:498–504.
  6. Sturman N, Saiepour N. Ethics and professionalism in general practice placements: what should students learn? Aust Fam Physician 2014;43:468–72.
  7. Knapp TR. Treating ordinal scales as interval scales: an attempt to resolve the controversy. Nurs Res 1990;39:121–23.
  8. Plichta SB, Kelvin EA. Munro’s Statistical methods for Health Care Research. 6th edn. Philadelphia: Wolters Kluwer/Lippincott, Williams & Wilkins, 2013.
  9. Cruess R, Cruess S. Professionalism and medicine's social contract with society. Virtual Mentor 2004;6:virtualmentor.2004.6.4.msoc1-0404.
  10. Dharamsi S, Osei-Twum J, Shroff F, Mu L, Woollard R. The health advocate role: preparing future physicians for socially responsive practice. Vancouver: University of British Columbia, 2010. Available at https://circle.ubc.ca/bitstream/id/106145/The [Accessed 24 October 2014].
  11. National Health and Medical Research Council. Cultural competency in health: a guide for policy, partnerships and participation. Canberra: NHMRC, 2005.
  12. Henderson S, Kendall E. Culturally and linguistically diverse peoples' knowledge of accessibility and utilisation of health services: exploring the need for improvement in health service delivery. Aust J Prim Health 2011;17:195–201.
  13. DesRoches CM, Rao SR, Fromson JA, et al. Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA 2010;304:187–93.
  14. Sturman NJ, Parker M, van Driel ML. The informal curriculum – general practitioner perceptions of ethics in clinical practice. Aust Fam Physician 2012;41:981-84.
  15. Birden H, Glass N, Wilson I, Harrison M, Usherwood T, Nass D. Teaching professionalism in medical education: a Best Evidence Medical Education (BEME) systematic review. Med Teach 2013;35:e1252–66.

Correspondence afp@racgp.org.au

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