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Understanding the clinical dilemmas that shape medical students' ethical development: questionnaire survey and focus group study

Lisa K Hicks, house officer ^a, Yulia Lin, house officer ^a, David W Robertson, medical student ^a, Deborah L Robinson, house officer ^b, Sarah I Woodrow, house officer ^a. 

^a University of Toronto Faculty of Medicine, Toronto, Canada M5S 1A8, ^b *Authors are listed in alphabetical order because they made equal contributions to this work. University of Western Ontario, Faculty of Medicine, London, Ontario, Canada N6A 5B8

Correspondence to: D Robertson, 8 Clarence Square, Toronto, Canada M5V 1H1 davidw.robertson{at}utoronto.ca

During the past 30 years new medical technologies and public concern about medical ethics have led medical schools in Europe and North America to increase their teaching of formal ethics considerably. Most of this teaching focuses on dilemmas that students may face in their future practice, rather than the ethical problems they encounter as medical students. Several studies and editorials suggest that students' clinical experiences constitute an informal or "hidden" ethics curriculum,¹ which can undermine their developing professionalism. Clinical teachers who act as negative role models, especially those who show unethical behaviour towards patients, is the most frequently cited problematic aspect of this hidden curriculum.^1-5 Previous studies have focused on the prevalence of ethical dilemmas as perceived by students, rather than the nature of the dilemmas that students encounter. ^{4 5} Our study's premise was that the prevalence and the nature of medical students' ethical dilemmas need to be recognised and understood as a first step in resolving them.

	Methods and results

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We surveyed 108 clinical students (90% response rate) who were about one year away from completing medical school at the University of Toronto. We asked them to report how often they had been placed in a clinical situation in which they had felt pressure to act unethically. Nearly half (47%; 48/103) of students reported that this had happened to them very frequently, frequently, or occasionally. When asked to rate how often they had witnessed a clinical teacher acting unethically, 61% (62/102) of students reported that this had happened to them very frequently, frequently, or occasionally.

Having ascertained that students encountered ethically problematic situations in their clinical training, we held four focus groups with 20 clinical students who were one year from completing medical school. Our content analysis of the focus groups revealed three categories of ethically problematic situations: conflict between the priorities of medical education and those of patient care, responsibility beyond a student's capacities, and involvement in patient care perceived to be substandard (table).

Finally, in the focus groups, students reflected that the ethical problems they encountered were seldom discussed or resolved with clinical teachers. For instance, one medical student described a situation in which a number of medical students were disturbed by a situation they encountered, but felt powerless to resolve it.

"We were in seeing the patient and there were four medical students in there and this girl had already sat through an hour with me going through a complete history and physical. And then, the staff [clinical teacher] decided that he would use her for the rest of the two hours for all of us to do the exam on her and she had no idea why we were there . . . One of the medical students was looking at her fundi and he couldn't see them. So, the staff was yelling, "Any idiot can see the optic fundus. How can you not see it? I can see it. Look! Why can't you see it?" Then he said, "I want each and every one of you to keep looking until you see it." So the poor girl is getting blinded by four of us trying to see her fundi . . . He was just so inappropriate, the poor girl was almost in tears . . . We were all very intimidated; we thought it was inappropriate and we all talked about it later, but he [the clinical teacher] put us all in a position where we were scared to death of him. We were afraid to say anything [although] he was probably wrong."

	Comment

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Previous research indicates that medical students experience ethical dilemmas concerning patient care; our study confirms this and goes further by identifying three types of ethical dilemma characteristic of early clinical training. It also suggests that these dilemmas are seldom resolved during medical school. We hope that by learning to recognise and explore these ethical dilemmas medical educators will be able to expose, and ultimately dismantle, deleterious aspects of the "hidden curriculum" which currently hinder the ethical growth of medical students.

	Acknowledgments

Dr Sophia Ahmed helped conceive the study and carry out the survey, and Dr April Boyd helped with statistical analysis. Dr Peter Singer, Dr Philip Hébert, and Walter Atkins advised the authors or commented on drafts of this paper.

Contributors: All five authors conceived and carried out the study, analysed the data from the survey and focus groups, and wrote the manuscript. DWR is the guarantor.

	Footnotes

Funding: Faculty of Medicine, University of Toronto.

Competing interests: None declared.

	References

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1.	Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994; 69: 861-871[Medline].
2.	Swenson SL, Rothstein JA. Navigating the wards: teaching medical students to use their moral compasses. Acad Med 1996; 71: 591-594[Medline].
3.	St Onge J. Medical education must make room for student-specific ethical dilemmas. Can Med Assoc J 1997; 156: 1175-1177[Abstract].
4.	Bisonette R, O'Shea RM, Horwitz M, Route CF. A data-generated basis for medical ethics education: categorizing issues experienced by students during clinical training. Acad Med 1995; 70: 1035-1037[Medline].
5.	Feudtner C, Christakis DA, Christakis NA. Do clinical students suffer ethical erosion? Students' perceptions of their ethical and personal development. Acad Med 1994; 69: 670-679[Medline].

(Accepted 17 November 2000)