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The quotes from the Pillar 1 students were selected by faculty, using accepted qualitative methodologies, as typical student narrative responses to issues raised during introductory bioethics lectures. The quotes from the Pillar 2 and Pillar 3 students were selected by two ethics faculty who reviewed all of the student responses posted on the online discussion boards that are developed for each course.

In each case, the quotes were selected to be representative and illustrative of the ideas offered by students in response to the readings and clinical vignettes under discussion. The guiding framework, when selecting representative quotes, embodied an effort to shed light on themes, concerns, and concepts that seemed relevant and meaningful to students. Notable was the movement from unease and discomfort that Pillar 1 students often expressed when encountering ethical issues to the interest and willingness to respond expressed by the Pillar 2 and Pillar 3 students.

In order to uphold ethical standards, written permission was sought from all students prior to inclusion of their unattributed quotes.

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Methods: Designing an Integrated Ethics Program. For a number of years, the SSOM ethics faculty have used traditional pedagogic strategies like lectures, small group discussions, reflective writing, and individualized study when providing ethics education. In , these approaches were bolstered by the creation of online and distance coursework that could both deepen the program and include students who pursue the FARM, global, or out-of-state options afforded by the SSOM three pillar system.

The curriculum that has emerged appears to both enhance ethical awareness and augment the development of skills over time and in diverse — including very rural — settings. All Pillar 1 students explore the topics of medical ethics and professionalism via four minute seminars that employ lectures, small group discussions, and film.

The seminars are led by physician role models who can attest to the importance and relevance of the practical issues under consideration. Freeman, Schellinger, Olsen et al. Since the micro-ethics of everyday practice requires a practical interaction with patients, resolution speaks to the actions and words that are chosen or avoided in every day care. The second seminar focuses on the practical challenges of decision-making. The third session uses lectures, assigned readings and small group discussions to explore how contextual factors like culture, research, disease status, competing values, and interpersonal relationships influence the plan of care.

The fourth session focuses on professional challenges posed by issues like the difficult patient and the impaired physician.

Rachel Naomi Remen. In Pillar 2, all students enroll in a required, 1-credit online Clinical Ethics course that is delivered weekly over a 5 month period of time and reinforces the topics introduced during their Pillar 1 ethics sessions. For this innovative course, the students are divided into four cohorts that are small enough in size to permit meaningful discussion and dialogue.

Carefully selected weekly readings, clinical vignettes, and discussion questions help students explore how they recognize, analyze, approach, discuss, and resolve ethics-related issues.

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Throughout each week, students are required to respond to readings, vignettes, and questions by posting their reactions, questions, ideas, and suggestions on their cohort discussion board. The discussion board provides a safe space for students to learn from one another, to reflect, to find the words to describe the issues they face, and to practice what it means to actually engage in peer dialogue about ethical issues across diverse placement sites without fear of repercussions. Students are further encouraged to seek opportunities to apply insights to their Pillar 2 clinical experiences and to discuss the readings and vignettes with their attending physicians.

Such discussions help move considerations about ethics from the classroom to the bedside. Thus, incrementally over the 5 month time span, the students build conceptual tools and practical experiences that enhance recognition of ethical issues, facilitate discussion among faculty, peers and patients, and integrate ethics into practice. Pillar 2 students also participate in three Friday Academy group sessions, led by physicians and senior medical students that reinforce the lessons and key concepts of the Pillar 2 online ethics course.

For group sessions, students at the FARM sites are linked via video conferencing. Pillar 2 students also develop and submit a reflective paper on professionalism. This paper provides an opportunity for students to integrate their Pillar 1 and Pillar 2 experiences, reflecting on where they have been and where they might be going. During Pillar 3, students at multiple clinical sites across the state may take individual on-line ethics electives or opt to complete requirements for the credit Certificate in Bioethics.

Since Pillar 3 is an 18 month experience, this coursework affords the involvement of students who are nearing the end of their training as well as students who will graduate in the following year. Daily assignments include readings, clinical vignettes, and discussion questions. Students are required to engage in an ongoing discussion with each other and with faculty throughout the day. They are asked to monitor, evaluate, and document their decisionmaking processes.

The certificate courses foster adaptive learning as students learn individually and together with peers, teachers, and attending physicians in multiple contexts. Results: Making Ethics Education Matter. Responses from students suggest that the SSOM model is providing a solid ethics education in a manner that student find meaningful and helpful. Students have become increasingly adept at the practical work of ethics as they learn how to ask questions, collaborate with peers, and engage patients, families, and attending physicians in ethics-related discussions.

Activities that include reflective writing, discussions of articles and vignettes, and integration of clinical experiences appear to strengthen ethical judgement, critical thinking, and behavioral responses. As students process the course materials, they become adept at recognizing forces that influence their decisions like the impact of the hidden curriculum, their own moral values, or their fears of potential consequences when considering a moral response.

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The reflective narratives, submitted by Pillar 1 students suggest a growing appreciation for the role that ethics will play in their professional lives. A physician contributes gifts of knowledge, attentiveness, kindness and protection. Would they be upset with me? Would my actions be more closely monitored in the future because I addressed concerns about an issue? I think many of us choose to fly under the radar to prevent unwanted scrutiny toward our own actions.

The students often underscore the value of the reading, reflective writing, and dialogue with one another. During daily discussions, they question and affirm one another, offering advice and support as they ponder and debate when and how they might respond to their clinical experiences. As the course progresses, the posts from the Pillar 2 Clinical Ethics students show a growing consensus about the value of training in ethics. It is an art of theoretical science blended with life. Remembering medicine as such is essential to its practice.

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We get so used to putting our heads down and pushing through whatever emotions we are fighting for the day, that we too often forget what it is like to slow down and take time to breathe. By the second month of the 5 month online ethics course, students consistently and more confidently discuss the linkages between the course and their clinical work, reflecting on how the readings and discussions influence their interactions with patients and with attending physicians. Our patients put us in these positions, so we must decide how to act. We need to make the choices regardless of if they are easy or difficult.

By engaging others in our "navigation" of choices, we may have our eyes opened to another course of action that hadn't occurred to us before. When the Pillar 2 course was first offered, some student resentment was expected as this 5 month online course requires considerable ongoing time and effort. And certainly some medical students lack enthusiasm about the work entailed in an ethics course, viewing such content as potentially less important than the acquisition of other clinical skills.

But those who perceive less value in the subject of ethics appear to be a distinct minority. As these more skeptical students consider and process the ideas of their peers, most seem to develop a more positive view of the importance of the topic matter. One skeptic noted that an assigned article had proven helpful when dealing with the challenges of a new rotation. Such actions suggest a level of maturational change in response to the articles, vignettes, and peer discussions.

SSOM is now in year 3 of the integrated ethics curricula. Appreciation and enthusiasm for the coursework have remained high among students enrolled in individual Pillar 3 electives or the entire bioethics certificate program. Pillar 3 students who enrolled in the Advanced Studies in Bioethics course showed increased awareness, skill, and competency as they discussed topics that included: the rights of parents and children, care of adults with and without decision-making capacity, care in special situations and with vulnerable populations, and conflict competence when encountering and resolving ethics-related problems.

Students became adept at recognizing the different contextual factors — and different moral interpretations — that can complicate ethical decision making. The course seems to encourage moral imagination. Pillar 3 students often entered the Research Ethics class with a sense that adequate protections for human subject research were firmly established. As they gleaned more information, perspectives changed. Students adeptly integrated notions of covenant, the concept stressed in their 1st ethics session of Pillar 1 into their discussions.

The third Pillar 3 elective, Ethics, Professionalism, and Leadership , helped Pillar 3 students explore how inter-related aspects of those three domains influence the provision of care in both urban and rural settings. Emphasis is placed on approaches that help physicians assume a leadership role in developing processes for recognizing and resolving ethical dilemmas that challenge the delivery of healthcare. Topics included: exploring the call to covenant, micro and macro ethics consultation, citizenship in the medical community, the role of conscience when providing care, integrating ethics into the organizational culture, managing moral distress and clinician wellness, and exploring controversies in the socioeconomics of healthcare.

The value of reflective writing, the growth in student awareness, and the increasing willingness to seek resolution were reflected in the student responses. It is such a mind boggler for me.

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So for today's cases. They're all difficult encounters, but mostly because of physician factors. Our own discomfort with a patient, or our reticence to give medical advice to family.

When voicing concerns about how such behaviors undermine patient care, the students frequently engaged in discussions about their own moral courage, their hesitancies to take action, and the kinds of moral courage that might be contemplated. Students frequently highlighted the value of their evolving perspectives on their clinical work. Discussion: Pondering the Impact. An ethics curriculum is successful to the extent that it guides student behavior during training and provides useful tools for future clinicians as they care for patients. While it is not possible to predict future behavior, representative comments suggest that this longitudinal ethics coursework will help medical students prepare for their clinical work.

The students enrolled in these courses have reported a growing recognition of ethical issues and increased willingness and ability to respond to them. Not assuming the worst about someone is a caring thing to do.

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  8. With burnout or even becoming numb to certain situations, it is sometimes hard to remember not to assume the worst. When we would discuss them, I noticed that there seemed to be a choice that most people agreed on, but usually one person had a different opinion. Eventually, it was easier to see what "other" opinions my classmates might have and I even thought what their rationale might be, too. Finally, it became clearer that even if you have a good idea what the right or best idea is, it is rare that when ethical dilemmas arise, the execution of those ideas is easy.

    I came in to the course thinking that we would be debating what decisions were the best, but I came away with an appreciation for navigating the in-betweens and the journeys to reach those decisions. We hope to track students post-graduation and learn how the ethics training received during medical school influences their clinical decisions. The SSOM ethics program does require considerable investment of time and energy by the faculty as they serve as teachers, mentors, and coaches.

    Faculty in the Pillar 2 and Pillar 3 elective coursework participate in the daily discussions by asking questions, sharing experiences, and suggesting resources. Medical schools should strive to be on the cutting edge of understanding, modeling, and teaching the elements of professionalism and ethics. Students should recognize that issues of ethics and values permeate medicine, impacting physicians, patients, and society. A key skill is learning how to perform comfortably and kindly with uncertainty. Responses from students in the SSOM longitudinal ethics program suggest that those lofty goals may be attainable.

    The responses further suggest that students will embrace and actively seek ethics coursework if they believe that it meets their needs. The Pillar 3 electives were originally envisioned as intensive experiences that would appeal to students who had a particular interest or affinity in medical ethics. An enrollment of students per class was anticipated.