Ethics Training in Graduate Medical Education

Despite the growing number of trained bioethicists, the majority of day-to-day medical ethics decisions are made by clinicians without any formal bioethics training. Therefore, an analysis of the state of the field of bioethics and bioethics education needs to include some inquiry into the bioethics education clinicians receive. Just as every clinician needs to know enough cardiology to handle routine cardiac issues and to know when to refer to a specialist, every clinician also needs to be able to handle routine ethical issues and needs to know when to consult a specialist. Most clinicians receive little ethics education, and, in my experience, few feel there is a deficit in their ethics training. Clinicians often believe that if they are moral, ethical people they are fully prepared to handle moral and ethical conflicts in their medical practice. As the field of bioethics grows and residency training reform incorporates more emphasis on ethics and professionalism, residents need to be taught that passive ethics education does not prepare them for the ethical challenges they will regularly face in practice.

Ethics training in clinical medicine is often a small part of the formal curriculum. Ethics are learned by example and through the "hidden curriculum"—all those things that physicians are taught during their socialization as physicians that reflect the values and mores of the profession. Physicians generally tolerate ethics education grudgingly. Further, physicians frequently treat challenges to their ethical decision making as personal challenges to their own morality and professional stature. Clinicians not only need more ethics training exposure but also a reformulation of the role of ethics in daily practice.

I am a second-year internal-medicine resident. Bioethics is my "specialty" but I plan to maintain a general clinical practice as well. My interest in clinical medical ethics began in medical school. I am fascinated by the ethical conflicts that pervade the practice of medicine. As a result of the inadequacy I felt in analyzing ethical problems, I enrolled in law school. The legal overtones in many ethics issues made me feel that I needed some legal expertise to be effective in resolving common clinical ethical concerns. I left my first residency program over ethical conflicts with policies and practices in my training environment, which fueled my interest in bioethics. I went on to a University of Chicago MacLean Center for Clinical Medical Ethics fellowship to broaden my formal knowledge of philosophy and ethical traditions, as well as to gain experience in ethics consultations. I was very pleased with my experience. I left feeling well-prepared to analyze and discuss the practical as well as the philosophical aspects of clinical ethical problems.

After finishing my training in law and clinical ethics, I was lucky to find a hospital where I could participate in the internal medicine residency program while also working in the bioethics institute and teaching. As a lawyer and ethicist I actively analyze my residency experiences from a bioethical perspective. I observe the clinical training process, looking for ethical issues and how they are handled. I believe my training program is an excellent clinical program that values ethics and promotes professional behavior. Even at a program that I consider to be one of the best in this regard, there are serious flaws in the teaching and practice of clinical medical ethics.

Ethics training in residency is viewed by the residents as "soft" medicine at best, and more often as a waste of time. Residents frequently skip ethics-related educational experiences because they feel it isn't an effective use of their time to learn ethics. I have heard residents repeatedly make comments like "I don't do family consults on call," "I don't have time for social work rounds," and "My job is to practice medicine" when ethical issues come up on service. Surrogate decision making is poorly understood by the residents (and often the attendings). Informed consent is merely a paper...