August 1, 2011

Medical educators miss teachable moments with young docs

A frail but perfectly coherent patient refuses medical attention for problems with mobility. With slight hesitation, a doctor in training performs a biopsy, noticing excessive bleeding afterward. Another resident elects not to order expensive treatment for a seriously ill patient because it will leave him in deep debt.

Physicians in training face ethically fraught scenarios like these every day. But a new study by medical educators at the Johns Hopkins Berman Institute of Bioethics finds that the doctors who oversee residents in the clinic often don’t explicitly mention and discuss these issues with trainees.

“Teaching about ethics and professionalism in real time is a very important part of the training experience,” said Joseph Carrese, the study’s lead author and a core faculty member at the Berman Institute. “It appears from our findings that opportunities to identify those issues and teach about them were missed.”

The two-week observational study of 53 internal medicine residents and the 19 faculty preceptors (mentoring physicians) overseeing them is described in the July issue of Medical Education. The study found that a variety of “everyday ethics” were raised in about 80 percent of the conversations that trainees had with preceptors. But these mentoring physicians explicitly pointed out the ethical issue and taught about it just 12 percent of the time, the study found.

When residents see a patient, they must first discuss the case with a preceptor. These interactions are an essential part of medical training, a way to dissect real problems in the moment, supplementing seminars and similar sessions, says Carrese, director of the Berman Institute’s Program on Ethics in Clinical Practice.

Members of his research team took detailed notes on 135 mentor-trainee interactions and later identified the specific ethical issues that came up. The issues fell under one or more of the following categories: “doctor-patient interactions,” “interactions with the health care system” or situations unique to “residents as learners.”

Although the preceptors pointed out the precise issue and discussed it with trainees just 12 percent of the time, Carrese says that they implicitly acknowledged the topic much more often—about 40 percent of the time. For instance, faculty often made a passing reference to an issue.

Carrese says that previous research looking at whether this approach is an effective educational strategy suggests it isn’t.

A preceptor typically oversees three to four residents at a time, according to Carrese, and each resident must review every patient appointment with the preceptor. So time constraints may be one of the most likely obstacles to explicitly discussing the embedded ethical issues. But Carrese says that more studies are needed to identify the barriers and find ways to address them.

If the main hurdle is lack of time, Carrese says that tools and strategies can be developed to assist faculty preceptors and streamline difficult discussions. For instance, Carrese and colleagues developed a checklist with an easy-to-remember acronym that can help doctors assess a patient’s decision-making capacity during an emergency and in other clinical situations.

The acronym, described in the February 2010 issue of the journal CHEST, is CURVES: Choose and Communicate, Understand, Reason, Value, Emergency and Surrogate.

Physicians, seasoned or not, will inevitably struggle with some cases: the elderly patient who refuses help to prevent the hip-cracking fall that will inevitably happen, or the poor man who needs a costly treatment he can’t afford. But even preparing residents for that moment—getting them to start thinking of a “game plan,” as Carrese puts it—may help them when the difficult questions arise.

“If we better understand what the barriers and needs are,” Carrese said, “then we as ethics faculty are going to be in a better position to help preceptors and enhance how they teach trainees about ethics in real time.”

Carrese’s co-authors include fellow Berman Institute core faculty members Margaret Moon, Holly Taylor, Mary Catherine Beach and Mark Hughes. Erin McDonald and Kiran Khaira, both former research staff at the Berman Institute, also co-authored the paper.