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Clinical education

60 UTMJ • Volume 84, Number 1, December 2006
Introduction In 1995, the Royal College of Physicians and Surgeons of
Canada (RCPSC) and the College of Family Physicians of
Canada (CFPC) set out four objectives for bioethics education
in postgraduate programs: 1) to integrate bioethics
skills and knowledge into the clinical practice of residents in
accredited programs; 2) to assist postgraduate specialty and
subspecialty programs in teaching bioethics to their residents;
3) to develop model curricula for use within these programs;
and 4) to develop methods to evaluate the bioethics
knowledge, skills, and attitudes of residents.1 These objectives
were linked to residency program accreditation.2,3 In 2003,
the RCPSC set out guidelines for bioethics education in
accredited programs.4 Although the development of curricula
is left to the discretion of each residency program, the
RCPSC published web-based bioethics curricula in 1997 as a
model for teaching bioethics in postgraduate specialties.2
Concurrently, the Pediatric Ethics Network project
(PedEthNet), a national multi-disciplinary collaboration of
Canadian bioethicists and pediatricians produced, “The
Good Pediatrician: an ethics curriculum for use in Canadian
pediatrics residency programs.”5 Both resources are promoted
by the RCPSC as useful tools to meet educational objectives.
Although residents face ethical dilemmas related to their
clinical practice and to the behaviour of their clinician teachers
on a daily basis,6,7,8 it is not clear whether the challenges a
trainee confronts are adequately addressed using formal education.
The North American literature indicates that
bioethics is being taught in postgraduate medical programs;
however, the nature of the education varies widely.9,10,11 In an
effort to assess the response of University of Toronto (U of T)
residency programs to the RCPSC and CFPC requirements,
we undertook an investigation of the current state of
bioethics teaching for residents at our institution.
At the U of T, there are 67 subspecialty residency programs
and approximately 1,100 residents. Each program
must identify one faculty member to act as Bioethics
Education Coordinator (herein referred to as
“Coordinator”), who is responsible for ensuring that residents
receive bioethics education. The Coordinator may be a
physician from the program or a non-physician with formal
bioethics training who is internal or external to the program.
In some cases, one person acts as the Coordinator for more
than one residency programs. Therefore, the total number of
Coordinators at U of T is 55. The overall curriculum for all
residency programs is directed by a clinician-ethicist (Dr. Alex
V. Levin) who provides advice, holds seminars, and supplies
teaching aids. While 16 of the Coordinators are formally
trained in bioethics, the majority of the remaining
Coordinators have participated in teaching workshops and
seminars at the Joint Centre for Bioethics (JCB). The JCB is a
partnership between the U of T and 15 healthcare organizations.
Its membership is composed of a network of over 180
“Ethics teaching is as important as my clinical education”:
A survey of participants in residency education at a single
Alex V. Levin, MD, M.H.Sc., Hospital for Sick Children, Joint Centre for Bioethics, University of Toronto
Scott Berry, MD, M.H.Sc., Sunnybrook and Women’s Health Sciences Centre, Joint Centre for Bioethics, University of Toronto
Charles D. Kassardjian, B.Sc. (0T8), Institute of Medical Science, University of Toronto
Frazer Howard, B.A., Hospital for Sick Children, Joint Centre for Bioethics, University of Toronto
Martin McKneally, MD, Ph.D., Joint Centre for Bioethics, University of Toronto
Introduction. In 1995, the Royal College of Physicians
and Surgeons of Canada and the College of Family
Physicians of Canada mandated that in order to be
accredited, all residency programs include bioethics
education in the curriculum. We assessed the
University of Toronto’s response to this mandate.
Methods. We surveyed Bioethics Coordinators and
Chief Residents from the University’s 67 residency programs
regarding teaching methods, resources, goals
and objectives, course content, and suggested improvements.
Results. All respondents reported that ethics education
is important, worthwhile, and should stay in the
curriculum. Ninety-eight percent of Coordinators
reported that ethics was taught in their programs.
Seventy-nine percent of Chief Residents felt that ethics
teaching was as important as clinical education.
Amount of time spent teaching bioethics ranged from
1.5 to 9 hours/year; fifty-five percent of programs
spent 4 hours or less. There was some discordance
between topics taught and ethical issues faced by residents.
Formal evaluation of ethics education took
place in only 46% of programs.
Conclusions. Postgraduate bioethics educators at the
University of Toronto have implemented bioethics
teaching in almost every program, and the importance
of this teaching is validated by their residents. We identify
a number of challenges, including matching session
topics to student need and administering appropriate
course evaluation.
UTMJ • Volume 84, Number 1, December 2006 61
multi-disciplinary professionals who study health-related topics
through research and clinical activities.
A questionnaire was sent to the Coordinator of each residency
program by email, along with a cover letter explaining
the nature of the study. Each Coordinator was given the
option to respond by letter mail, email, fax, in-person interview,
or telephone interview. The same method was used to
contact the Chief Resident of each residency program, using
a version of the questionnaire designed to examine the perception
of bioethics teaching from the perspective of a resident.
(Questionnaires are available upon request to the
Corresponding Author).
Questionnaires were administered over a two-year period,
beginning in June 2001. The questionnaires focused on
teaching methods and resources, goals and objectives, course
content, and suggested improvements. The questionnaire
was comprised of both short-answer and check-box responses.
The subjects were given a two-week period to complete the
survey. If an email reminder sent two weeks after receiving
the survey failed to elicit a response, potential participants
were contacted by telephone.
Descriptive statistics were used to analyze and present the
data. As this data collection was conducted for the purposes
of quality assurance and curriculum assessment, and was
reported as anonymous aggregate data, Research Ethics
Board approval was not obtained.
The Coordinator response rate was 76% (42/55). The
Chief Resident response rate was lower (57%, 37/64, p=
0.05). Not all respondents answered every question.
All respondents felt that ethics teaching was important to
residents and should remain in the curriculum. Almost all
Coordinators (98%, 41/42) indicated that ethics was taught
in their program(s). Seventy-nine percent (27/34) of Chief
Residents felt that ethics education was as important as clinical
training (Figure 1). The most common reasons for the
importance of ethics teaching cited by both Coordinators
and Chief Residents were that it provided residents with the
tools and skills to: 1) identify, 2) analyze, and 3) deal with ethical
The Coordinators were asked about which ethics topics
were taught in their programs, while the Chief Residents were
asked to list the ethical issues that they most often face at
work. The results were ranked and compared. Although
informed consent and end-of-life issues were ranked high by
both teachers and students, Table 1 illustrates some discordance
between what is being taught in the programs and
what the residents consider to be their most important ethical
challenges. Family issues are identified by 35% of Chief
Residents, but taught in only 13% of programs, while
research ethics is ranked third by Coordinators and sixth by
Chief Residents.
Issue Issues Issues Covered
Residents Face in Curriculum
End of Life 1 1
Consent 2 2
Family Issues 2 8
Disclosure† 3 10
Medical Industry 4 9
Resource Allocation 4 4
Research Ethics 6 3
* a lower number indicates a higher priority
†includes error, breaking bad news, and truth-telling
Table 1. Ranked list of ethical issues.
Coordinators devote between 1.5 and 9 hours per year to
formal bioethics teaching. However, the median is below 4
hours per year (Figure 2). Sixty-nine percent (22/32) of
Coordinators felt that the current amount of ethics teaching
was sufficient. Almost the same percentage of Chief Residents
(67%, 20/30) felt the same way.
Based on the responses to the questionnaires, the most
common method for teaching ethics at U of T is the casebased,
small group discussion (95%, 36/38). Eighty-seven
percent (32/37) of Chief Residents felt that this was the most
effective teaching method, because it was relevant, realistic,
and practical (74%, 20/27) and because it was interactive and
encouraged participation (33%, 9/27). Eighty-two percent
(23/28) indicated that the least effective methods were didactic
lectures (82%, 23/28) and open-ended discussions (14%,
4/28), because they were boring (47%, 8/17), quickly forgotten
(24%, 4/17), and not relevant to clinical practice
(4/17). Over one-third (37%, 10/27) of Chief Residents felt
that there was little that could further improve the effectiveness
of teaching.
Ethics Teaching
Figure 1. Importance of ethics teaching as compared to clinical
teaching as ranked by Chief Residents.
As important More important Less important Much less important
Figure 2. Total amount of time spent teaching ethics in postgraduate
programs at the University of Toronto per year.
4 hours or less Between 4-6 hours Greater than 6 hours
Number of Programs
62 UTMJ • Volume 84, Number 1, December 2006
The majority of programs (80%, 33/41) had sessions
taught by a formally trained bioethicist (either a physician
from the residency program or elsewhere in their own hospital,
or a non-physician from the JCB). The remainder of the
programs utilize teachers who are physicians (attending staff)
that are not formally trained in bioethics, including Program
Directors. Three programs reported that attending staff had
conducted their sessions with the assistance of someone with
formal bioethics training.
Eighty-two percent (28/34) of Coordinators felt that their
residents were better able to identify and deal with ethical
issues that arose in clinical practice because of their ethics
education, although formal evaluation of ethics education is
performed by less than half (46%, 17/37) of the programs.
Similarly, Chief Residents felt that formal ethics sessions had
helped them to recognize (81%, 26/32) and deal with (85%,
22/26) ethical issues. The majority (69%, 22/32) of Chief
Residents reported that they did not undergo any formal evaluation
of their ethics learning.
Our assessment of ethics teaching within the 67 residency
programs at the U of T identified three key findings: 1)
bioethics teaching occurred in almost every program, and
was considered to be valuable by teachers and students; 2)
there appeared to be some mismatch between the educational
agendas of staff and ethical issues faced by residents;
and 3) both staff and students indicated that they felt that
ethics teaching had a positive impact, but there was a lack of
formal evaluation to confirm this impression.
The mismatch between what is being taught and the ethical
issues that residents face most frequently suggests that the
formal bioethics curriculum may not adequately represent
the resident experience. The formal curriculum is not
addressing the challenges found within the informal and
“hidden” curricula, as described by Hafferty and Franks.12
Some components of ethics education must be participantdriven
and training stage-specific.8 A relatively simple survey,
like the one developed by Malhotra, could be effective in
determining what issues residents would like to see addressed
in their bioethics teaching program.13 However, residents
should not be the only arbiters of their bioethics curriculum.
In developing a bioethics teaching program, more attention
should be paid to ethical dilemmas made by trainees in the
context of medical training.
Despite the impression of teachers and students that
bioethics teaching has a positive impact, there was limited
formal evaluation to externally validate these impressions.
While teachers and students may have the capacity to successfully
evaluate bioethics education, these findings indicate
that physician-teachers lack the appropriate methods to do
so. Similar findings are reported in North American medical
schools, where only 48% of Deans indicated that students‚
moral reasoning abilities are formally evaluated through casebased
essay exams or Rest’s Defining Issues Test, and only
one-third reported formal evaluation of students‚ behaviours
in ethically-difficult situations.10 Blackmer’s survey of nine
Canadian Physical Medicine and Rehabilitation residency
programs identified similar methods of evaluation, such as
the use of Observed Structured Clinical Examination stations
with standardized patients, rotation-specific evaluation, and
written exam questions.9 PedEthNet suggests adapting,
where appropriate, current methods of medical education
assessment, such as written and oral exams, patient examinations
(both real, and standardized), In-Training Evaluative
Reports, and self-assessments, to evaluate a resident’s ability
to manage ethical issues. However, each of these methods has
limited suitability for evaluating all aspects of a resident’s ethical
knowledge and behaviour.5 The development of appropriate
evaluation instruments for ethics education remains a
challenge for residency programs.
Inconsistency in the amount of time devoted to bioethics
training is an issue that appears in many assessments of
bioethics teaching across the United States and
Canada.9,10,11,13 In a survey of the Deans and Course Directors
of American and Canadian medical schools, Lehmann found
that lack of time in the curriculum and in faculty schedules
were two of the top three perceived obstacles to increasing
bioethics teaching time.10 A survey of 134 medical schools in
the United States reported anywhere from 5 to 200 hours
devoted to teaching bioethics over four years to medical students,
with 63 schools in the 5-to 40-hour range.11 Surveys
within individual specialty programs also found great variation
in the amount of time spent teaching ethics at the postgraduate
level.9,14,15 In the model curricula for residents published
by the RCPSC, it is suggested that the indicated specialties
designate at least ten hours to cover identified
bioethics topics.16,17,18,19 Other published specialty curricula
suggest devoting between 1 and 3 hours per subject, while
covering 6 to 10 subjects over the course of a resident’s training.
20 Even within the same university with central coordination,
the considerable variation in the amount of time spent
teaching ethics in our residency programs indicates a lack of
consensus about the appropriate amount of time that should
be designated to formal ethics teaching. The time assigned
for teaching bioethics in most of our programs seems insufficient
to cover the range of identified ethical issues. However,
two-thirds of Coordinators felt that ethics teaching time was
sufficient, and only one-third of Chief Residents would like to
have more. This might indicate that their needs are being
met outside the formal curriculum. Further investigation is
required in order to determine the optimal time that should
be allocated for formal bioethics teaching, as well as the
appropriate mix of formal and informal learning sessions.
The limited pool of trained bioethics teachers covering all
67 programs may explain the lack of time devoted to
bioethics in individual programs. In a 1994 survey of 256
graduate and undergraduate obstetric and gynecology programs,
it was reported that 29% of programs had faculty
trained in ethics, and the amount of time devoted to ethics
teaching was low relative to the list of ethical issues.14 Eightysix
per cent of medical schools in North America have at least
one full-time ethics teacher, and those with a dedicated ethics
faculty member were twice as likely to have a mandatory
introductory ethics course.10,11 Silverberg reported that the
majority of ethics teachers in American medical schools are
ethicists, PhDs, or physicians.11 In a survey of all accredited
general surgery residencies in the U.S., it was found that
those programs with a faculty surgeon with expertise or special
interest in ethics had a greater number of ethics teaching
Ethics Teaching
UTMJ • Volume 84, Number 1, December 2006 63
activities.21 A group of dedicated expert and interested teachers
is vital to the continued growth and sustained excellence
of bioethics teaching within residency programs. Developing
strategies to improve bioethics expertise in faculty may help
to increase the time spent on bioethics education and the
quality of that education.
Variations on the case-based, small group discussion are
the primary methods of ethics training reported in both medical
schools and individual specialties.10,15,22 It is also a popular
method within suggested curricula.5,9,16,17,18,19,23 The effectiveness
of alternate forms of bioethics teaching, using standardized
patients, debates, narratives, movies, and other creative
techniques, might be explored to strengthen bioethics
educational programs.
There are some limitations to this study. There may have
been responder bias with more responses from those who
liked bioethics, and fewer responses from programs not in
compliance with the new requirements. Since our study
focused on a single institution, our findings may not be representative
of bioethics education programs in other settings.
However, many of the themes we identified have been
encountered in other North American institutions.
This study describes the successes and challenges faced by
residency programs at the University of Toronto in complying
with the mandate for bioethics education from the RCPSC
and CFPC. Furthermore, this study highlights the need for
further work on determining methods of evaluating the
impact of bioethics education. The mismatch between curriculum
and ethical issues most prominently faced by residents
needs further exploration and remediation.
To ensure content validity, the questionnaires used in this
study were developed with the consultation of Dr. Richard
Tiberius, an education researcher who was at the University
of Toronto during the planning of this study. We are grateful
for his expert advice.
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Ethics Teaching

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