EXECUTIVE SUMMARY
Ethics education is often underfunded, both in the hospital and medical school settings, due to lack of importance being placed on it historically, and administrative obstacles. Possible approaches include the following:
- Align funding with students’ educational needs.
- Integrate ethics into sessions covering scientific topics.
- Conduct a needs assessment to determine which topics are most relevant to the setting.
Medical institutions didn’t always understand the importance of ethics to physician training, notes Timothy Lahey, MD, MMSc, chair of the clinical ethics committee at Lebanon, NH-based Dartmouth-Hitchcock Medical Center, and associate professor at Dartmouth’s Geisel School of Medicine.
“We valued physiology and histology and other canonical topics, and paid to teach them,” he says. This failure to recognize the importance of ethics training has left many departments underfunded.
“Upon realizing ethics training was important, those negotiating for funding to teach it often were late to the table, and at risk of getting the scraps of educational funding,” Lahey explains.
Administrative obstacles are another complicating factor. If funding for medical education flows through departments organized around scientific topics like anatomy or genetics, then ethics education can end up underfunded. “Ethics departments are often small and less powerful, and thus, last to the table if they exist at all,” says Lahey. He says the following are the two best ways of supporting ethics teaching despite tight funding:
- align funding with students’ educational needs
- integrate ethics into multidisciplinary teaching
Rather than accept that there is little money left over for teaching an important topic like ethics, says Lahey, leaders in medical education need to ask first what students need to learn, then pay for teaching that addresses that need. “There is little argument physicians confront ethics issues on a regular basis, and thus, that ethics training is a core skill whose teaching should be funded,” says Lahey.
One way to make ethics training more cost-efficient is to integrate it into sessions that address other “bedrock” topics. “For instance, students can learn about the ethics of end-of-life care decision-making in a session about respiratory failure and ventilator physiology,” says Lahey.
Ethics education faces some similar challenges in the hospital setting. “High-quality ethics education can only be provided by clinical ethicists,” says Katrina A. Bramstedt, PhD, a clinical ethicist and adjunct professor at Bond University School of Medicine in Australia, and former faculty in the Department of Bioethics at Cleveland (OH) Clinic Foundation.
“These professionals have advanced training and applied skills in inpatient and outpatient medical ethics,” she explains. Not all hospitals have a fellowship-trained clinical ethicist on staff, however.
“In my experience, hospitals in this situation have reached out to me, essentially borrowing me from my primary institution, to provide their on-site education,” says Bramstedt. She created monthly and quarterly Bioethics Grand Rounds for many hospitals. The sessions are open to doctors, nurses, allied health staff, and students.
“These sessions are video or audiotaped to create a local educational archive. They are sometimes live-streamed to remote in-network hospitals,” says Bramstedt.
She recommends that hospitals first conduct a needs assessment to identify which topics are most appropriate to the setting. For example, a session on transplant ethics would not be appropriate for a hospital that doesn’t perform organ transplants, but a session on organ donation ethics is appropriate for any hospital.
“Hospitals might have specific needs based on recent events such as a serious medical error, media relations fiasco, or complex clinical trial,” says Bramstedt. To increase attendance at ethics education sessions, she suggests the following:
- make attendance mandatory
- provide CME units
- provide a meal
“Also, clinical ethicists must go beyond the basic PowerPoint slide set, and engage their learners with technology such as e-polling, videos, and cases,” says Bramstedt. She says e-polling is best used at the start of sessions by asking the audience questions they can answer anonymously in an electronic poll that is visible to everyone. “The resultant data set informs both the teacher and the audience about their current knowledge, as well as lack of knowledge,” says Bramstedt.
Ethics education “should not be a philosophy course,” in Bramstedt’s view — but rather, applied medical ethics that shows clinicians how to identify and resolve ethical dilemmas.
The cost of “borrowing” a clinical ethicist is about $200 per session for an honorarium, plus additional costs to provide CME and meals, Bramstedt estimates. “These expenses should be viewed as the cost of doing business, rather than an impediment or burden,” she says.
Furthermore, there is the potential for considerable “downstream” cost savings. “Ethics education of healthcare staff may reduce staff moral distress and turnover, increase patient satisfaction, and reduce litigation,” says Bramstedt.
SOURCES
- Katrina A. Bramstedt, PhD, Clinical Ethicist, Bond University School of Medicine, Queensland, Australia. Email: [email protected].
- Timothy Lahey, MD, MMSc, Chair, Clinical Ethics Committee, Dartmouth-Hitchcock Medical Center, Lebanon, NH. Phone: (603) 650-6063. Fax: (603) 650-6110. Email: [email protected].
