New Approaches to Improve Medical Trainees’ Ethical Confidence

By Stacey Kusterbeck

Medical schools incorporate some education on ethical issues, but the content varies and is a relatively small part of the curriculum. ”New clinicians need training in how to approach fundamental ethical dilemmas using sound ethical reasoning applied to specific cases. This requires practice and repetition, to begin to acquire a comfort level with thinking through these dilemmas and appropriate solutions,” says Katherine Wasson, PhD, MPH, professor and director of the Bioethics and Professionalism Honors Program at Loyola University Chicago.

Ethics faculty are finding new approaches to prepare trainees for clinical practice. “While residents consistently encounter ethically complex decisions, few programs provide a standardized framework to navigate them,” says Baila Maqbool, MD, faculty in the Department of Surgery at University of New Mexico.

Maqbool and colleagues conducted a needs assessment by surveying 38 residents about ethics education. Nearly all residents agreed that ethics expertise was essential to surgical practice. However, many lacked confidence in applying ethical principles in practice, and about one-quarter reported having had no previous ethics teaching. Individual study and role modeling from faculty were the residents’ most common sources of ethics education.

To address gaps in ethics education, the researchers developed the Resident Immersion in Surgical Ethics (RISE) curriculum.¹ “The RISE curriculum equips residents with structured, evidence-informed, and practical tools to handle ethical challenges in surgery with professionalism and compassion,” says Maqbool.

One of the main challenges was integrating a new ethics curriculum into an already crowded residency schedule. “This required aligning content with existing educational priorities and clinical realities,” says Maqbool. The curriculum consists of quarterly ethics morbidity and mortality (M&M) forums, case-based didactics, and role-play simulations.

“It addresses both cognitive understanding and applied ethical reasoning. Each component builds on the others, reinforcing learning through reflection, discussion, and practice. This layered design creates a safe environment where residents can analyze real cases, explore moral reasoning, and translate theory into action,” says Maqbool. Simulation and role-play sessions use standardized patients to mirror real-world ethical conversations on informed consent or end-of-life care. Residents get to practice their communication skills, then receive immediate feedback from faculty and peers.

Post-curriculum data showed a marked improvement in residents’ confidence. Three-quarters of residents felt confident leading ethics discussions, compared to 28% before the intervention. “Residents consistently described these simulations as transformative, noting they felt better prepared for complex patient interactions,” says Maqbool.

Ethics programs can implement a similar program at their institutions, since the RISE framework was designed to be adaptable and scalable. “Even small-scale programs can start with ethics M&M forums and gradually expand, fostering an institutional culture of ethical awareness and patient-centered care,” suggests Maqbool.

Role-playing is one proven approach for gaining practice during medical school years. At Emory University Center for Ethics, Hilary Mabel, JD, HEC-C, core faculty and healthcare ethicist, incorporates role-playing into a session with third-year medical students titled “The Ethics of Speaking Up.” “We highlight concrete strategies for speaking up in sticky situations and then have students practice these strategies. Becoming skilled at navigating ethical issues requires practice, just like taking a medical history or doing a good physical exam,” says Mabel.

Other faculty are using simulation-based learning to improve ethics education. During a required bioethics course at Concordia University, 13 student nurses participated in a simulation-based learning experience involving an ethical dilemma.² Elizabeth Vega-Belluscio, DNP, CHSE, an associate professor and simulation director, collaborated with the bioethics course instructor in choosing a case from a database involving a patient from a vulnerable population — a prisoner with tuberculosis. Vega-Belluscio and colleagues created a simulation based on the case. Two adjunct faculty and two laypeople took turns playing the role of the patient, and a medical doctor candidate from a neighboring medical facility played the part of the doctor. Four rooms were identically outfitted as an infirmary, with one standardized patient per room. Three or four student nurses played nurses in the prison infirmary setting. The medical doctor visited each room sequentially for approximately five minutes to interact with the nursing staff for a total of 20 minutes, replicating the same scene in each room. Each of the nurses was instructed to tell the doctor that the prisoner did not want the tuberculosis medication regimen. The doctor told the nurses to give it to the patient anyway because the patient lacked authority or agency to refuse it. The nurses pushed back, responding with “No, the patient is refusing.”

“Nurses wrestled with that ethical dilemma: Do I obey this authority figure, or do I advocate for the patient? The nurses learned something there — they found their voice and advocated for the patient,” says Vega-Belluscio. To prepare for the simulation, nurses reviewed the American Nurses Association Code of Ethics. Nurses were able to identify other ethically acceptable options, such as putting the patient into isolation, discharging the patient to the hospital, or giving the patient more education.

The simulation was intended to provide nursing students with the confidence to advocate for patients after they enter clinical practice. “This gave them suggestions for what to say to another healthcare worker in the hierarchy in the healthcare system, whether it’s a medical director, surgeon, or anesthesiologist. It’s bound to happen to them again,” says Vega-Belluscio.

Many experienced clinicians are finding that medical students lack real-life experience with ethical dilemmas. “We found that many trainees struggled to translate abstract principles into bedside decision-making. There was no validated assessment method to help educators understand where learners excelled, where they struggled, and how best to tailor teaching,” reports David Soffer, MD, an assistant professor of pediatrics at Children’s Nebraska/University of Nebraska Medical Center.

Soffer and colleagues developed the Pediatric Ethics & Professional Assessment Tool (Pedi-EPAT) to help supervising staff to evaluate the ethical behavior and professionalism of pediatric trainees.³ Faculty use the tool to evaluate pediatric trainees engaging in conversations during simulated scenarios. “The goal of Pedi-EPAT was to create a structured, reliable way to evaluate applied ethical reasoning and communication in pediatric settings,” says Soffer.

Existing guidelines from the Accreditation Council for Graduate Medical Education lacked specificity in assessment of ethical behavior and professionalism, according to Christy L. Cummings, MD, associate professor of pediatrics at Harvard Medical School and director of medical ethics and humanities for Newborn Medicine at Boston Children’s Hospital. Evaluating these nebulous skills can be challenging. “Our study aimed to bridge this gap, providing a tool that would facilitate meaningful assessment and feedback for pediatric trainees and supervising clinicians in real-world clinical interactions,” says Cummings. The researchers expected to see some variability in expert ratings when using the tool. The low-to-moderate inter-rater consistency underscored the complexity of achieving uniformity in judgment across diverse clinical scenarios.

The tool’s internal reliability exceeded expectations. “This highlights the potential for widespread adoption in diverse educational pediatric settings, from ambulatory clinics to ICUs [intensive care units], and from general pediatrics to other pediatric subspecialties,” says Cummings.

Different levels of trainees (residents, fellows, and even new attendings) identified the same areas of difficulty. “This reinforced that ethical competence is not simply acquired with seniority. It requires intentional training and feedback,” says Soffer. Certain skills, such as navigating value conflicts with parents and communicating uncertainty, emerged repeatedly. Across institutions, trainees and faculty commonly experience difficulty with these ethical issues:

• communicating bad news or prognostic uncertainty;
• negotiating disagreements with families (such as withdrawing life-sustaining technologies);
• distinguishing parental autonomy from parental authority;
• applying ethical concepts in real time.

“These struggles aren’t due to lack of caring. Rather, trainees often receive limited structured opportunities to practice these skills before they are expected to use them under pressure,” says Soffer. Many new clinicians have never received constructive feedback that would have allowed them to hone their ethical expertise. “This can lead to a lack of confidence in navigating complex ethical decisions, particularly under pressure or in high-stakes environments,” says Cummings. These issues are especially challenging if there are discrepancies, or even disagreement, among family members or clinicians.

“Additionally, new clinicians may find it challenging to balance personal moral beliefs with professional responsibilities, and to recognize the implicit biases that may influence their ethical judgment,” says Cummings.

In pediatric settings, clinicians face unique ethical dilemmas involving interactions with young patients and their families. Clinicians must navigate relationships among patients, parents or guardians, and the clinical team in cases involving high-stakes decision-making and emotionally charged situations. “The most important considerations are transparent communication, developmentally appropriate engagement of the child when possible, and proactive identification of value tensions early — before they escalate into conflict,” says Soffer.

Balancing the best interests of the child with family dynamics and ensuring informed consent processes are both child- and parent-friendly are other important ethical practices. “Cultural competency and sensitivity are crucial. Pediatricians often serve families from a range of diverse backgrounds with varying beliefs about healthcare and ethical considerations,” says Cummings.

Assessment tools such as Pedi-EPAT allow educators to move from intuition-based evaluation to a consistent, observable framework. The Pedi-EPAT tool identifies specific areas where a clinician needs improvement. “By identifying specific domains — communication, ethical reasoning, professionalism, and team engagement — we can provide targeted feedback, track growth over time, and tailor curricula to real needs,” says Soffer. Tools like this also help normalize ethics as a teachable, measurable competency rather than a “soft skill” learned informally. “Ultimately, structured assessment strengthens confidence, enhances patient-family communication, and reduces moral distress for trainees,” says Soffer.

Such tools can be used in simulated scenarios or real-world situations. Trainees can practice and refine their ethical reasoning and decision-making skills in a supported environment. “This tool is currently part of an ongoing quality improvement project to increase the frequency and quality of feedback provided to trainees in challenging situations, such as prenatal consultations at extreme prematurity or involving complex decision-making,” reports Cummings.

Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.

References

1. Maqbool B. RISE: Resident Initiative in Surgical Ethics. Creating a comprehensive curriculum for general surgery residents. J Surg Educ. 2025;82(11):103712.

2. Dutta RR, Hunter J, Vega-Belluscio E. Simulation-based ethics education: Building confidence and competence in nursing students. J Clin Ethics. 2025;36(3):251-262.

3. Soffer OD, Newman LR, Brennan M, et al. The Pediatric Ethics & Professionalism Assessment Tool (Pedi-EPAT): Development and implementation of a novel, competency-based assessment. PEC Innov. 2025;7:100433.