AMA Journal of Ethics^®

The obstetrics and gynecology specialty addresses issues that span from preconception to end of life; hence, the obstetrician/gynecologist encounters the need to call upon ethical principles to assist in decision making and providing optimal care for women on almost a daily basis. While greater skill in the application of ethical principles evolves with ongoing engagement with patients, a knowledge base and methods for approaching challenging situations in a supportive environment are crucial for medical students, residents, and fellows. For residents and fellows, time on the gynecologic oncology service provides an opportunity for the application of ethical principles to real patients and cases. Developing a curriculum that allows medical trainees to engage ethically challenging situations with confidence and thoughtfulness is imperative to shaping well-rounded physicians.

The Council on Resident Education in Obstetrics and Gynecology (CREOG) requires that residents graduating from accredited programs demonstrate a commitment to adherence to ethical principles as part of their professional development [1]. Specifically, CREOG mandates that graduates be able to describe basic ethical concepts such as respect for autonomy, beneficence, justice, and nonmaleficence; be familiar with the meaning of informed consent; demonstrate an understanding of the use of living wills and durable power of attorney; and comfortably engage in discussions about withdrawal of care, including “do not resuscitate” orders [1]. Similarly, the American Board of Obstetrics and Gynecology (ABOG) requires that gynecologic oncology fellows understand and practice ethical medicine, including appropriate professional conduct, addressing patient and family care needs, and using advanced directives [2]. Acknowledged by the Accreditation Council on Graduate Medical Education (AGCME) as a component of the core competency “professionalism,” adherence to ethical principles is a requirement for successful completion of a program [3].

Despite the universal agreement that ethics education is an important component of any medical training curriculum, it is questionable whether the drive to implement such programs has been successful in obstetrics and gynecology. A recent survey of 118 ob-gyn residency program directors found that only 50 percent of programs had incorporated ethics into their core curricula and that most ethics training did not follow a standard curriculum to be used repeatedly [4]. Fewer than five hours of ethics training per year was provided in more than half the programs [4]. More than 70 percent of respondents indicated that they would like to incorporate more ethics education and that they thought it should be a required component of residency training, but less than 40 percent were familiar with relevant resources, such as the Association of Professors of Obstetrics and Gynecology (APGO)/CREOG ethics case study [5]. Barriers to increasing the amount of time for ethics training included an already overcrowded curriculum and lack of faculty expertise in ethics topics [4].

Unfortunately, these data are not that dissimilar from a survey of ethics education in ob-gyn residency programs performed more than 20 years ago. In the report by Cain et al. [6], the average amount of time for ethics training for residents was only four hours; faculty members lacked training in medical ethics; and the method of teaching was generally lacking in structure.

Designing a Curriculum: Things to Take into Account

In designing a medical ethics training program, the first concern is what should be included in a curriculum. With increasing duty-hour restrictions, time is at a premium. As with all didactics, time needs to be protected so that clinical duties do not supersede nonclinical educational opportunities, but the topics to be covered should also be beneficial, relevant, and engaging: for example, while consideration of pregnancy termination for genetic malformation may be important on an antepartum ward, it has no place on the gynecologic oncology service.

Identify the most important topics. Although identifying which ethical topics are most important would seem to be an easy problem to solve, the perception of which issues are most important appears to vary by level of training. In 2006, Goold and Stern [7] reported on a survey that asked medical residents and a group composed of ethics committee members, patient advocates, practicing physicians, and program directors to select ethical themes upon which to develop a focused curriculum. Although trainees selected “family interactions” as the most important theme for education, the nontrainee group—with more experience to draw upon—selected “informed consent” as the most important theme. The authors argued that opinion or anecdotal experience alone may not provide a strong enough foundation for curriculum development.

At the University of Texas MD Anderson Cancer Center, we addressed this conflict by designing a gynecologic oncology ethics education program around the results of a retrospective review of all ethics consults completed at a tertiary cancer center over a period of 15 years [8]. The most common clinical case types, including level of appropriate treatment (i.e., code status), withdrawal of care from an incompetent patient, surrogacy, futility of treatment, and obligations to a noncompliant patient, were identified and used as the basis for a quarterly ethics education program for gynecologic oncology fellows.

Don’t assume everyone will share the same ethical approach. A second consideration in curriculum design is diversity amongst the trainees. Medical school graduates not only come from different regions, but also vary by gender, ethnicity, sexual orientation, religious background, and other traits. Recognizing this diversity is crucial because these personal attributes contribute much to the individual’s baseline approach to complicated ethical questions. A survey of Canadian obstetrics and gynecology residents asked about factors that most influenced their individual decision-making processes to gain an understanding of potential biases [9]. Residents indicated family views as being the most influential factor in their decisions (34.2 percent), followed by previous learning during undergraduate work (17.1 percent), religious background (15.4 percent), residency training (11.1 percent), and peer attitudes (9.4 percent) [9]. These findings underscore the importance of developing a curriculum that allows open exchange of ideas in a nonthreatening setting. The introduction of medical ethics principles provides a common lens through which students can examine and perhaps alter their biases.

Structure programs to engage trainees. A key component of any curriculum is engagement of the trainee. If the resident or fellow is disinterested or detached, assimilation of knowledge is unlikely. Multiple ethics education models have been suggested to connect trainees to the topics being explored. Mueller and Koenig [10], for example, have recommended that ethics consults themselves be the basis for a training initiative, inasmuch as they reflect the actual experiences of patients and physicians and highlight important ethical topics seen in clinical practice. Although this model would provide trainees with direct patient contact that may be meaningful, clinic responsibilities might limit its success.

Researchers have also demonstrated that use of small groups is a feasible and successful way to augment learning and application of ethics principles. For example, Smith et al. [11] performed a direct comparison of the effects of two teaching methods on medical students’ recognition and assessment of common ethical dilemmas in three case scenarios. One cohort submitted responses to a professor who then provided feedback. A second cohort participated in a discussion group about the cases and then submitted evaluations of them. It was found that the students in the discussion group had improved recognition and assessment of ethical issues and greater ability to formulate a plan. Similar problem-based learning models have been advocated for use as early as the first year of medical school as a way to introduce professional behavior, challenging students to explore their own values, become active learners, and thoughtfully engage complicated situations with peers [12, 13].

In addition, trainees should be invited to participate in decisions about how best to achieve their educational goals, and educational sessions should be provided in an interactive format.

Tailor efforts to each program and institution. In designing an ethics curriculum for trainees in obstetrics and gynecology and gynecologic oncology, the considerations above are all important. For the curriculum to be successful, it needs to be engaging, relevant, effective, and efficient. It would be a disservice to think that what works for one program will be universally successful for all. Residency and fellowship training programs are as diverse as the young physicians they attract, with differing resources and patient populations. The unique features of each training hospital should be explored as ways to highlight and promote discussion about specific ethical principles. For example, in a hospital that provides care for an underserved patient population, there will be opportunities to discuss the principle of justice and equitable allocation of health care resources (e.g., access to pap smear screening for cervical cancer).

Furthermore, the particular institution’s resources should be tapped. At the very least, a member of the institutional ethics board, and preferably a clinical ethicist, should be invited to participate in curriculum development. People in such roles are highly trained and provide a different, and frequently enlightening, perspective from that of supervising clinicians.

Conclusion

As residency and fellowship training requirements continue to evolve, so, too, will ethics curricula. It is incumbent on trainees and programs alike to recognize the importance of ethics education and advocate for appropriate opportunities to hone the skills required to critically assess ethical dilemmas that graduates will undoubtedly face. Competency in ethics truly is a measure of professionalism, and as a community of obstetricians-gynecologists and gynecologic oncologists, we are obligated to train young physicians to be capable of delivering comprehensive and meaningful care to women.