In recent years, issues of ethics and professionalism have played an increasingly prominent role in psychiatry resident education. The literature includes a number of efforts aimed at sharpening the way that these topics are conceptualized (1), understanding how they are best taught and assessed (1–3), and surveying learners' attitudes and preferences toward this dimension of training (4–8). With regard to pedagogy, most accounts emphasize traditional didactics or case-based learning. Although a few notable papers highlight the importance of role-modeling (9, 10), surprisingly little attention has been paid to the value of experiential learning, in which ethical dilemmas are explicitly identified, discussed, and negotiated in vivo. This may be due, in part, to the fact that residents generally train in robust systems that shield them from gross ethical conflicts, thereby limiting opportunities for experiential learning. When health systems collapse, however, issues of ethics and professionalism move abruptly to the foreground; they tend to occur more frequently, and to be far more explicit than in functioning systems. One might, therefore, expect a health-systems crisis to provide a rich practicum in learning to negotiate these issues. This article highlights the use of a health-systems crisis as a classroom—for teaching and learning about ethics and professionalism. We present a case study of a “learning encounter,” drawn from our experiences providing care in the public mental health system in Sacramento County, California, during a period of major service reductions. The paper is intended to alert educators and trainees to the unique opportunities for experiential learning that may arise in other crisis-like settings, and to provide practical guidance about how to use those opportunities to sharpen trainees' skills in ethical decision-making.
Over a 6-month period in 2009, a series of funding cuts decimated the system of public mental health services in Sacramento County: outpatient services were eliminated for 4,500 adults; capacity at the county's sole public inpatient treatment facility was reduced by 50%; and the county's psychiatric emergency room was closed (11). Without access to vital services, patients sought treatment in increasing numbers at local emergency departments (12). Mentally ill patients were routinely treated by providers without specific mental health training, and patients often waited on gurneys in ED hallways for several days before being transferred to an appropriate inpatient treatment setting—a situation we have characterized elsewhere as a “slow disaster” (13).
In response to these changes, PGY2 and PGY4 residents began rotating through the local university hospital emergency room, providing psychiatric consultation. Trainees and supervisors quickly observed a marked shift in the focus of learning: whereas clinical issues were fairly straightforward, and not much different from those seen in other acute-care sites, issues of ethics and professionalism were far more prominent. Trainees' experiences focused, to an unusual degree, on issues of autonomy and coercion, (mis)use of legal holds, safety (of patients and staff), altered standards of care, marginalization of mentally ill patients, and countertransferrence in other ED staff.
To capitalize on these new learning opportunities, two residents kept detailed logs of “learning encounters” (Table 1) related to issues of ethics and professionalism. At the end of the training period, we used our logs to formulate a general “anatomy” of the learning experience. The goal was to examine critically these novel experiences—to dissect them, in order to better understand the anatomy of experiential teaching and learning around issues of ethics and professionalism. Below, we present and discuss one learning encounter as an illustration of the opportunities for experiential learning that occurred in this setting. Here, neither the clinical details nor the ethical issues are the main focus; rather, we emphasize the didactic elements of the encounter.
TABLE 1.Mr. X: Anatomy of a Learning Encounter
The vignette illustrates several features of the learning encounter—some of which went well and others that could be improved. From a didactic standpoint, the vignette might be useful in a case-based learning setting, to prompt reflection and discussion. Also, some readers may find the anatomy we have articulated to be useful in its own right—as a tool to sharpen awareness of potentially important didactic elements of experiential learning in this setting. Beyond the value of this tool, several broad lessons flow from our experiences, which may guide others interested in experiential learning in other crisis-like settings (Table 2).
TABLE 2.The “Four A's” Guiding Ethics Teaching in a Crisis Setting
Whereas other areas of resident training commonly emphasize in-vivo learning, didactic methods for teaching ethics and professionalism are frequently divorced from practical experience. Training in a crisis setting may eliminate this gap. Other professions emphasize the value of in-vivo, experiential learning in developing the skills of ethical decision-making (15). Similarly, our study underscores the role for supervised experiential learning as an element of pedagogy in teaching about issues of ethics and professionalism for psychiatric residents. Traditional teaching methods, such as formal didactics, run the risk of conveying implicitly that “ethics” is mostly a fund of knowledge, or at best, the mere application of principles to various types of clinical and professional encounters. Formal didactics may emphasize answers and outcomes, rather than a process or approach to making ethically sound decisions. By contrast, the value of the experiential method stems from a different conceptualization of what ethics is—namely, a way of seeing, understanding, and negotiating a particular kind of problem, an experience in which ethics becomes as much a process as a product. In the case study, for example, the second-year resident was exposed to several supervision “perspectives,” which enriched her understanding about different ways of thinking about the dilemma, conveying implicitly that the process of making ethically-sound decisions entails more than getting a quick answer from an Attending physician (as might have been the case with a clinical question). This mirrors our observation that the supervisor's role in these encounters shifted from simply imparting the right decision, to helping the trainee learn how to make the right decision. If ethics is conceptualized as a decision-making skill, rather than a set of conclusions, then the crisis setting, which presents prominent, challenging issues of ethics, becomes a rich practicum in learning and practicing the skill of ethically-sound decision-making.
Future directions for this work may include efforts to further develop and operationalize the anatomy we have presented here as a set of practical guidelines. Such a tool, informed by experience and supported by empirical and theoretical work, might serve to help supervisors and trainees to capitalize on opportunities for teaching and learning in other crisis-like settings.
Another potential avenue for future work includes investigating the educational value of this particular kind of learning; specifically, determining 1) whether this type of learning is effective in helping trainees develop observable skills in ethical decision-making; and 2) whether it might be a useful adjunct to current, didactic methods.
To conclude, the observations described in this article apply equally to established systems of care, where, of course, trainees and supervisors are confronted with issues of ethics and professionalism that demand thoughtful consideration. Nonetheless, our experiences underscore the role of robust health systems in protecting against gross violations of ethics and professionalism. Providers, in our experience, came quickly to appreciate the ways in which ethical safeguards and professional standards are embedded in the stability of the functioning systems in which we normally train. When systems devolve, not only are services lost, but also lost are the protections and respect we give our patients and each other through the very maintenance of robust systems of care. Thus, in a disaster or crisis, the obligation to provide care in a way that continues to protect and respect patients—that is, in a way that is ethical—falls more directly on the provider. Training systems, supervisors, and residents bear novel obligations and opportunities in a crisis setting, where it becomes more explicitly their burden to ensure that patients are treated ethically, and that trainees learn from the experience.